Can the Government fix the NHS Crisis?

No they can’t.

The headline in the Times sums up how grim things are. 1000 extra deaths a week due to problems in the NHS.

This graph showing delayed admissions shows how dramatically how performance has deteriorated

The reasons for this crisis are straightforward.

Money is the obvious one. In the years up to 2010 the outgoing Labour Government had invested to bring spending on the NHS to the average of the 14 richest EU nations. From 2010 investment in the NHS fell to the lowest level on record, and stayed there for nearly 7 years. The last 5 years has seen more money come into the NHS, but we are still about 24% below the EU14 average – a gap of £39bn per year.

The Government has spent more on the NHS over the last few years, including record amounts during Covid, lots of which was wasted on PPE that couldn’t be used, and Nightingale Hospitals which never saw a patient. Some of this spend is currently subject to criminal investigations.Essentially the UK invested far too little in healthcare in the pre-Covid period, spent huge sums trying to catch up during the Covid period, much of which was wasted.

What is worse is that capital spend has been slashed, and is still way below the EU14, a gap of 10s of millions. As a consequence the UK has fewer hospital beds, operating theatres or A&E departments than nearly any other comparable country.

The other obvious problem is social care. Spending on social care was slashed in the age of austerity, and in real terms it is lower than in 2010 despite a massive increase in demand. As a consequence there is a critical shortage of places to discharge patients too. At the moment 14% of NHS beds are occupied by people fit for discharge who can’t go home due to lack of social care.

When the Conservatives came into power they declined to implement the outgoing Labour Government’s plans to reform social care, preferring instead to develop their own – they had campaigned against these proposals in 2010 calling them the “Death Tax”. Cameron held reviews, but developed no policy. Theresa May produced ambitious if flawed proposals in 2017 which Labour in turn dubbed the “Dementia Tax”. These proposals were also dumped. Boris Johnson came to power promising new proposals which never saw the light of day. The official position is that new policies will be announced in the next 2 years.

The reason why the Conservatives can’t develop policy on social care is property. There is a large cohort of older people who need social care who collectively have lots of accumulated property wealth,. There is no way to pay for that social care without using some of that accumulated property wealth. The problem is that older people with lots of accumulated property wealth are the Conservative parties core vote, and were the backbone of the Brexit. The Government can’t afford to annoy them, and so the problem has been allowed to fester.

In contrast the Government has allowed poverty to rise to record levels with millions unable to afford to feed themselves or heat their homes. It is an absolute fact that if you take a vulnerable population and make them poorer, colder and hungrier you increase the rate at which they need secondary healthcare. This relationship has been known about for a century and yet the Government has allowed poverty to rise at a time when the NHS was under the worst pressure in it’s history. The subsequent surge in sick people turning up in A&E was absolutely predictable, and completely ignored by a Government unable to face up to it’s own failures.

But the existential issue is staffing.

The NHS is incredibly short staffed, patient care is compromised, and morale has collapsed. Clinicians are asked to deliver sub standard care, compromising patient safety, knowing that if something goes wrong they will get the blame, not managers or politicians.

I have said this before, but it bears regular repetition – the NHS only exists because staff believe in it. Once that belief goes the NHS is finished. Right now staff don’t see any light at the end of the tunnel, and the NHS is in an existential crisis.

The staffing crisis has 3 main components:

  1. Below inflation pay rises going back more than a decade
  2. Brexit and the hostile environment massively reduced recruitment from abroad
  3. Cuts to nursing bursaries, medical school places and junior doctor training places reduced the ability to recruit UK trained staff

All of these problems were know about years ago – I have been writing about them for years, and if I knew there were problems then Ministers should too. So should NHS England and Health Education England.

But nothing was done. The Government’s approach to difficult problems was to change the subject and promote good news stories instead. No problems were ever solved, only managed off the front page.

There were some good senior managers in NHSE and HEE but too often Ministers were successful in promoting leaders who would toe the Ministerial line and not speak out. The hopeless attempts to replace Sir Simon Stevens with Dido Harding illustrate how much being on messaged trumped competence and experience.

This sadly is true across Government, the leadership of key Government Departments as at it’s weakest just as the challenges are at their greatest.

Normally in a situation where performance is deteriorating Ministers and Senior Managers have performance management systems to try and address the problem.

But with any performance management system you rely upon the fact that most organisations hit their targets in order to focus on the few who don’t. If no-one can hit their targets the whole performance management system becomes a joke – Ministers and NHSE can huff and puff all they like – it means nothing.

That is where the NHS is at right now – Ministers and the bosses of NHSE shaking their fists in impotent rage at a system that no longer responds to their commands. The levers of power are broken.

