How do we repay our debt to the NHS and the people who power it?
Before Coronavirus, the British public had already identified that the NHS was what made them proudest to be British.
The public support shown for the NHS in recent weeks – from rainbows in windows, #ClapForCarers, to companies producing PPE for their local hospitals – has been hugely moving to staff, strengthening resolve in extraordinarily challenging times. The NHS’ place as ‘the closest thing we have to a national religion’ seems further established.
There are risks to treating the NHS as a religion though. As others have noted, if NHS staff are thought of as ‘saints’ or ‘angels’ then we risk not recognising their human needs and fallibilities. What’s more, if the NHS is considered sacred, we might think it is perfect and that it needs just to be ‘saved’ and ‘protected’ from those who would do it harm, rather than encouraged and indeed challenged to ‘always be changing, growing and improving’ as Bevan said it must.
The first place to look for improvement is in how we staff the frontline. At the start of this crisis, when it was feared the NHS would be overwhelmed, huge efforts were made to bolster staffing – bringing the recently retired back into service and accelerating the release of those in training. Such efforts reflected not just the uncertainty of the demands to come but also knowledge that in recent years the NHS has struggled with persistent staff shortages with more than 100,000 posts vacant in England, (equal to 8.5% of staff) in 2018. Vacancies are often caused by lack of available qualified staff rather than lack of budgets – cuts to training places and financial support for trainees in the last decade has contributed to a shortage in England of more than 40,000 nurses.
The commitment of NHS staff throughout coronavirus has been unstinting: working long additional hours, separated from their families, suffering physically, experiencing mental trauma. Tragically more than 100 NHS staff so far have died.
NHS staff numbers must be increased, not just to allow recovery from coronavirus but to reduce the significant reported burdens on existing staff. As an urgent first step we must retain the staff we have. The NHS has for some time relied on significant immigration: 1 in 8 NHS staff are foreign nationals. There must be permanent leave to remain for all foreign national NHS workers.
The long-awaited NHS People Plan was due for publication as coronavirus hit. Announcements suggested a key plank of policy, alongside improved retention and increased training, would be an intensification of efforts at ‘ethical international recruitment’, the ‘ethical’ emphasis recognising past questioning of whether active recruitment of clinicians from developing countries with healthcare shortages is appropriate. In a post-pandemic world, when all other countries’ health systems will be more fragile and will need capacity to deal with further coronavirus spikes, the feasibility and appropriateness of an international recruitment strategy is likely to face more scrutiny.
An alternative is desperately needed – staff shortages mean that even in ‘normal’ times many NHS Trusts cannot open the capacity they wish to, and this has contributed to the occupancy rates of NHS beds rising steadily in recent years to above 90%: a level that few believe is consistent with the highest quality care. Fears that coronavirus admissions added to existing high bed occupancy would overwhelm hospitals seemed a key driver for the guidance that patients must be urgently discharged to care homes at the start of the crisis – which created significant conflict and may, in retrospect, have put additional pressure on a sector that was already fragile, as Sonia Sodha notes in her piece.
The impact of persistent staff shortages on front-line care was such that in the 2019 NHS staff survey, only 32% of staff agreed that ‘there are enough staff in this organisation for me to do my job properly’, and 40% of NHS staff reported feeling unwell as a result of work-related stress. The toll of giving care during this crisis has led to significant further mental health pressures on NHS staff.
Despite the shortages and stresses, all NHS staff, from cleaners to consultants, from porters to physiotherapists, have pulled together in the crisis. Yet while all staff employed directly by the NHS now earn at least the living wage, there are an estimated 100,000 staff who are part of the NHS team who are contracted out to private or Trust subsidiary companies and who receive poorer basic and sick pay as a result. After coronavirus, it should be unthinkable that any member of the NHS team is paid less than the living wage – and the unity of commitment shown by all NHS staff should be reflected in a unified employment structure and an end to a two-tier NHS workforce.
Health is deeply unequal in Britain
The impact of coronavirus has been proportionately higher on poorer communities and among BAME groups, with more than twice as many deaths per head of population in the poorest parts of England compared to the wealthiest areas, and among British black Africans and British Pakistanis. The extent to which existing poor health can lead to further poor health has been made more visible to the public by the explicit need to ‘shield’ those with underlying health conditions from further health risks.
Coronavirus reveals that underlying health conditions are not equally distributed across the population, and that differential mortality by socio-economic group is far from a unique feature of this disease. Despite providing universal free-at-the-point-of-access healthcare through the NHS, the UK has huge existing health inequalities: a boy born in the most deprived part of the country is expected to live more than 9 years less than one born in the wealthiest – and that gap has been growing in the last decade. People living in lower socio-economic groups have 60% more chance of having a long-term underlying health condition, and when the poorest people do get sick they have worse outcomes. Overall, 140,000 deaths a year in the UK are considered to be avoidable – with men in the most deprived areas 4.5 times more likely to die from an avoidable cause than those in the least deprived areas.
