Can the NHS sur­vive the pan­dem­ic? The ques­tion would have been unthink­able a few months ago. But with chal­lenges rang­ing from daunt­ing wait­ing lists to grow­ing abuse of health­care offi­cials, the out­look is fore­bod­ing. 

These are momen­tous times for an organ­i­sa­tion that has been respon­si­ble for the nation’s health for more than 70 years. There’s a huge back­log of care, with almost 6 mil­lion peo­ple wait­ing for treat­ment. The wait­ing list is ris­ing by about 100,000 a month as more peo­ple who did not seek or could not access NHS treat­ment over the past 18 months vis­it a GP and are referred to hos­pi­tal. 

The num­ber of patients wait­ing more than two years has risen to near­ly 10,000. Peo­ple who are seri­ous­ly ill are unable to access the care and sup­port they need, which puts their lives at risk. In many hos­pi­tals, ambu­lances are unable to unload patients because there’s nowhere for them to go. 

The week­ly clap­ping for the NHS feels like a life­time ago. Today, at the front­line of care, GPs have become the tar­get of pub­lic anger and frus­tra­tion over the chal­lenges faced by the health ser­vice. Increas­ing­ly, health­care pro­fes­sion­als in hos­pi­tals and health cen­tres face abuse from patients and their fam­i­lies. 

To tru­ly meet the scale of the chal­lenge over the longer term, gov­ern­ment needs to shift the focus to cre­at­ing the con­di­tions that keep peo­ple healthy in the first place

Dr Kather­ine Hen­der­son is a senior A&E con­sul­tant in Lon­don and pres­i­dent of the Roy­al Col­lege of Emer­gency Med­i­cine, which rep­re­sents A&E doc­tors. “It is a sad real­i­ty that in recent months there has been a rise in abuse direct­ed towards health­care work­ers, but this abuse is not some­thing new to front­line staff or emer­gency depart­ments,” she says. “It was bad before the pan­dem­ic, but there’s a changed atmos­phere now.” 

For all the talk of a “post-pan­dem­ic” world, the NHS is still strug­gling with a live coro­n­avirus cri­sis. There are almost 9,000 peo­ple in hos­pi­tal being treat­ed for Covid-19. This takes up resources and requires iso­la­tion on wards, lim­it­ing admis­sions of oth­er patients. There are fears this is like­ly to increase in the win­ter in the absence of mea­sures like social dis­tanc­ing, com­pul­so­ry face masks and work­ing from home. 

Funding boost

The cost of address­ing these chal­lenges is for­mi­da­ble. The chan­cel­lor of the exche­quer, Rishi Sunak, set aside an extra £5.9bn for the NHS in his Autumn Bud­get in Octo­ber. The mon­ey is intend­ed to help clear the record back­log of peo­ple wait­ing for tests and scans, which has been wors­ened by the pan­dem­ic, as well as to buy equip­ment and improve IT. This is in addi­tion to the £12bn announced in Sep­tem­ber, to be raised through increas­es in Nation­al Insur­ance and, from 2022, the Health and Social Care Levy. 

This is the biggest increase in core cap­i­tal invest­ment in health since 2010, accord­ing to the Trea­sury. Paul John­son, direc­tor of the Insti­tute for Fis­cal Stud­ies, said the increas­es in depart­men­tal spend­ing have “more in com­mon with Blair and Brown than Cameron and Osborne”. About 44% of the cash increas­es in the Autumn Bud­get will go on the NHS over the next three years, the IFS esti­mates. 

How­ev­er, many ques­tion if even this colos­sal amount will be enough, giv­en the health sector’s struc­tur­al weak­ness­es – staff short­ages, crum­bling build­ings, fail­ing social care, lack of equip­ment and out­dat­ed tech­nol­o­gy. There are cur­rent­ly around 100,000 vacan­cies across the NHS. Many staff are iso­lat­ing because of Covid-19, putting fur­ther pres­sure on an already over­stretched work­force. 

The pan­dem­ic has made it clear that the entire sys­tem is built on a flawed infra­struc­ture of insuf­fi­cient and dis­con­nect­ed triage

 “The sig­nif­i­cant increase in cap­i­tal fund­ing will help the NHS reduce the elec­tive care back­log, car­ry out more tests, reduce health inequal­i­ties and con­tribute toward the NHS net-zero tar­get,” says Dan­ny Mor­timer, deputy chief exec­u­tive of the NHS Con­fed­er­a­tion.

