When is the NHS overwhelmed? When it has used up ways to describe the state it’s in. Ask Alastair McLellan, editor of the Health Service Journal. “We’ve run out of language,” he says. “We’ve exhausted the adverbs and adjectives, the thesaurus has run dry.” But when exactly did the NHS cross a red line? “I won’t provide a definition of what being overwhelmed would constitute,” Boris Johnson says wisely. Yet it’s happening now, and there’s no sign of the situation improving.
TV news may need images of stretchers laid out on winter pavements, but ambulances were already queueing for hours outside A&Es before the pandemic. We hear of ambulance services telling patients with heart attacks and strokes to get a lift to hospital. Even during the winters before Covid, we’d grown used to trolleys lined up in corridors and 12-hour admission waits. GP appointments had long grown scarce. Cancer delays are the longest on record. Expect no tipping points: “This is the new normal,” a London teaching hospital medical director warns me.
The admirable NHS “copes”. It triages and triages again, treating people according to available beds and who is nearest to death. That’s rationing, a word politicians shun. Waiting used to be the traditional rationing mechanism in a financially capped system. There’s no mystery as to why this is happening: waiting lists rise and fall according to the level of funding. Seasoned observers used to assume queueing was a permanent function, until New Labour all but abolished waiting times, ensuring everyone was treated within 18 weeks from GP to hospital. During the post-2010 austerity years, funding increases fell behind the country’s growing, ageing population. By 2017, waiting lists had risen to just over 4 million.
Let’s hope that despite the record infection rates we’ve seen in recent days, hospitalisations stay low enough so that the NHS still “copes”. If so, Johnson will get away with his high-risk plan B, with its new year pubbing and clubbing in the face of scientists’ concerns. But you wouldn’t praise someone for surviving a dash across the M1 with their eyes shut, especially if we all had to run across with him.
Covid may calm to a low permanency within months, but what then for the NHS? In the trail of the pandemic is a fast-rising 6 million-strong waiting list – Sajid Javid even warns of far higher. Nigel Edwards, the Nuffield Trust’s chief executive, along with anyone else you ask, warns of exhausted staff and rising vacancies, with people quitting and retiring early, while long Covid and untreated illnesses add to the burden. According to the Royal College of Nursing, half of nurses are over 50, one in five leaves during training, one in three in their first year, while social care is even more bereft.
A new report from the health and social care select committee blames the government for refusing to build a future workforce strategy. Perversely, former health secretary Jeremy Hunt’s amendment to the health and care bill, calling for a regular independent assessment on workforce estimates, was knocked down by the government in November, and Hunt’s demand for one kicked away again at PMQs this week. Staffing costs take up 70% of the NHS budget, so the Treasury knows that putting numbers on the needs of the next decade will expose severe underfunding.
It takes 10 years to train a consultant and four years to train a nurse, but their training was one of the first things to be cut in 2010: more nursing places have been added since, but entire cohorts are still missing. The NHS England (NHSE) People Plan last year offered kindly advice on retaining staff, but the Treasury banned it from adding hard numbers for future needs. Health Education England held out for training funds, a sum that has still not been fixed, but the body has been punished and demoted, merged into NHSE and losing its voice to speak out.
On Christmas Eve, NHSE produced 10 goals for the year, a wish list to send up the chimney asking for everything: “outstanding care”, “tackling the elective backlog”, “growth” in mental and community services – and much more. (There was no mention of Covid lessons or the need for permanent emergency preparation for the next contagion.) There will be no money for anything but bare-bones “coping”. The Financial Times’ annual poll of 100 economists predicts we will trail other rich countries in economic recovery this year. John Appleby, chief economist at the Nuffield Trust, warns that although the government promises the NHS £5.4bn in extra funding, hospitals have already overspent by £4-5bn, so much of that funding will vanish in repaying debts. Covid emergency money stops in April.
The big question – for government and voters – is how much more they want to spend on health. Labour proved it’s not a “bottomless pit”, but you get what you pay for. Forget the groundswell of calls for “reform” from ignoramus Tory voices who imagine French and German “insurance” schemes magic up more private money. The only major difference from our national insurance is that they pay more and get more per head – beds, doctors, nurses and results. In this forever undertaxed country the tax revenue is 33% of GDP, while the 14 EU states pay an average 39%, according to the IFS.
Would we pay that EU average? A bigger question: should we really spend such a high proportion on the NHS and care, weighted towards the last years of people my age, while education suffers? Teachers have seen their pay cut by 8% since 2007, while FE and schools are miserably threadbare, denuded of arts and sports.
The unavoidable answer is yes, voters will put the NHS first: once the emergency passes the government will face angry patients. The sobering experience of Labour’s years, says Ben Page of Ipsos Mori, is that people waiting for hip and knee surgery notice no cut in waiting times until they drop right down to three months: anything above is unacceptable. But after the years of underfunding restoring the NHS to its 2010 state is unthinkable: that’s another 10-year project that requires high funding. The government itself may feel “overwhelmed” when public complaints at its decade of damage swells into an NHS political crisis, too late for any easy solutions.