When it comes to the NHS, the pandemic has changed everything. It will emerge exhausted and facing colossal demand. Yet attitudes to it have been utterly transformed. In a special report, Lawrence Dunhill considers what lies ahead for the service.
The coronavirus vaccination programme offers realistic hope the NHS will soon be through the worst of this pandemic, and what has undoubtedly been the toughest period in history. But when the Covid tidal wave of finally recedes, an almighty wreckage is going to be revealed beneath.
The health service was already creaking before we had even heard about Covid-19, with squeezed budgets, workforce shortages, and rising demand all chipping away at its capabilities for the best part of a decade. The pandemic has simply put a wrecking ball to what was already a shaky façade.
Although the NHS-led reforms – given formal backing by ministers this month – offer some helpful tinkering of management structures, they will do nothing in themselves to address the main challenges the service now faces.
For some time, the NHS workforce has needed some major attention and bolstering.
Staff had only just started to see modest wage rises after years of pay restraint, and had become increasingly despondent about rising workloads, stress levels, and the increasing difficulty of maintaining good standards.
‘Efficiency’ was the theme championed by ministers in the 2010s, who were not so worried about the NHS having a significantly higher vacancy rate (around 8%) than other industries and public sector bodies, because this meant the services would always be close to full utilisation.
While this undoubtedly makes economic sense, it also leaves services highly vulnerable to sharp rises in demand.
This is why acute hospitals typically struggle so much in the winter months, and why the NHS simply could not cope with Covid-19 without cancelling swathes of routine treatments.
Responding to the demands of the virus meant dramatic reductions in surgical operations, for example, as staff in those areas had to be redeployed en masse to help with Covid care.
That lack of spare capacity means those same staff, who were already weary and frustrated prior to the pandemic, have suddenly had to deal with a new and far more extreme surge of pressures.
Added to fears around their own safety (hundreds of staff have died from the virus), and having to work in different teams and environments, on tasks they are not fully trained for, many will be completely exhausted and need time to recover physically and mentally.
Some may need a permanent break and understandably choose to leave the service, which would exacerbate the workforce challenge even further, while Brexit and potential long term barriers to overseas travel due to Covid means international recruitment could be significantly more difficult.
The mass cancellation of planned care last spring, and substantially reduced activity volumes throughout 2020 have turned a backlog resembling a Lake District peak into a Himalayan mountain.
Back in January 2010, there were just 7,000 patients who had been on waiting lists for key diagnostic tests such as MRI or CT scans for longer than the target six weeks.
A gradual deterioration over the following decade meant the number had risen to 46,000 by January 2020, but this was nothing compared to what was to come. The impact of coronavirus means the number now stands at more than 300,000.
The diagnostic delays are mirrored by the waiting list for life-changing treatments such as hip or knee surgery. In January 2010 around 240,000 patients had been on the waiting list for longer than the target 18 weeks. By the start of the next decade, the figure had risen to 730,000.
That number has now doubled over the last 12 months, to 1.4 million, a figure which would be significantly larger had there not been a huge drop in referrals from GPs (which is expected to filter through eventually).
Perhaps a better metric, unaffected by the drop in referrals, is the number of patients who have been on the waiting list for more than a year, which has increased from 1,600 in January 2020, to a staggering 223,000 in January 2021.
Provisional data also suggests the general worsening of cancer waiting times over the last decade has also been exacerbated further, although not to anywhere near the same degree, thanks to the efforts made to protect these services.
The left behind
Between 1950 and 2010, there were pretty consistent annual improvements to life expectancy in the UK, along with other advanced countries.
But these improvements had almost ground to a halt in the years leading up to the pandemic, with life expectancy even reversing in some of the poorest boroughs.
A whole range of socio-economic factors meant old industry heartlands and many coastal towns were being left behind, with the gap in life expectancy between the richest and poorest areas widening.
Coronavirus has struck directly at those inequalities, proving more potent against those working in front line jobs, living in more crowded circumstances, or suffering from underlying health conditions.
After the first wave of the pandemic last spring, researchers at the Office for National Statistics found the age-standardised mortality rate of deaths involving Covid-19 in the most economically deprived areas was more than double that of the least deprived.
The long-standing structural disadvantage experienced by people of black, Asian and minority ethnic communities was also increased.
With unemployment also expected to rise, the government will have even further to go on its ‘levelling up’ pledge than it did before the pandemic.
Tsunami of mental health demand
Mental health services have long been an after-thought to those funding and planning the NHS, with staffing levels and waiting times making those in acute hospitals look spoiled.
This had at last been recognised in Whitehall in recent years, with promises of increased funding to come. But much of that momentum has now been lost as attention understandably turned to the crisis engulfing hospitals and their critical care units.
But in time, a huge surge of demand (some have suggested more than 30%) is expected to flow from the psychological strain of the lockdown and its economic side-effects such as unemployment.
NHS mental health trusts were already struggling to deal with demand before the pandemic, as evidenced by the need to continually send patients to inpatient units which are often huge distances from their family and friends, due to a shortage of beds.
They are ill-equipped to deal with any significant rise in demand, let alone the “tsunami” predicted by the Royal College of Psychiatrists.