“But to ensure the extra mon­ey deliv­ers for the pub­lic, a strong and sup­port­ed NHS work­force is need­ed. This is why train­ing and increas­ing the sup­ply of doc­tors, nurs­es and oth­er health and care pro­fes­sion­als is so impor­tant at a time when pub­lic polling recog­nis­es that staffing is the biggest prob­lem fac­ing the NHS.” 

Accord­ing to Jere­my Hunt, the for­mer health sec­re­tary, “the extra mon­ey for the NHS will unrav­el quick­ly if we do not train the extra doc­tors and nurs­es need­ed.”

At this crit­i­cal junc­ture, the health ser­vice is led by two peo­ple new­ly appoint­ed to their roles. Sajid Javid, a for­mer chan­cel­lor, became health sec­re­tary in June, suc­ceed­ing Matt Han­cock. Aman­da Pritchard became chief exec­u­tive of NHS Eng­land on August 1, suc­ceed­ing Sir Simon Stevens, who stepped down after more than sev­en years. Pritchard was pre­vi­ous­ly chief oper­at­ing offi­cer for two years, hav­ing worked for the NHS for her entire career. 

Togeth­er, Javid and Pritchard must nav­i­gate the health ser­vice through this most tur­bu­lent peri­od. In an ear­ly sign of the dif­fi­cul­ties they will face, Javid court­ed con­tro­ver­sy with a £250m finan­cial pack­age for GPs, linked to mea­sures to increase the num­ber of face-to-face appoint­ments with patients. 

Under the new scheme GP prac­tices will be told they must “respect pref­er­ences” for face-to-face appoint­ments and should con­sid­er using the cash to extend open­ing hours and offer walk-in con­sul­ta­tions to increase the avail­abil­i­ty of in-per­son con­sul­ta­tions. Those fail­ing to offer suf­fi­cient in-per­son appoint­ments will be denied access to the fund. 

Offi­cial fig­ures show that 58% of GP appoint­ments in Eng­land in August were face-to-face. Before the pan­dem­ic, 80% of appoint­ments were car­ried out in per­son.

GP anger

The pack­age has caused anger among GPs, who say the invest­ment falls short of what’s need­ed while fail­ing to recog­nise the long hours they have worked to meet patients’ needs dur­ing the pan­dem­ic. The British Med­ical Asso­ci­a­tion (BMA) GP com­mit­tee urged prac­tices not to com­ply with “the very worst aspects” of the plan, includ­ing tar­get-dri­ven league tables. The com­mit­tee also called on GPs to take steps towards indus­tri­al action. 

Dr Richard Vautrey, the out­go­ing chair of the BMA’s GP com­mit­tee, says GPs have no alter­na­tive but to take the action. “All efforts to per­suade the gov­ern­ment to intro­duce a work­able plan that will bring imme­di­ate and longer-term improve­ment for doc­tors and their patients have so far come to nought.”

Part of the expla­na­tion for GPs’ anger can be traced to the begin­ning of the pan­dem­ic, when NHS pol­i­cy – sup­port­ed by the gov­ern­ment – was to pro­mote vir­tu­al ser­vices wher­ev­er pos­si­ble. Dig­i­tal First was adopt­ed as pol­i­cy and writ­ten into the NHS Long Term Plan, with incen­tives to invest in new tech­nolo­gies. The Depart­ment of Health and Social Care gave enthu­si­as­tic sup­port to pri­vate dig­i­tal pio­neers like Baby­lon, which man­ages “GP at Hand”, the NHS’s app-based ser­vice. 

To ensure the extra mon­ey deliv­ers for the pub­lic, a strong and sup­port­ed NHS work­force is need­ed

Yet the adop­tion of tech­nol­o­gy, par­tic­u­lar­ly around the remote deliv­ery of care and sup­port, is crit­i­cal to the sus­tain­abil­i­ty of the NHS, not just by GPs and pri­ma­ry care but across all ser­vices. Invest­ment in tech­nol­o­gy is a clear focus of the new cap­i­tal spend­ing sup­port­ed by the Trea­sury. Around £2.3bn of the addi­tion­al funds promised by the chan­cel­lor are ear­marked for invest­ment in dig­i­tal IT. There will be a par­tic­u­lar focus on cre­at­ing addi­tion­al capac­i­ty for diag­nos­tic tests, like CT, MRI and ultra­sound scans.

