Urgent care: waits in accident and emergency departments rise and rise. Photo Workers.
Workers want shorter waiting lists for NHS treatment, and to be able to see a real doctor in a reasonable timeframe. That’s a long way off…
Millions of potential patients are unable to access the care that they require, whether elective, emergency, mental health, or maternity. Why? Because the service lacks the beds, doctors and nurses to serve the population, to help those of working age who are sick back to productive work, and to care for the old, the young, and those at the end of life.
Frustrated by the impossibility of making an appointment to see a GP, many patients turned to accident and emergency departments, the always-open front door of the NHS. Waits in emergency departments continue to rise: the Royal College of Emergency Medicine drew attention to the latest performance data from NHS England, which shows that 122,852 patients faced a wait of 12 hours or more last month. This is the second highest number for the month of July since records began in 2010. And in Scotland 51,400 older patients endured stays of 12 hours or more last year.
As for planned care, there are several minimum targets and operational standards currently set for waiting times, reflecting each area’s policies and needs. The targets are generally not achieved anywhere:
• In England, 92 per cent of patients should not wait longer than 18 weeks from referral to treatment (RTT).
• In Scotland, 95 per cent of patients should be seen at a new outpatient appointment within 12 weeks of referral, and 100 per cent of patients should wait no longer than 12 weeks for treatment as an inpatient or day case.
• In Wales, 95 per cent of patients should start treatment following referral within a 26-week target.
Against this backdrop, in July the government published The 10 Year Health Plan for England: fit for the future.
NHS workers and patients have probably lost count of the number of times NHS plans and strategies have promised a better future. We’ve had devolving more care into the community, this time through new “neighbourhood health centres”. Then IT solutions would magically manage increasing demand for services, in this case a new NHS app and the application of AI. And not forgetting proposals to move from treating sickness to practising preventative medicine. All of these have been couched in the peculiar management speak that the consulting firms have made their specialty, and which holds the most senior NHS managers in thrall.
In principle, any plan is welcome, rather than relying on the anarchy of the market. The 2023 NHS Long Term Workforce Plan was a welcome recognition that the NHS could no longer rely on poaching doctors and nurses from abroad, but must educate and train our own. Elsewhere in this issue of Workers we report on how newly qualified professionals, desperately needed in hospitals, clinics and general practices, are unable to find posts.
Medical Royal Colleges, responding to the latest plan, expressed caution and several drew attention to the need to expand specialty training. The Royal College of Anaesthetists pointed out that in 2024 there were 25,496 doctors applying for just 12,743 training posts.
A big conversation?
The plan promises, or threatens, a “big conversation” on changes to the NHS staff contracts, with suggestions of a new “opt-in” “ultra-flexible” staff contract offering pay-for-performance bonuses.
The plan also predicts that in ten years’ time the NHS will run on fewer staff, an aspiration described as concerning by the Royal College of Physicians who said, “The suggestion that staff numbers in 2035 will be lower than those projected in the 2023 Long Term Workforce Plan is concerning. We know we don’t have enough staff currently to meet demand – AI and tech alone won’t solve the problem of capacity.” NHS workers now await a refresh, so-called, of the Long Term Workforce Plan, and will be vigilant to ensure that gains already won are not eroded.
After years of development, the NHS App was launched in January 2019 as a front door to digitally enabled health services, but its functionality was basic and limited. Patient access to their health records was also limited, and often required registering with a third-party commercial provider.
A study published in January in BMC Medicine found that what patients expected as added value from the app often did not materialise in day to day practice. It is not yet clear that any revamped version of the app would result in the “doctor in your pocket” the plan claimed.
‘There are several minimum targets and operational standards for waiting times. The targets are generally not achieved anywhere…’
And while AI clearly has a role in health, for example in applying its ability to process large amounts of data to the initial screening of diagnostic images, according to an Academy of Medical Royal Colleges report Artificial Intelligence in Healthcare, there is a “tension between the tech mantra, ‘move fast and break things’ and the principle enshrined in the Hippocratic Oath, ‘First, do no harm’”.
Some elements of the plan look backwards rather than forwards. The plan revives the intention of the Conservative health secretary Andrew Lansley that every NHS provider should be a foundation trust, this time by 2035.