The NHS has a role to play in promoting health and ensuring equity of access to the best healthcare – but levels of health are overwhelmingly caused by ‘broader determinants of health’ rather than healthcare provision itself and therefore must be addressed by cross-government action. Unfortunately implementation of the recommendations from the 2010 Marmot review of health inequalities has stalled and public health funding for local authorities has been cut by more than 20% since 2015.
It’s time to stop people’s health being determined by how much money they have or where they live by establishing a national strategy on health inequalities, galvanising action and setting targets to reduce such inequalities and investing in health prevention by reversing the 20% cuts made to the local authority public health grant since 2015.
Building on the NHS’ strengths: towards a better, more resilient future health service
Since coronavirus was declared a serious national incident, the NHS has responded with remarkable speed, including creating the equivalent of 53 district general hospitals worth of capacity and rolling out overnight digital appointments. The scale and pace of these actions reveals key NHS strengths: a truly national service allowing full integration with the government’s emergency management arrangements including the military and concentration of provision in a relatively small number of provider Trusts allowing consistency of approach and local integration. But the speed of transformation in response to coronavirus only highlights the impediments the NHS faces to change in more normal times, including the confusing structures and forced-competition regime imposed by the 2012 Health and Social Care Act.
High-profile concerns about PPE supply and distribution have highlighted the extent to which healthcare supply is now global in nature. Less noted has been the extent to which, while British testing capacity was constrained, Germany’s leading biotech industry was able to provide at volume the reagents that laboratories require, allowing Germany to test more than any other European country at an earlier stage of the crisis. With the government maintaining that there are no circumstances in which it would agree to an extension to the Brexit transition there is an urgent need to develop an emergency healthcare supply approach.
We can build and learn from the NHS’ coronavirus response by doing two things. Firstly, simplifying the NHS’ structure, allowing NHS providers to continue to change services for the benefit of the populations they serve, with a reduced number of intermediate organisations and the removal of mandated competition. And secondly, by enhancing our healthcare supply capability – considering whether greater strategic national capacity in health manufacturing needs to be developed, and ensuring low-friction trade in healthcare products after the Brexit transition ends.
With huge public and political support for the NHS’ response to coronavirus, a key determinant in whether these changes are adopted will be the extent to which policy-makers become convinced that they must be a necessary part of the post-coronavirus NHS settlement.
Improvements to NHS staffing numbers, pay and terms and conditions face potential barriers from any renewal of public sector austerity during a post-coronavirus recession, and the risk from any emerging narrative that ‘there were enough staff to deal with coronavirus, so there must be enough staff to run the NHS in normal times’. There is a risk that the NHS workforce who deserve additional recognition following coronavirus becomes defined solely as those clinicians on the frontline, and that critical support staff, especially those who are contracted out on lower pay, are not made a priority for investment and recognition.
Furthermore, there is a risk that high levels of NHS support will reduce once the negative impact of the wholescale cancellation of NHS elective activity due to coronavirus is felt – with some suggesting it may take 5 years for elective surgery waiting times to return to levels the public expect.
Coronavirus will mark a moment of fundamental reset for healthcare in the UK. With the NHS’ operating model fundamentally changed and the impact on staff, waiting lists and the wider health of the population likely to persist for years to come, it seems inconceivable there will not be a significant policy and likely structural reset.
The history of NHS reform suggests that the most enduring changes, such as those heralded by the 2000 NHS Plan, are those sought by the government but that command wide support from a coalition of established health and civil society organisations and prominent individuals.
So how can we ensure that after coronavirus the government is inspired to take the specific actions necessary to ensure a fairer NHS that does right for all of its staff, that works within a renewed national focus on tackling health inequalities, and that is able to evolve rapidly to meet future challenges without being slowed by the burdens of overlapping structures and forced-competitions?
It sometimes seems there is limited health-specific campaigning institutional infrastructure in the UK, with the existing non-governmental organisational actors tending to be endowed think tanks focused on expert policy analysis, disease specific charities, or trades unions representing staff.
To win the change needed to repay our coronavirus debt, we need an approach that harnesses the huge public support and political backing for the NHS into clear and specific asks. We need to move from claps to campaigns – and the formation of an umbrella health campaigning coalition of NHS staff unions, patient groups, and wider public NHS supporters would give the best chance of ensuring it is staff and the public driving the changes that will come.