Dr Mur­ray Ellen­der, co-founder and CEO of eCon­sult, believes fund­ing should be pri­ori­tised for dig­i­tal triage, to give patients the most direct pos­si­ble route to need­ed care.

“Cash injec­tions like these may help with eas­ing the imme­di­ate blow. But our health­care sys­tem des­per­ate­ly requires a care­ful over­haul,” he says. “The pan­dem­ic has made it clear that the entire sys­tem is built on a flawed infra­struc­ture of insuf­fi­cient and dis­con­nect­ed triage. If we don’t invest in this wide­spread change now, we not only face a bleak win­ter, but we may wit­ness the ulti­mate break­ing point for our NHS.”

Digital dividends

In health­care, dig­i­tal infra­struc­ture is about more than the inter­face with patients: it’s also about what goes on in back offices. Increas­ing­ly, automa­tion is being imple­ment­ed in areas like refer­rals. It helps ensure that patients are seen as effi­cient­ly as pos­si­ble, val­i­dat­ing their data on the wait­ing list so they’re set at the right pri­or­i­ty and con­firm­ing that they still require care. Dig­i­tal work­ers are com­plet­ing sim­i­lar process­es to over­come the can­cer care back­log by audit­ing key mile­stones across can­cer path­ways. 

IT infra­struc­ture must be an ear­ly pri­or­i­ty for the new inte­grat­ed care sys­tem (ICS) con­cept if it is to deliv­er joined-up care. These sys­tems bring togeth­er organ­i­sa­tions across the NHS, local coun­cils and the vol­un­tary sec­tor, who will need to share infor­ma­tion to estab­lish effec­tive col­lab­o­ra­tive projects. This will mean cre­at­ing com­mon frame­works that some­how bring togeth­er the mul­ti­plic­i­ty of IT sys­tems cur­rent­ly being used. 

Guid­ance pub­lished by NHS Eng­land and NHS Improve­ment requires each ICS to have “smart dig­i­tal and data plat­forms” in place by April 2022, when ICSs will be put on a statu­to­ry foot­ing. By then, each ICS should have a senior exec­u­tive with respon­si­bil­i­ty for gov­er­nance and account­abil­i­ty for dig­i­tal strate­gies. 

Shared care records and cross-sys­tem data shar­ing will under­pin the core pur­pose of ICSs, with an ambi­tion for patient records to trav­el seam­less­ly from one provider to anoth­er with­out delay. How­ev­er, putting this into prac­tice across each ICS requires sig­nif­i­cant invest­ment and care­ful plan­ning to ensure that sys­tems are effec­tive and secure. 

Challenges ahead

It’s easy to be cyn­i­cal about the NHS and health­care tech­nol­o­gy, giv­en patients’ expe­ri­ence of lum­ber­ing IT in hos­pi­tals and GP surg­eries. But there is anoth­er side, which includes world-lead­ing genome sequenc­ing and the rapid devel­op­ment of the Covid-19 vac­cine. The NHS App is cur­rent­ly the most down­loaded free app in Eng­land. Users ben­e­fit from eas­i­er access to NHS ser­vices, includ­ing GP appoint­ments and repeat pre­scrip­tions. 

Barts Health NHS Trust Health Cen­tre, the largest in the UK, uses a dig­i­tal sys­tem that helps patients and their clin­i­cians con­nect through vir­tu­al appoint­ments. The sys­tem cap­tures bio­met­ric data, such as blood pres­sure and heart rate; health­care pro­fes­sion­als can inter­vene if need­ed by com­mu­ni­cat­ing direct­ly with patients through the ser­vice. Patients also have access to data like med­ical doc­u­men­ta­tion and clin­i­cal notes that sup­ports the man­age­ment of their long-term con­di­tions at home.  

But in its quest for a sus­tain­able future, the NHS faces a chal­lenge. It must find a way to har­ness the infor­ma­tion it col­lects for the ben­e­fit of mil­lions of patients and ser­vice users. As wait­ing lists con­tin­ue to grow and the ser­vice strug­gles to recruit and retain the health and care pro­fes­sion­als it des­per­ate­ly needs, this future can’t be tak­en for grant­ed. 

