The challenges facing the NHS during COVID and beyond

When the NHS roared into life on July 5, 1948, it marked an his­toric moment both for the UK and the world. It was the first time any­where that free health­care was avail­able at the point of use and paid for by the tax sys­tem. At the time, health min­is­ter Aneurin Bevan said it was “the biggest sin­gle exper­i­ment in social ser­vice that the world has ever seen”. 

The exper­i­ment paid off. The health ser­vice has been a major source of nation­al pride ever since; sur­veys show that we love the NHS even more than the Roy­al Fam­i­ly. But more than 70 years on, the nation looks very dif­fer­ent. 

The NHS grap­ples with con­sid­er­able chal­lenges such as long wait­ing lists, staff short­ages and a pop­u­la­tion that is get­ting old­er and sick­er with increas­ing rates of chron­ic dis­eases such as type‑2 dia­betes and demen­tia. These prob­lems exist­ed long before coro­n­avirus, but they have been bru­tal­ly exposed dur­ing the pan­dem­ic. Tough con­ver­sa­tions about how to secure the health service’s future are long over­due.

Hospital backlog

Once the pan­dem­ic is final­ly extin­guished, a major stum­bling block will be the back­log of care the cri­sis has cre­at­ed. In March 2020, the econ­o­my and life as we knew it was forced to shut down to pre­vent the very real risk of the NHS being over­whelmed. Although the worst-case sce­nario did not occur, many patients deal­ing with non-COVID needs found the health ser­vice was not avail­able for them. 

Rou­tine care and many sched­uled oper­a­tions were sus­pend­ed to free up resources, so hun­dreds of thou­sands of patients could be admit­ted to COVID wards. NHS Eng­land says more than 300,000 peo­ple in Eng­land have now wait­ed more than a year for rou­tine hos­pi­tal treat­ment, the high­est num­ber since Jan­u­ary 2008. 

Sal­ly War­ren, direc­tor of pol­i­cy at The King’s Fund, says long wait­ing times are like­ly to be a fea­ture of the NHS for many years to come. “The NHS was already strug­gling with meet­ing some of their wait­ing-time tar­gets com­ing into COVID,” she says. “They then had 12 months of need­ing to shift their activ­i­ty away from nor­mal and now they have new demand as well. The big ques­tion is how they can start to recov­er.”

Morale on the frontline

Bounc­ing back will be tough with­out a ready work­force. COVID has put health­care work­ers under sig­nif­i­cant strain. “Doc­tors are exhaust­ed and in many cas­es near­ing burnout,” says Dr Hele­na McK­e­own, work­force lead at doc­tors’ trade union the British Med­ical Asso­ci­a­tion (BMA). No one could deny med­ical pro­fes­sion­als across the UK have demon­strat­ed extra­or­di­nary lev­els of com­mit­ment dur­ing the pan­dem­ic, but this has often been to their per­son­al detri­ment and with­out ade­quate pro­tec­tion, she points out. 

There may well be long-term effects for health­care work­ers too. Research sug­gests some doc­tors and nurs­es could devel­op severe men­tal health prob­lems, such as post-trau­mat­ic stress dis­or­der, after bat­tling coro­n­avirus on the front­line.

At the same time, there are sim­ply not enough health­care pro­fes­sion­als in the NHS to meet demand. One in ten nurs­ing posts are cur­rent­ly unfilled, amount­ing to almost 40,000 vacan­cies. The UK also has few­er doc­tors for its pop­u­la­tion than the major­i­ty of Euro­pean coun­tries, at 2.8 per 1,000 peo­ple com­pared to the Euro­pean Union aver­age of 3.4.

Ani­ta Charlesworth, direc­tor of research at the Health Foun­da­tion, believes one rea­son for the short­age is the government’s reluc­tance to invest in med­ical train­ing. It is expen­sive to train a doc­tor or nurse and those costs are very vis­i­ble in a pub­licly fund­ed sys­tem, she points out. But reduc­ing train­ing costs was shown to be a false econ­o­my dur­ing the pan­dem­ic. England’s tem­po­rary Nightin­gale hos­pi­tals were assem­bled in record time, but staffing them was a prob­lem. For much of the cri­sis, these field hos­pi­tals remained emp­ty. 

