NHS at 70: What does the future hold?
Issues such as Brexit and social care will influence whether the NHS is fighting fit or ailing in the years ahead
Issues such as Brexit and social care will influence whether the NHS is fighting fit or ailing in the years ahead
Today’s NHS deals with about a million patients a day, employing roughly 1.5 million people across the UK. This key British institution, which turns 70 on 5 July, is held in such high public esteem that it featured as part of the opening ceremony for the London Olympics in 2012.
But, according to a report by health think tank the King’s Fund, public satisfaction with the NHS dropped 6% in 2017, to 57%, with respondents highlighting staff shortages, long waiting times, lack of funding and government reforms.
So how much cause for celebration is there? Will the NHS survive to reach its centenary? Or might it not only survive but thrive? We asked people across the health service and the profession, from analysts and leaders to a newly qualified nurse.
How is the current health of the NHS: fighting fit, ailing or on its last legs?
Still functioning, but under considerable pressure is the view of independent health think tank the Nuffield Trust. ‘There are lots of signs of problems,’ says the charity’s policy and public affairs analyst Mark Dayan, who cites the underlying causes as cash and staffing. ‘They’re showing up in issues such as rising waiting times and the financial pressures on hospitals,’ he says.
For newly registered nurse Charlotte Hall the NHS has reached a crisis point. ‘Like my patients, it’s fighting to be better,’ says Ms Hall, who chairs the RCN’s students' committee and is also student member of RCN council. ‘But regardless of how much effort you put in, sometimes the outcome is not what you expect or want.
'I feel I’ve started my career at a really pivotal point, where the NHS will either succeed – and be amazing – or fail very quickly. But, despite all that, I still love nursing and I know I made the right choice.’
Looking back, when was its finest hour?
When the Labour government first came to power in 1997, pledging to save the NHS, they made unprecedented increases in funding, with the King’s Fund highlighting significant improvements in its review of the first six years. This included reduced waiting times and falling mortality rates for cancer and heart disease. In contrast, under the Conservative and Liberal Democrat coalition government of 2010-15, spending on health grew at just 1.1% – the smallest five-year growth rate since records began, says the Institute for Fiscal Studies.
‘We made some big improvements in the early noughties,’ says Lord Nigel Crisp, who was NHS chief executive from 2000-06. ‘For instance, when I first came into post, 4% of patients died on the cardiac waiting list and we got that down to nought.
'But I would say the NHS’s finest hour is its establishment [in 1948]. I work in countries where if someone is ill the whole family is in crisis because they can’t afford to treat the person or it may make them bankrupt. Before the NHS came along, people in the UK were frightened of that, but they don’t have to be today. It’s an enormous achievement.’
And its lowest point?
Almost certainly the Mid-Staffs hospital scandal, which according to the Guardian newspaper ‘has become a byword for NHS care at its most negligent’. Alongside appalling failings in care, those who raised concerns were ignored.
In response to the scandal the second Francis Report, published in 2013, made 290 recommendations designed to create a common patient-centred culture across the NHS. This included improved support for compassionate, caring and committed nursing.
The government has announced an extra £20.5 billion funding for the NHS in England by 2023. Is it enough?
Before the announcement of an average 3.4% annual increase for the next five years, the King’s Fund, Health Foundation and Nuffield Trust wrote jointly to the prime minister, arguing that the NHS needed a minimum 4%-a-year rise in real-terms funding.
‘Anything less than this risks further deterioration in standards of patient care and would delay tackling the growing backlog of buildings maintenance, including safety-critical repairs,' they say in their letter. 'If sufficient funding is not provided, patients and families will pay the price as the service declines.’
The promised funding increase is a significant sum but a bit below what’s needed, says the Nuffield Trust. ‘We’ll also need to pay close attention to public health and social care,’ it says. ‘Given the NHS barely has enough money to meet demand, if these come under pressure things still look quite difficult.’
While the RCN has also welcomed the award, it agrees further cash is needed to fund social care. ‘Investing in home care and local community services helps stop hospitals becoming overwhelmed,’ says RCN chief executive Janet Davies. ‘Theresa May must be under no illusion that there can be a long-term solution for the NHS without a solution for social care too.’
Is there the political will to reform social care funding, or will it continue to be kicked down the road?
Despite assurances that a green paper on older people’s social care would be published before the summer recess, on 18 June the health secretary announced its delay until the autumn. It has already been deferred since last year. In their letter to the prime minster, the three health think tanks say the current system is clearly failing, ‘with at least 400,000 fewer older people now able to access publicly funded social care than in 2010’. They go on to describe proposals for a long-term funding settlement as essential.
‘We’ll look back at a really unacceptable level of failure,’ says Nuffield’s Mark Dayan. ‘The unevenness of the financial burden leaves some paying hundreds of thousands, while others pay nothing. It’s essentially down to blind luck and that’s exactly the kind of healthcare lottery the NHS was originally set up to counter.’
Best thing since sliced bread or underperforming – how does the NHS really compare to other countries’ healthcare?
