Why NHS England is struggling – despite more staff and money

Overall public satisfaction with the NHS in England is currently at a 40-year low of 29%, a recent survey by the King’s Fund thinktank has found. People are not happy with waiting times for GP and hospital appointments. Over half of those surveyed think the service is beset by staff shortages. A similar percentage think the government does not spend enough money on the NHS.

This is despite the fact that in 2022-2023 the NHS received £152.6 billion in total budget – an increase (at 2022-2023 prices) of £28.4 billion compared to 2016-2017. The service has 32.4% more full-time staff too. Its workforce hit an all-time high of 1.275 million employees in February 2023 (up from from 963,000 in June 2013).

And yet, the figures around productivity show that people’s dissatisfaction is not without cause. Over the two years between 2019 and 2020 and 2020 and 2021, productivity across the NHS decreased by 23%. This extraordinary drop followed 14 years of productivity gains.

There are five primary reasons why the service is struggling to cope. These are: staff wellbeing, underfunded social care, an inadequate workforce plan, lack of access to emergency care and ongoing industrial action.

Continuing burnout and work pressures

In 2022, 23,838 doctors joined the profession but 11,319 left – an attrition rate 20% higher than in 2021, when 9,825 doctors left. The doctors’ union, the BMA, has highlighted concerns about doctors’ wellbeing.

In a survey of over 4,000 doctors in 2022, the General Medical Council found that, in 2022, 50% of doctors were satisfied, down from 70% in 2021. More doctors reported working beyond their rostered hours on a weekly basis (70%, up from 59% in 2021).

Almost the same percentage said they are often unable to take breaks each week (68%, up from 49% in 2021). Many feel unable to cope with their workload each week (42%, up from 30% in 2021). One in four of the doctors surveyed were categorised as being at high risk of burnout in 2022, compared with 17% in 2021.

The Care Quality Commission, the independent regulator of health and adult social care in England, recently highlighted staff being overworked, exhausted and stressed – sometimes to the point of becoming ill, injured or leaving their job altogether.

Continuing lack of access to adult social care

Despite the UK government’s stated commitment to addressing the long-term challenges facing the social care sector, the National Audit Office (NAO, the UK’s independent public spending watchdog) has painted a bleak picture of the state of reforms.

In its latest report, entitled Reforming Adult Social Care in England, the NAO highlights longs waiting lists (over 434,000 people waiting assessment or review by March 2023) and workforce shortages (over 150,000 vacancies in England). The report also notes pressures on local-authority finances, which are compounded by a lack of coherent planning to bring sustainable change. This lack of continuity of care is leading to unmet demands and delays in discharging patients.

An inadequate workforce plan

The UK government’s longterm workforce plan, published in June 2023, was widely welcomed as the first comprehensive longterm strategy for the NHS workforce. However, as the General Medical Council pointed out, doubling the number of medical places from 2025 will only reap benefits by 2030, when these new cohorts complete their medical education.

The latest report of the cross-party Public Accounts Committee has criticised the plan’s lack of meaningful details and clarity on several areas of expenditure, including salaries, estates and infrastructure. Also, other than confirming £2.4 billion in funding to cover the costs of training in the first five years, it fails to promise sufficient funding in the medium and long-term. This risks putting NHS under untenable financial pressure.

Further, the plan proposes annual staff productivity gains of 1.5% to 2%, but does not detail how this will be achieved. It is similarly weak on retention measures, failing to address measures to retain staff, or to improve the culture and working environment that contributes to high attrition rates.

Lack of access to urgent and emergency care

Latest data from the NAO reveals that key targets for unplanned or urgent care are not being met. In March 2023, the proportions of A&E patients being admitted, transferred or discharged within four hours of arrival varied from 53.3% in the midlands to 62.1% in the south east against the target of 95%.

Ambulance average response times for category-1 incidents (life-threatening incidents) was eight minutes and 49 seconds in March 2023, against the average standard of seven minutes. Ambulance average performance for category-2 incidents (urgent but not life threatening) was over 39 minutes in March 2023, against the average standard of 18 minutes.

This reveals considerable variation in service performance and access, both between regions and between different providers.

I have long highlighted the challenges facing the emergency services. These include: staff wellbeing, performance being prioritised over people, leaders deeming response time targets to be the barometer of good organisational performance, hospital handover delays and the 999-call triage system.

Continued industrial action

The unprecedented situation of ongoing strikes by junior doctors and consultants, since September 2023, is proving damaging. NHS England estimates the financial costs of over 40 days of industrial action to be around £1 billion.

This has resulted in over 880,000 operations and outpatient appointments being rescheduled. It has further seen 210,000 people added to already pressurised waiting lists.

Cutting down waiting lists was one of the five pledeges Prime Minister Rishi Sunak announced in January 2023. Achieving that now seems highly unlikely.

Despite the challenges it faces, public support for the core principles of the NHS remains overwhelmingly strong. Yet, repeated attempts by the government to reform and reorganise the service have failed to “fix” the problems it faces. Recent evidence highlights significant challenges regarding governance, accountability and decision-making arrangements within the NHS.

The NHS, like many other health systems, is still dealing with the effects of COVID-19 but the challenges it faces long predate the pandemic. Instead of more structural reforms, what the NHS really needs is support and the adequate, long-term, reliable funding required to address the toll a decade of austerity cuts has taken on the nation.

Paresh Wankhade is a Trustee at the Fire Service Research & Training Trust (FSRTT).