It is now time for our national health chiefs and political leaders to acknowledge publicly that the NHS can no longer deliver what is being asked of it for the funding available.
Despite the best efforts of hard-working staff, hospital accident and emergency performance is now the worst it has ever been. In the first three months of this year only four of the 138 large A&E departments saw the required 95% of patients within four hours. One in 10 patients had to wait more than four hours, the highest level at this time of year since 2003-04.
Waiting lists for operations, with 3.9 million patients, are now at their highest point since December 2007. The three million mark used to be considered a line not to cross, but experts have suggested that the waiting list target is irrecoverable. There are similar problems of dropping performance against cancer and ambulance standards, with mental health and community services under similar pressure.
At the same time, we ended the last financial year with trusts reporting the largest deficit in NHS history – £2.45bn but, in reality, above £3.5bn once you strip out one-off transfers and accounting adjustments.
These challenges are being matched by unprecedented staff shortages, including nurses, key specialists, GPs and emergency doctors. These have led to closures of A&E departments and other services, unsustainable pressure on GPs and, in 2015-16, an unaffordable extra £3.6bn agency staff bill.
Demand for NHS services also continues to rise much faster than predicted: between April and June, A&E attendances and emergency hospital admissions were up by more than 6% compared with last year – three times the predicted increase. If funding fails to keep up with this demand, the challenge for the NHS grows year on year.
These problems are now affecting the whole NHS. In the first three months, 94% of A&E departments missed the four-hour A&E standard. At the end of 2015-16, nearly two-thirds of trusts, and more than eight in 10 acute hospitals, were in deficit.
It’s no surprise that cutting social care year after year has created major problems. Given the lack of capacity in community and mental health services, the number of patients waiting for a hospital discharge is now the highest it’s ever been. As a result, hospitals are being asked to routinely run at capacity levels that risk patient safety and would be unthinkable in France, Italy or Germany.
Taken together this means the NHS is increasingly failing to do the job it wants to do, and the public needs it to do, through no fault of its own.
This concrete evidence is supported by the testimony of frontline NHS leaders. Thanks to the dedication of staff, NHS performance rarely goes off the edge of a cliff. As the 1990s showed, instead we get a long, slow decline that is only fully visible in retrospect. It’s therefore difficult to isolate a single point in that downward trajectory to sound a warning bell.
But NHS trust bosses are now ringing that bell – we face a stark choice of investing the resources required to keep up with demand or watching the NHS slowly deteriorate. Trusts will, of course, do all they can to deliver efficiency savings and productivity improvements. But they are now saying it is impossible to provide the right quality of service and meet performance targets on the funding available.
Something has to give. This is particularly so since NHS funding increases are about to drop from 3.8% this year to 1.4% next year and 0.3% in 2018-19. As total NHS demand and cost rises inexorably, by at least 4% a year, this will mean even larger gaps after seven years of the deepest and longest financial squeeze in NHS history.
So what does give? A range of options are now open to political and NHS leaders. Additional funding is the most obvious, with the new government’s first autumn statement on 23 November providing an immediate opportunity.
If, however, there are is to be no extra funding, the NHS must make some quick, clear choices on what gives, however unpalatable these choices may be. The logical areas to examine would be more draconian rationing of access to care; formally relaxing performance targets; shutting services; extending and increasing charges; cutting the number of priorities the NHS is trying to deliver; or more explicitly controlling the size of the NHS workforce. These are all approaches adopted by other public services such as prisons, local government and the police when faced with similar funding challenges over the past decade – though they would clearly provoke public unease and ministerial anxiety if applied to the NHS.
In reality, individual areas are already having to make decisions like these on a piecemeal basis. For example, in the last three months, clinical commissioning groups like St Helens and Vale of York have developed proposals to suspend all non-urgent care for four months or suspend non-urgent treatment for obese patients and smokers for a year. A number of trusts have had to close services on safety grounds and others have announced plans to reduce the size of their workforce. Unsurprisingly these decisions triggered local opposition and adverse national media coverage.
NHS trust leaders rightly argue that this piecemeal approach is unsustainable. It is not tenable to ask local leaders to deliver the impossible, make unpopular local decisions as quietly as possible and then carry the can when the decisions become public. As the junior doctors’ dispute shows, it is also untenable to ask NHS staff to close the gap by simply working harder and harder.
In the absence of extra funding, we need an open, honest, realistic, national debate on what gives, translating into immediate clear choices, with national leaders explaining why such choices are necessary. Any such debate must extend beyond the NHS and involve the public. The earlier that debate starts and the more open and honest it is, the better.
The gap between funds and delivery is a chasm in the NHS: something has to give | Chris Hopson