In an opinion piece published before last year’s general election, the King’s Fund highlighted the difficulties of comparing different countries’ health systems. It argued that international league tables have been used to support arguments that the NHS is both the best in the world and failing its patients. But while it cautions against overreliance, it argues that global comparisons highlight one of the unique features of the NHS: ‘that access to care does not depend on how much money you earn’ – making the UK a world leader on equitable access.
The Commonwealth Fund’s 2017 report on the healthcare systems of 11 wealthy countries ranks the UK’s top. ‘But it greatly rewards being free at the point of use,’ explains Mr Dayan. ‘Whether that’s the same in terms of outcomes is a trickier question to answer – and the report ranked the UK relatively low on that. So really it all depends on what you want to look at.’
Is there enough progress on equality and diversity in the NHS workforce?
In 2014, Roger Kline published his seminal report, Snowy white peaks, highlighting extensive patterns of discrimination faced by black and minority ethnic (BME) staff in the NHS and its potential impact on patient care. Since then, the Workforce Race Equality Standard (WRES) has been implemented in England, mandating employers to chart their progress on issues affecting BME staff such as bullying and harassment, gaining promotion, training opportunities, and representation on trust boards.
‘There is a lot more progress to be made in nursing, with BME staff under-represented in promoted posts,’ says James Buchan, professor in health and social sciences at Queen Margaret University, Edinburgh. ‘Women too are under-represented. We can and should be doing better. Monitoring will help to expose variations between trusts, leading to questions about why some are doing better than others.’
Five years ago, the government pledged to create parity of esteem between NHS mental and physical health services. Have we achieved it?
A report by the King’s Fund, published in January this year, showed that mental health trusts continued to receive far smaller budget increases than acute and specialist trusts. But for Lord Crisp, there is progress.
‘I hear mental health mentioned much more in parliament,’ he says. ‘And I think it’s one of the areas where we’re better than most countries. I don’t know of any others that have made the same pledge – and it’s a start, although making it a reality is a long journey.’
Nurses in the NHS have just been awarded their first real pay rise since 2010. Is it enough to keep them?
According to the most recent figures published by the Nursing and Midwifery Council (NMC), there were 1,678 fewer nurses and midwives registered in September 2017 than in the year before, with 27% more nurses leaving the register than joining it. Meanwhile, NHS Digital reported that nurses and midwives accounted for 40% of NHS vacancies last September.
But pay is just one part of the equation, says Professor Buchan. ‘On its own, it is never going to be enough to effectively retain nurses over the long term,’ he says. Other issues such as working conditions, staffing levels and access to continuing professional development also need to be considered by employers.
‘Of course, you need to pay a fair wage, but the overall package needs to respond to nurses’ needs,’ he argues. ‘As there are shortages, nurses are in a sellers’ market for their skills. Sensible employers will realise that to recruit and retain them, they need to be looking at what motivates them.’
The lifting of the pay cap is welcomed by newly registered nurse Ms Hall, who has been working for three months in an acute medical unit. ‘It’s a positive thing,’ she says.
‘The work that the RCN and other unions have done has paid off and we’re now seeing a bigger pay rise than we would have had – and it’s completely necessary. I don’t think it’s the whole answer, but it’s the best we could achieve at this time.’
NHS nurse workforce planning has been characterised by boom and bust. Are we doomed to repeat the cycle?
For Professor Buchan, the issues are political. ‘The technical aspects of workforce planning are not where failure lies,’ he says. ‘It’s the inability of successive governments to adequately fund what planning tells them they need. At times they have decided to ignore what they’ve been told is required, reducing intakes to nurse education when it was very clear these should be increased.’
In England, the shift from student bursaries to loans will leave government with less control over decisions on the numbers of new nursing students, he says.
The effects of Brexit may also complicate the ability to plug shortages. Figures released by the NMC in April showed an 87% drop in those joining the register from the EU in the year up to March 2018 – from 6,382 down to 805. Over the same period, 3,962 people from the EU left the register, a rise of 29%.
‘We still don’t know the outcome on mobility between the UK and the EU,’ says Professor Buchan. ‘All the indicators are that it will be tougher for EU nationals to come in and possibly more problematic for them to stay.’
Looking towards its centenary, what role could nurses play in the NHS of the future?
A pivotal one, is the view of Lord Crisp. ‘We’re at a shift and nurses are the wave of the future, and will have an even more prominent role,’ he says. As the emphasis moves more towards managing long-term conditions, such as diabetes, the nursing model of care will become more important and relevant, argues Lord Crisp, who co-chairs Nursing Now, the global campaign that aims to raise the status and profile of nursing. ‘We’ve had such changes in the profession over the past 20 or 30 years, with more and more services being nurse-led – that can only increase,’ he says.
Specifically, he believes nurses will have a greater impact on primary care. ‘Thirty years ago, this was very much the territory of doctors – it’s changed massively,’ says Lord Crisp. ‘I wouldn’t be surprised if in 30 years’ time, it was largely nurse-based.’
Nurses can also play a much bigger part in prevention, promotion and developing health literacy, he believes. ‘They do some now but it’s not as central a role as I think it will become,’ he says.
‘Nurses are part of the communities they serve and understand the culture. They are much better able to help people change their behaviour, identifying prevention issues. In my view, if we’re going to improve health globally, we have to liberate nurses.’
Lynne Pearce is a freelance health journalist