Foundation trusts will no longer be required to have governors. League tables return, which are supposed to inform patient choice. Choice, an obsession of health secretaries, does not loom large in patients’ real-world priorities. Evidence suggests that, although patients respond positively when asked in the abstract if they would like more choice in their care, their real-life behaviour when they need care shows a preference for the hospital, practice or clinic nearby.
Although previous attempts to create a “primary care-led NHS” have led nowhere, the issue needs tackling. The proposal to establish Neighbourhood Health Centres isn’t a bad one; it’s a slightly reworked version of the 150 polyclinics proposed in Lord Darzi’s NHS Next Stage Review. These were popular, but in some cases the number of walk-in patients far exceeded expectations, without reducing pressure elsewhere in the system, and polyclinics were aborted by Lansley’s 2012 Health and Social Care Act, before they could be allowed to work properly.
Integration
Key to planning is integration, and integration is key to control of all of the NHS, including primary care. This means that general practices and general practitioners have to be integrated, not stand at one remove. Getting GPs centrally contracted has often been seen as a diversion. But that needs to be revisited as it may be the rock on which the plan will founder.
As the plan’s Multi Neighbourhood Providers develop, they will be attractive for capitalists looking for profits, as has happened with large groups of veterinary practices. This would be far worse for the NHS than the current position under which GPs are self-employed contractors.
The plan makes no attempt to address the fundamental problem, that workers are unable to receive the care they need when they need it. The move towards a preventative, primary care-led service will fail. Many of the ways that the minister suggests to achieve this are impractical or ill-directed. Others border on fantasy, more PR than anything else.
The failures of the devolved administrations in Scotland and Wales mean that the same issues and problems exist there too. The authorities in Cardiff and Edinburgh complain, inaccurately, about insufficient support from central government in order to gloss over their own failings.
When the NHS was established in 1948, in Scotland it was set up as a separate entity with its own legislation: the National Health Service (Scotland) Act 1947. Northern Ireland likewise had its own legislation. Wales was part of a single system with England for the first 20 years of the NHS. In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales from the Secretary of State for Health, who was thereafter just responsible for the NHS in England.
Lack of confidence
In November 2022 a survey by Ipsos and the Health Foundation found that just 28 per cent of the Scottish public were confident about their devolved administration’s plans for the NHS. For Wales, just 19 per cent were confident.
The geography of Wales means that there are areas where cross-border arrangements are necessary. The population of north Wales is too small to support specialist units, so patients travel to Liverpool and Manchester. There are no large hospitals in Mid Wales at all.
Scotland has even more remote areas, and access to hospitals can mean several hours driving. There have even been trials of drones to deliver medical goods to remote areas and islands.
‘The plan tries to address financial need without addressing the reality that the NHS is adrift in a swamp of capitalism…’
The fragmentation of the NHS across Britain means different healthcare policies, commissioning processes and patient data systems for planned care; these affect the data coverage available on referral to treatment or stage of treatment waiting lists, and the extent to which data can be compared across the NHS in Britain, whether that is in England, Wales, or Scotland.
England, Wales and Scotland have each announced (at different times) the use of the private sector in an attempt to reduce waiting lists. It is an admission of failure. NHS Scotland has now ended the use of the private sector in this way, yet around 29 per cent of Scots accessed private treatment in the last two years, often making sacrifices to do so.
The sections in the plan on finance are weak. Why? Because they try to address the financial need without addressing the reality that the NHS is adrift in a swamp of capitalism. Real integration requires the people to take control, integrating NHS finances as part of a whole system in which those who produce control the money they create.
A survey carried out in 2023 (the NHS’s 75th anniversary) but reported in March 2024 showed that despite record low levels of satisfaction with the NHS (24 per cent), public support for its founding principles is as strong as ever. The overwhelming majority expressed high levels of support for the principles when asked if they should still apply in 2023: that it is free of charge when you need it (91 per cent), primarily funded through taxation (82 per cent) and available to all (82 per cent).
There was much talk of reform from Starmer. Even the previous government mentioned reform. The NHS, like the country as a whole, doesn’t need reforming, it needs rebuilding. To try to rescue the NHS while ignoring the country and the economy it lives in and for is the plan’s biggest defect.