It’s like a scene from an old war movie. The NHS is a Royal Navy ship crashing through a stormy sea being buffeted by wave after wave of surging demand. Fuel is running low. The captain calls for more power. The needle on the engine room pressure dial goes above 100 per cent, and becomes stuck deep in the red zone. After ten minutes of running at absolute maximum power the engines falter and the ship shudders. Nervous glances cross the bridge. How much longer can the ship stay in the red zone? Can it stay afloat? When will it founder?
Pardon the dramatic license, but that’s how it feels in the health service at the moment – wherever we look, we’re trying to run the NHS permanently above its sustainable limits, well into the red zone.
We’re trying to run the NHS permanently above its sustainable limits, well into the red zone.
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Pressure
Take NHS funding. We are in the middle of the longest and deepest financial squeeze in NHS history. Costs and demand are growing by 5 per cent a year, but we are in the midst of a twelve year stretch where funding, on current plans, will rise by less than 1 per cent a year on average.
Although NHS trust finances have started to stabilise, there is still an underlying deficit of at least £3.5 billion. We are only balancing the books by robbing capital budgets, selling off land and making one off non recurrent accounting adjustments or savings. The consequences are increasingly obvious – for example, the safety critical NHS maintenance backlog has more than doubled in just two years from £458 million to a whopping £947 million. As the National Audit Office has pointed out, the health service at a local level remains under considerable financial pressure and the NHS still has a long way to go before we can regard it as being on a sustainable footing again.
We are only balancing the books by robbing capital budgets, selling off land and making one off non recurrent accounting adjustments or savings.
Chief executive
The workforce pressure dial is firmly in the red as well. We have widespread staff shortages. There are growing recruitment and retention problems due to Brexit and ongoing NHS pay restraint. Many staff argue they can’t provide the safe, high quality, care that patients deserve, even though they’re routinely working longer than recommended or paid hours.
I was particularly struck by a conversation I recently had with a nurse who, after building her experience and expertise for 12 years, had decided to leave the profession because she had woken up too many times at three in the morning worrying about whether she had been able to do her job safely. That is what trying to run the NHS permanently in the red zone looks like from a staff point of view.
It’s the same situation on NHS performance. We have now reached a point where the health service is no longer able to deliver all that is being asked of it. Mental health bed occupancy rates regularly reach 100%. District nurses are run ragged, trying to cover an impossibly large number of patients. Despite best efforts, for the first time ever last year, all four key NHS hospital performance targets were missed. Waiting lists for routine surgery are the longest they’ve been for a decade. And only a handful of trusts are consistently meeting the four hour target in A & E.
We have now reached a point where the health service is no longer able to deliver all that is being asked of it.
Chief executive
Last winter provided graphic evidence of what running in the red zone looks like for patients. Far too many mental health and community services stretched to capacity. Far too many patients stranded in ambulances queueing outside overcrowded A&E Departments. Far too many twelve hour trolley waits in busy corridors. Too often, patient safety put at risk.
The trust leaders we represent – the people who are responsible for providing frontline care to a million people every 36 hours – are clear what they need to offer the safe, high quality, care we all want the NHS to provide.
Honesty and realism
First, honesty and realism about what can be delivered for the funding available. Trusts want to deliver the performance standards set out in the NHS constitution. But they can only do this if they are properly funded to meet those targets. Their leaders are not magicians. They can not deliver the impossible. So the November Budget needs to set a clear plan for the rest of the Parliament which matches delivery expectations of the NHS to the money available.
The November Budget needs to set a clear plan for the rest of the Parliament which matches delivery expectations of the NHS to the money available.
Chief Executive
We must also, as a matter of urgency, come up with a clear strategy to address the workforce challenges that trust leaders now say are their biggest problem. That includes a plan to end pay restraint and much needed reassurance and clarity for the current and potential future NHS workforce on what happens after Brexit. Above all we need urgent steps to fill gaps in the current workforce and an affordable long term strategy that sustainably matches workforce supply to likely future demand.
Integrated health and care
Finally, we should support the NHS to deliver the transformation in care that is required to meet the growing and changing needs of our society. That means putting greater emphasis on preventing ill health and ensuring wellbeing. It also means delivering much more care closer to home so hospitals are used just for those who need acute care. We need a better integrated health and care system where different elements – community, mental health, ambulance and hospital services, GPs and social care – come together to serve the needs of their communities.
As the health service nears its 70th birthday now is a good time to make the big decisions that are urgently needed to reach calmer waters, and bring that pressure dial round to “safe”.
Chief Executive
The NHS is clearly now running in the red zone. We need national NHS leaders to acknowledge this is simply unsustainable. As the health service nears its 70th birthday now is a good time to make the big decisions that are urgently needed to reach calmer waters, and bring that pressure dial round to “safe”.
This article was first published by the New Statesman on 13 October 2017.