“To tru­ly meet the scale of the chal­lenge over the longer term, gov­ern­ment needs to shift the focus to cre­at­ing the con­di­tions that keep peo­ple healthy in the first place,” says Charles Tal­lack, assis­tant direc­tor of the Research and Eco­nom­ic Analy­sis for the Long Term (REAL) Cen­tre at the Health Foun­da­tion. “This means imple­ment­ing a whole gov­ern­ment approach that places improv­ing health at the front and cen­tre of all major poli­cies.”

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NHS shake-up aims at joined-up care

Health and care ser­vices in Eng­land are under­go­ing their biggest reor­gan­i­sa­tion in a decade, thanks to the cre­ation of inte­grat­ed care sys­tems (ICSs). These are part­ner­ships that bring togeth­er providers and com­mis­sion­ers of NHS ser­vices across a geo­graph­i­cal area with local author­i­ties and vol­un­tary organ­i­sa­tions to col­lec­tive­ly plan health and care ser­vices. 

The cen­tral aim of ICSs is to inte­grate care across dif­fer­ent organ­i­sa­tions and set­tings, join­ing up hos­pi­tal and com­mu­ni­ty-based ser­vices, phys­i­cal and men­tal health, and health and social care. The expec­ta­tion that stan­dards of care would be improved by com­pe­ti­tion among providers has been swept aside in favour of col­lab­o­ra­tion. The ambi­tion is to remove bar­ri­ers that often stand between patients or ser­vice users as they try to access the care or sup­port they need.

All parts of Eng­land are now cov­ered by one of 42 ICSs. Chairs and chief exec­u­tives have been appoint­ed and the Health and Care Bill cur­rent­ly before Par­lia­ment is expect­ed to put ICSs on a legal foot­ing by April 2022, with for­mal pow­ers and gov­er­nance struc­tures. Exist­ing clin­i­cal com­mis­sion­ing groups (CCGs), groups of GPs pre­vi­ous­ly respon­si­ble for com­mis­sion­ing ser­vices, will then be fold­ed into ICSs. 

Local leadership

There’s no blue­print for devel­op­ing an ICS. In con­trast to many pre­vi­ous attempts at NHS reform, nation­al NHS bod­ies have so far adopt­ed a rel­a­tive­ly per­mis­sive approach, allow­ing the design and imple­men­ta­tion of ICSs to be local­ly led with­in a broad nation­al frame­work. As a result, there are sig­nif­i­cant dif­fer­ences in the size of sys­tems and the arrange­ments they have put in place, as well as wide vari­a­tion in the stage of devel­op­ment each sys­tem has reached.  

A num­ber of ICSs are devel­op­ing new mod­els of care which ben­e­fit patients. For exam­ple, in West York­shire and Har­ro­gate almost 4,000 patients have avoid­ed unnec­es­sary hos­pi­tal appoint­ments and received spe­cial­ist sup­port while remain­ing in pri­ma­ry care after three hos­pi­tals and 64 GP surg­eries estab­lished a new Shared Refer­ral Path­way. Sur­rey Heart­lands ICS set up the Tech to Con­nect scheme with local part­ners, sup­port­ing dig­i­tal lit­er­a­cy. Frim­ley Health and Care imple­ment­ed schemes to bring rapid sup­port to the most vul­ner­a­ble com­mu­ni­ties dur­ing the pan­dem­ic, includ­ing Black, Asian and minor­i­ty eth­nic groups at great­est risk.

Widespread support

Will ICSs make a dif­fer­ence? While there’s wide­spread sup­port for join­ing up ser­vices across the NHS and broad­er col­lab­o­ra­tion with the local coun­cils respon­si­ble for social care, there is uncer­tain­ty about how this will be achieved in prac­tice.  

For exam­ple, the BMA thinks the pos­i­tive ele­ments of CCGs – such as a strong clin­i­cal voice, local deci­sion mak­ing and account­abil­i­ty to clin­i­cians – must be kept in ICSs. In par­tic­u­lar, it high­lights the voice that CCGs have giv­en GPs with­in local health and care sys­tems. 

Mean­while, The King’s Fund think tank warns that evi­dence from pre­vi­ous attempts to inte­grate care indi­cates that these reforms will take time to deliv­er results, and that local and nation­al lead­ers need to make a long-term com­mit­ment to change. 

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