Political crisis in the NHS

The real NHS crisis is political not humanitarian. Politicians of all parties have failed to provide sufficient funding for health and social care, with predictable and sometimes distressing consequences.

Hospitals are struggling to meet rising demands from a growing and ageing population, and most are failing to hit the four hour waiting time target in emergency departments. Patients are being cared for on trolleys in corridors, and this is compromising patient safety—sadly illustrated by reports of the death of patients in Worcester.1

The challenges facing hospitals result from failure to invest sufficiently in services in the community to provide care in people’s homes and help them remain independent. General practices, district nursing, and social care have all been affected, resulting in patients attending hospital because of the lack of appropriate alternatives. Many of these patients could be cared for out of hospital if community services were properly funded and staffed.

Social care is in the eye of the storm, with the number of people receiving publicly funded care falling by more than 400 000 since 2009-10.2 Neglect of social care means that a growing number of people receiving hospital care cannot be discharged when their treatment has finished because of lack of community support.

Many emergency departments are seriously overcrowded, with patients waiting for a bed to become available.3 The spectre of ambulances waiting to discharge patients to emergency departments is the inevitable and unwelcome consequence.

None of this should be a surprise. Winter pressures are a familiar feature of the NHS, and the result of cuts in social care funding and constraints in NHS funding have been clear for some time. The NHS is approaching breaking point, and urgent action is needed to avoid a bad situation becoming much worse.4 5

This is as much a test of politicians as it is of the NHS, which has worked tirelessly to ensure patients are cared for safely after months of winter planning. Will the government heed the warning signs and bow to pressure for a fundamental review of health and social care funding? Or will ministers resort to sticking plaster solutions that deal with the presenting problem in emergency departments without tackling the underlying causes across the whole of the NHS and social care?

The answers to these questions matter because they affect millions of people at a time of need and, often, anxiety. Older people, people with disabilities, and patients with acute medical conditions are experiencing longer waits for care,6 and publicly funded social care is provided only to those in greatest need and with limited resources. The impact on staff, who have become the shock absorbers in an underfunded health and care system, is increasingly a concern.7

The government’s response to the prison crisis suggests that a sticking plaster solution to the problems of health and social care is the most likely outcome. This could involve finding extra cash for hospitals to signify to the public that ministers are taking the problems of the NHS seriously. It might also entail a boost to social care to support patients to be discharged from hospitals and free up beds for those waiting in emergency departments.

While any support is to be welcomed, it is unlikely to make an immediate impact because of the time it takes to use new funding to improve services. What is far more important is to recognise that current pressures are an “acute on chronic” manifestation of a system that needs fundamental reform. Not only is the level of funding inadequate, but how care is provided has failed to keep up with changing demography.

A succession of expert reports has reviewed what needs to be done, including the Royal Commission on long term care in 1999,8 Derek Wanless’s review in 2006,9 the Dilnot Commission in 2011,10 and the Barker Commission in 2014.11 All have concluded that root and branch changes are needed to the funding and delivery of care, and yet none has been implemented. Fundamental reform should include increased public funding, integration of NHS and social care budgets, and closer alignment of entitlements to health and social care, as proposed by the Barker Commission.

The failure of successive governments of all stripes to act on these reports is an indictment of a political system that too often avoids dealing with complex social issues.

That is why the real NHS crisis is political. It is the result of short term thinking geared around election cycles and an unwillingness to deal with long term challenges that are not amenable to incremental policy changes. A preference for adversarial point scoring rather than crossparty consensus is an insurmountable obstacle to the kind of political leadership that is desperately needed.

We should of course be concerned about the huge pressures on the NHS and social care and their effect on patients and service users, but we should be terrified by a political process that seems incapable of tackling the root causes of these pressures.