Social care on the brink
Success and failure in the NHS is heavily linked to the fortunes of social care, which was in an even more perilous pre-Covid state than the health service.
Although the NHS experienced a funding squeeze in the 2010s (meaning highly restricted budget growth), it was at least spared from ‘cuts’ in the purest sense of the word. By contrast, local councils actually saw their budgets reduced, while having to deal with similarly rising levels of demand and costs for social care.
Care staff are poorly paid, often with miserly terms and conditions compared with their NHS counterparts, and it is no surprise that the system has been failing those who rely on it, and work within it.
Despite a cross-party consensus on this, and repeated promises of reform and repair, multiple inquiries, commissions and reviews have failed to bring forward any solutions.
The pandemic has brought that neglect into an even sharper focus. The care sector was treated as an afterthought by the government at the start of the crisis, allowing rapid discharges of non-tested hospital patients, seeding the virus into care homes. These facilities then had major difficulties accessing personal protective equipment and testing kits.
The failure to protect care homes – where there have been almost 23,000 Covid deaths since March – is a national tragedy, and will be heavily scrutinised in future inquiries into the government’s handling of the pandemic.
In crude financial terms, care providers have also lost thousands of clients, while incurring significant extra costs on equipment and segregation measures.
Many were in a perilous state without the pandemic, and will collapse without unprecedented levels of government support.
The NHS only started off on a new ‘long term plan’ in 2019, after years of preparation and a hard-fought uplift to the annual budget from Theresa May’s government, ensuring it would rise by £20bn in real terms by 2024 (a rise of around 3.4% per year).
It has probably been the shortest lived plan in the service’s history, with the pandemic sweeping its ambitions, priorities and funding into irrelevance.
It is unlikely to be replaced quickly, as ongoing uncertainty around the length of the pandemic and the effectiveness of vaccines means the NHS cannot swiftly revert back to its normal state when the lockdown ends.
There will need to be a series of mini recovery plans, which recognise the ongoing pressures from the virus including the impact of ‘long Covid’ and those who need rehabilitation care.
But once the situation has normalised, a major new ‘recovery’ plan for the whole health and care system is going to be essential, with a far more substantial budget increase in recognition of the damage caused by the pandemic.
What happens after coronavirus should not just be about recovery, though.
The last crisis on a similar scale to the pandemic was the Second World War, and the years after 1945 not only offered the chance for recovery, but also renewal.
The extent to which the state should provide healthcare through universal taxes was still hotly disputed before the war, but the treatment given to large numbers of casualties gave people access to health care they had never experienced before, while the state controlled almost every aspect of people’s lives during the conflict.
Rationing actually improved the health of the poorest, and so the idea of the government looking after its citizens’ health had become normalised and accepted by the time peace finally arrived.
It was in this context that the post-war consensus for a National Health Service was built, before it formally launched in 1948.
Although devastating, coronavirus could also help forge consensus in key areas.
The exposed fragility of the social care sector could finally force ministers into meaningful reform and investment, while the nation’s respect and devotion to the NHS, which has been underlined during the crisis, can be used to bolster recruitment and provide a platform for a proper workforce strategy.
Everyone has experienced the full impact of public health policies during the pandemic – and ministers can have more confidence in applying more forceful measures to other priorities such as obesity and smoking.
The NHS itself has worked differently over the last year, with the crisis encouraging far greater levels of cooperation and mutual support between neighbouring hospital trusts and regional planners.
There had already been a shift away from Thatcherite principles of competition to a system which incentivises collaboration, but this was happening painfully slowly.
Many hospitals were desperate to hold on to their autonomy and self-interested plans, but there is now a sense the pandemic has weakened that mindset.
Greater co-operation can provide the foundation from which crucial service changes that have been stymied for years by organisational interests can finally happen. The new Health and Care Bill – if it passes through parliament as expected – should help solidify these changes.
There is also hope around new technology, with the pandemic forcing parts of the NHS to make bigger leaps in the use of virtual consultations over the last 10 months than they have done in the previous ten years.
Large swathes of the population now use video technology on a regular basis, and there is huge potential for care to be accessed and provided far more easily.
We also have a government with a large majority which is committed to a major building programme, which gives dozens of struggling health systems encouragement to plan for the future, rather than continuing to tread water.
Whether the prime minister’s pledge for 40 new hospitals is reached or not, the ambition should mean a great deal more building is done in the next ten years than the last.
Paying for it
The government has already spent eye-watering amounts of money on paying for coronavirus – with the Office for Budget Responsibility estimating that borrowing will reach almost £400bn in 2020-21, compared to an expected £55bn.
Eventually costs will reduce as measures such as the furlough scheme and support for businesses are phased out, but addressing the residual damage will require far higher levels of government spending than were previously envisaged.
Ultimately, borrowing will need to be scaled back and ministers will need to persuade the country of the need to pay more tax.
According to the Organisation for Economic Co-operation and Development, tax revenues in the UK before the pandemic were equivalent to around 33% of gross domestic product, which was slightly lower than the average for advanced nations.
Paying for recovery and renewal of the health and care system, as well as the wider economy, will need that percentage to rise much closer to the 40%-plus levels seen in Scandinavian countries.
What do you think? Have your say on this and more by emailing email@example.com