“Not pro­tect­ing the NHS became the Treasury’s prob­lem because then we had to shut down our econ­o­my,” adds Charlesworth, sug­gest­ing that staff should be seen as an asset rather than a cost to the pub­lic bal­ance sheet.

Brex­it is anoth­er stick­ing point, says McK­e­own. Free­dom of move­ment enabled the UK to har­ness the best tal­ent from with­in the EU. “Now we have left the bloc, the UK is putting up bar­ri­ers to inter­na­tion­al recruit­ment at a time when the NHS needs it most, as well as send­ing entire­ly the wrong mes­sage to our over­seas col­leagues about mak­ing Britain a wel­com­ing coun­try to pur­sue their careers,” she says.

Health consequences of public service cuts

A nation’s health isn’t sole­ly deter­mined by the num­bers of doc­tors and nurs­es, though. The NHS does not oper­ate in a vac­u­um, says Lind­say Forbes, pro­fes­sor of pub­lic health at the Uni­ver­si­ty of Kent. Cop­ing with demand for health ser­vices is not only to do with the size of the NHS, but is also about fac­tors that cause peo­ple to get sick in the first place. “The key thing over the past few years that has caused the NHS to near­ly fall over has been the relent­less pick­ing away at local gov­ern­ment spend­ing,” she says. 

In par­tic­u­lar, local author­i­ty pub­lic health ser­vices, which large­ly focus on pre­vent­ing dis­ease, reduc­ing health inequal­i­ties and improv­ing res­i­dents’ health have been reduced sub­stan­tial­ly, accord­ing to King’s Fund research. 

While spend­ing on pub­lic men­tal health ser­vices and pro­mot­ing phys­i­cal activ­i­ty has increased, cash for smok­ing ces­sa­tion ser­vices, sub­stance abuse clin­ics and occu­pa­tion­al health has been large­ly cut. Many local author­i­ties warn they will have to slice their bud­gets even small­er in the wake of the pan­dem­ic if sup­port from cen­tral gov­ern­ment is not increased. 

Scrimp­ing on local ser­vices will cost the NHS dear­ly in the long term, says Devon-based GP Dr Michael Dixon, who is chair of the Col­lege of Med­i­cine. It will increase demand for down­stream acute ser­vices such as hos­pi­tal care. “The fun­da­men­tal chal­lenge is how we increase the abil­i­ty of peo­ple to stay healthy and look after them­selves as much as they can,” he says.

Interacting with the private sector 

Whether some of the NHS’s chal­lenges could be relieved by the pri­vate sec­tor is a hot­ly debat­ed top­ic. But it’s per­haps a less con­tro­ver­sial issue than the pub­lic imag­ines, says War­ren. Pri­vate com­pa­nies have always played a role in the NHS; most GP prac­tices are inde­pen­dent busi­ness­es, for instance.

Despite claims to the con­trary, King’s Fund research shows NHS spend­ing on exter­nal providers has not sub­stan­tial­ly increased in recent years. War­ren believes sup­port from pri­vate hos­pi­tals could be use­ful in meet­ing the post-COVID back­log chal­lenge and help the NHS work through wait­ing lists more quick­ly.

Call­ing on pri­vate com­pa­nies doesn’t always bring the intend­ed results, though. The pan­dem­ic has exposed the best and worst of this approach. On one hand, the rela­tion­ship between the life-sci­ences indus­try and the NHS has result­ed in the devel­op­ment of an effec­tive COVID-19 vac­cine and a suc­cess­ful roll­out cam­paign. On a neg­a­tive note, NHS Test and Trace, the UK’s sys­tem for iden­ti­fy­ing peo­ple who have been in close con­tact with a COVID suf­fer­er, has been wide­ly crit­i­cised.  