In reponse to this the Government, and their pals in the press and in think tanks have 2 solutions. The first is increasing productivity.

Productivity in healthcare isn’t the same as productivity in other industries, sadly most Ministers don’t get that. This is something that people like Alan Johnson understood, but hardly any SofS has since.

The NHS has a high fixed cost – the cost of having a massive hospital full of Doctors and Nurses, with expensive machines. This means that it has a very low marginal cost. You can improve productivity by cramming more and more patients through the same hospital with the same number of Doctors and Nurses. I know, I’ve done it loads.

But you reach a point where you hit a step cost – you can’t simply cram more patients into the same number of hospitals with the same number of Drs and Nurses – you need more beds, more operating theatres, bigger A&Es, and more staff to run them.

People think that the NHS is at that point now, but they are wrong – it passed that point a few years ago – it is just now that the failure to invest has reached crisis point

If you drive for more productivity under those conditions all you do is more care worse for patients. And that is exactly what is going on. Ministers trying to crank the handle faster on a system that is already running too fast to deliver proper patient care.

The other solution, increasingly promoted by right wing think tanks is to scrap the NHS and create a new system. This cackbabble from Alister Heath in the Telegraph is typical:

Alister Heath was of course also thought the Kwasi Kwarteng’s budget was a massive triumph

It is hard to overstate how stupid this idea is. Anyone who thinks the answer to the NHS’s problems is a massive top down re-organisation is an utter chump. Bonkers.

The only people who will benefit from this as private health insurers and management consultants. If this crazy idea ever happens I will be leaving the Distillery and becoming a private sector healthcare change consultant charging the Government £0.3m a year for the benefit of my wisdom.

So what can be done?

The problem is that there is very little you can do in the next 12 months to improve things, however I feel obliged to try and make some suggestions:

1. Lift all immigration restrictions on people coming to this country to work in health and social care indefinitely, including scrapping the fees they pay to the NHS
2. Local government to take back control of failing care homes, and to take over unused hotel space as emergency social care facilities
3. A massive pay rise for all health and social care staff and a public apology for being so shitty to them
4. Re-integrate public health back into the NHS
5. Scrap the internal market completely and direct the savings back into pay and conditions – fewer managers, better paid staff!
6. Take urgent and immediate steps to reduce poverty, hunger and fuel poverty. This is driving the surge in admissions
7. Scrap plans for capital spend on vanity projects like Shotley Bridge and spend the money instead increasing bed stock in large DGHs and tertiary centres
8. Sack Steve Barclay, make Alan Johnson or Alan Milburn emergency SofS
9. Change tax rules for high earning Drs to remove the incentive for them to leave the NHS in their mid 50s
10. Contract with the private sector for additional emergency capacity, using the over 50s Drs who left the NHS to do the work

It would be expensive, but it would be better than some mealy mouthed crap about productivity while people are dying.

The chances of the Government taking such radical steps are close to zero.

Instead it is more likely that these problems will spread elsewhere – if you look at the workforce problems in Education they look like the same problems health and social care had a few years back. If nothing is done Schools will face the same crisis as Hospitals before very long. Even mainstream Government Departments aren’t invulnerable – I have worked with the Child Support Agency and Rural Payments – the 2 Government bodies that came closest to complete collapse.

Key Government Departments like HMRC and DWP look just as fragile today as the CSA did at it’s worst, at a time when International Markets and investors already have doubts about the stability of the UKs financial institutions.

A new pay settlement with Nurses will help keep some of the worst of the headlines off the front pages. But it is more likely that the crisis will spread than be solved.

If you want a vision of the future imagine nude civil servants breakdancing while the UK collapses.

5 thoughts on “Can the Government fix the NHS Crisis?

  1. That’s a pretty darn good critique of the current state of play. There is a way out of this mess but this government is incapable of seeing it – although that’s probably a generous interpretation. If they do decide to have another reorganisation you can count me in as one of your associate management consultants though…🤔😉

    1. I always thought that there was an opportunity for a management consultancy called HenchMan. We would come in and do all of the miserable jobs that needed doing but which Trust leaders couldn’t face doing themselves. I also think that there is another opportunity for a consultancy called Escape Committee for senior NHS managers who want to get out

      1. I could have done with some ‘Escape Committee’ assistance a few years ago… I sense it’s needed even more so now.

      2. Yes, at the risk of being too philosophical people who have been in the NHS for a long time have 3 challenges – they don’t know what they want to do in life. they don’t know what transferable skills they bring, and they are scared of being laughed at or losing status once their position in a hierachy is gone. All of which are easily solved with the right help

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.