In his Autumn Statement to the House of Commons on 17 November 2022, Jeremy Hunt, Chancellor of the Exchequer, allocated extra funds of £3.3 billion to the NHS for each of the next two years, with the expectation of “Scandinavian quality alongside Singaporean efficiency, better outcomes for citizens and better value for taxpayers”. Almost immediately, analysts at the Nuffield Trust calculated that inflation and rising demand would take up three quarters of the additional funding for 2023/2024 and the whole of the sums allocated for 2024/2025. The planned health budget for England for 2022/2023 already stands at £178.5 billion.
The founding principles of the NHS, ensuring free healthcare at the point of delivery from birth to death, continue to be widely accepted by all political parties in Britain. But funding for the NHS first came under pressure as far back as 1951, when government spending was diverted to the rearmament programme by a Labour government. The first bout of rationing, or rationalisation, thus put an end to free dentures and spectacles. This was followed soon after, in 1952, by the introduction of the prescription charge by a Conservative government. Ever since, the NHS has been engaged in a long-drawn out battle to keep costs under control, but with uneven results. This has led us to the present crisis of understaffing, restricted access to primary care (general practice), deficient mental healthcare provision, underfunded drug and alcohol addiction and sexual health services, long waiting times for both emergency and elective treatment, regular bed shortages, queues of ambulances outside hospitals, crumbling buildings, equipment shortages, insufficient and outdated IT systems (computers, servers, networks), and poor integration of healthcare with local authority-funded social services, delaying the discharges of older people from hospital.
Although healthcare spending has risen in real terms by around 4 per cent each year, with 11.9 per cent of GDP spent on healthcare in 2021, this has failed to keep up with the demands generated by a growing and ageing population, a rising burden of long-term illness, new technology, and rising public expectations. The supply of services has been decisively outpaced by rising demand for the same. Yet the NHS, in contrast with some European healthcare systems, no longer routinely funds long-term nursing care, dental care, and optical services.
The NHS, with around 1.2 million full-time-equivalent staff in hospitals and community services, is by far the largest employer in England and also the world’s largest publicly-funded health provider. The staff salary bill is the single largest source of healthcare expenditure, but wages have not kept up with inflation ever since 2010, with a freeze on, followed by below-inflation, incremental pay progression. Unhappiness in the workplace, leading to recent planned strike action, is the result of a poor work environment, in which the effects of excessive workloads and resulting burnout are compounded by bullying, harassment, and racism, leading to frequent staff absences. Unmanageable workloads in turn are the result of poor long-term workforce planning, creating shortfalls in the recruitment and retention of nurses, midwives, GPs, and mental health workers, among others-with a negative impact on both patient as well as staff safety, and requiring expensive agency staff to fill in the gaps. Reliance on overseas nurses and doctors is not a sustainable long-term solution and often takes away trained staff from where they are most needed. Lower-paid staff, including paramedics and physician associates, have been brought in to substitute for, or complement, the work of doctors and nurses. The current desire to concentrate resources on direct patient care may require reductions in the numbers of managers, who do, however, have a key role in overseeing organisational strategy, managing finances, and reducing administrative burdens on healthcare providers.
Demand management has focused on controlling hospital referrals and emergency attendances by GPs in their role as gatekeepers and through the explicit rationing of interventions such as infertility treatment, cosmetic surgery, and gender reassignment surgery, but with exceptions, and the withdrawal of funding for other once-commonly performed procedures with limited or unproven clinical benefits, such as tonsillectomy and the insertion of grommets. There remains significant wastage from unnecessary investigations, including blood tests and imaging, that has been brought about by overtly cautious local guidelines and protocols, or driven by the practice of “defensive medicine”.
The burgeoning NHS drugs bill demands cost containment measures such as limited prescribing lists, generic and biosimilar drug prescription. an attack on the simultaneous prescribing of multiple drugs (polypharmacy), and the rationalisation of procurement costs for drugs, supplies, and devices. The widespread use of single-use disposable products where reusable products might suffice is both wasteful and environmentally unfriendly.
Variations and gaps in productivity and efficiency, both of which often go unmeasured, afflict the NHS. Waiting-list initiatives to clear backlogs of elective procedures, the concentration of super-specialised procedures in high-volume centres of excellence, and seven-day working in certain sectors (outpatient consultations, operating lists), whether remote or on-site can all be resorted to make better use of already available NHS resources.
The lack of capital investment in NHS-owned land and buildings, or NHS estates, has created a backlog of maintenance work estimated at around £9.2 billion, nearly a fifth of which is classified as “high risk”. This situation has arisen from the diversion of money earmarked for new buildings, equipment, technology, and vehicles to fund day-to-day running costs. Land sales, demolition of unsafe buildings, and removal of reinforced autoclaved aerated concrete, or renovation, co-location, or movement to a new site are among the options to either raise revenues or provide better premises in which to deliver services.
While we attempt to make up for lost time and just as all Britain’s political parties appear committed to continued increases in healthcare funding, the time is ripe for a fresh look at what is funded by the NHS, and how. The question is whether the current mechanism of funding, mainly from general taxation (along with National Insurance), in which healthcare spending competes with other areas of public expenditure (education, housing, transport infrastructure, utilities, defence), is sufficient to meet the demands of increasingly expensive 21st century healthcare. Successive waves of reform, involving administrative reorganisation, service reconfiguration, performance management against targets, and a regime of inspection and regulation, have failed to deliver the desired results. The underlying problems took many years to develop, and it seems unlikely that periodic cash injections by themselves, such as to tackle “winter pressures”, will reverse a long-term trend of decline. Funding, which is admittedly insufficient for its present purposes, must be accompanied by an NHS culture which emphasizes innovation and strives for continued improved service delivery. This can, however, only be achieved when a suitably recompensed and sincerely motivated workforce is in place to deliver the clichéd, but all-important, “patient-centred care”, in which users have timely access to a service that communicates with them effectively, respects their views, ensures their privacy, and provides them high-quality care in a suitable environment, appropriate to their individual needs.
Ashis Banerjee