In March, the Pub­lic Accounts Com­mit­tee warned the impact of Test and Trace, which relies on out­sourc­ing firms such as Ser­co for con­tact trac­ing, is still unclear despite the UK gov­ern­ment set­ting aside £37 bil­lion for it over two years. 

“The NHS is the jew­el in the crown,” says Forbes. “We can tin­ker around the edges with the pri­vate sec­tor, but we need to remem­ber the ser­vice is the envy of many coun­tries in the world. Just increas­ing the role of the pri­vate sec­tor won’t do any­thing to reduce the demand on the health ser­vice.”

What will save the NHS?

There is no mag­ic bul­let that can solve all the health service’s prob­lems, but there are sev­er­al approach­es lead­ers could explore to alle­vi­ate them. First up, the well­be­ing of health­care pro­fes­sion­als needs to be an absolute pri­or­i­ty fol­low­ing the pan­dem­ic, says McK­e­own at the BMA. “The impact on their men­tal and emo­tion­al health can­not be under­es­ti­mat­ed. Mean­while many will have had COVID-19 and will still be suf­fer­ing the long-term con­se­quences.” 

She would like to see full occu­pa­tion­al and men­tal health ser­vices offered to staff, as well as sup­port­ed phased returns for those who have had to take sick leave. A sil­ver lin­ing to the pan­dem­ic is that the pub­lic has nev­er been more aware of the amaz­ing work health­care staff do. And there is renewed inter­est in want­i­ng to work for the NHS. Appli­ca­tions to nurs­es cours­es in Eng­land rose by 17 per cent last year com­pared to 2019, with 28,920 stu­dents start­ing a nurs­ing degree in autumn 2020. 

If the gov­ern­ment wants to pro­tect the NHS, it must stop neglect­ing its poor­er cousin, social care, says War­ren at The King’s Fund. The pan­dem­ic has shone a light on the dif­fi­cul­ties many old­er peo­ple face; a large pro­por­tion of COVID deaths have occurred in care homes, for instance. But unlike health­care, elder­ly care is rarely free of charge and most peo­ple have to pay at least some of the eye-water­ing fees them­selves. 

In 2019, think tank the Insti­tute for Pub­lic Pol­i­cy Research claimed giv­ing free social care to the over-65s could save the NHS £4.5 bil­lion every year by allow­ing more elder­ly peo­ple to get help in the com­mu­ni­ty instead of end­ing up in hos­pi­tal. For years, lead­ers have promised reforms to the social care sys­tem, but no con­crete plans have emerged. 

This could be set to final­ly change. In Feb­ru­ary, a Depart­ment of Health and Social Care white paper stat­ed that a roadmap for social care would be announced lat­er in the year. As well as new social care fund­ing mod­els, War­ren would like to see more ways of deliv­er­ing sup­port for old­er peo­ple. A care home doesn’t have to be the only option for those who can no longer live inde­pen­dent­ly. Build­ing more extra-care hous­ing, accom­mo­da­tion that includes per­son­al care such as help with wash­ing, get­ting dressed and prepar­ing meals, is one pos­si­ble solu­tion, she sug­gests.  

The old adage that pre­ven­tion is bet­ter than cure has nev­er been more rel­e­vant. Lead­ers need to focus on improv­ing the health of the nation, says the Col­lege of Medicine’s Dixon, and even inject­ing the NHS with unlim­it­ed cash won’t achieve that. Improv­ing hous­ing, work­ing con­di­tions and giv­ing patients more agency in their well­be­ing could mean they won’t need a hos­pi­tal bed in the future. 

Social pre­scrib­ing, where GPs con­nect patients to non-clin­i­cal com­mu­ni­ty ser­vices such as gar­den­ing groups or finan­cial advice ses­sions, could also have a big impact. And Dixon thinks build­ing on the com­mu­ni­ty spir­it that was so evi­dent in the UK dur­ing the first wave of the pan­dem­ic will lead to health­i­er, more resilient com­mu­ni­ties. “The nation is going to have to roll up its sleeves,” he says. “Ask not what the NHS can do for you, but what you can do for the NHS.”