Is the NHS in crisis? What is going on with our health service, explained

Monday’s front-pages would have made for pretty grim reading in Number 10 and Jeremy Hunt’s office. “Critical: NHS in crisis as budgets cut”, said The Sun.  “Millions shut out of doctors’ surgeries”, added The Times.

Headlines about the NHS are exactly what the Conservatives don’t want ten months out from a general election.  Talk to our strengths, not our weaknesses, says Lynton Crosby.  However, as Monday’s headlines showed, this is difficult to pull off in practice.

But, behind the headlines and statistics, what is actually happening to the NHS in England and why?

I should say that I don’t believe the NHS is (yet) in crisis.  The NHS has performed remarkably well over the past four years against the backdrop of austerity.  We have not had the implosion that many people feared or predicted – due in part to a relatively warm winter.  However, the NHS is showing strain across many of the areas that indicate how well the system is performing: A&E attendances, waiting lists, access to a GP appointment, hospital finances and so on.

The reasons behind this worsening performance are complex.  However, there are three overarching issues that can help (in part) explain the current state of the NHS.

1. Changing demographics leading to rising demand

Since its creation in 1948, there has been a stark change in the country’s demographics. The number of people living longer has risen dramatically, as has the number living with one or more long-term conditions – such as diabetes or Parkinson’s.

This improvement in life expectancy has put an increased demand on the NHS, acutely felt in hospitals because of more people being admitted as a result of health complications.  Over the past ten years the number of people attending A&E – both major hospital units and smaller walk-in clinics – has increased by 50 per cent.

Today, what is keeping advisers in the Department of Health awake at night (and newspaper editors busy) is the unusual and (largely) unpredicted demand on major A&E units through this spring and summer, when it should be the NHS’s quiet seasons.  Figures show that the number of people admitted to A&E via major hospital units was 76,000 in the third week of July 2014, 10,000 more during the same period in 2011.  This is unprecedented and deeply concerning.

One in five people who visit A&E will be admitted to hospital, and over two thirds of hospital beds are occupied by people admitted in an emergency.  Hospital staff and the Department of Health will be conscious that current demand means the system is running “hot” 24/7.  Finance directors that started the year on Plan-A will be going through the alphabet at an alarming rate.

So, what is causing this spike in activity?  Again, there is no single answer and it will be a combination of factors, including an ageing population, hospital staffing levels and the quality of community care.

Last year, Jeremy Hunt blamed the rise on a decision by the last Labour Government to allow GPs to opt out of providing out-of-hours care.  The reality is that the majority of people visit A&E during working hours, so it is not simply about the lack of out of hours care.  However, polling data, as well as anecdotal evidence shows that people are finding it increasingly hard to get an appointment with their GP and are not aware of the alternatives.  This means attending A&E is, for some, the only option.

2. A fractured and fragmented social care system

The challenges facing the NHS cannot be considered in isolation.  The NHS is currently equipped and structured to prioritise treatment over prevention.  Caring for the elderly and people living with long-term conditions in the community is predominantly considered the responsibility of social care services which, over the past four years, have undergone £2.6 billion of cuts compounding decades of under-investment.

To meet these savings, councils are having to restrict access to the care services they provide to people with “substantial” or “critical” needs.  This means people identified as having “moderate” needs – e.g. someone who struggles to do the weekly shop on their own – are no longer eligible for support.

From 2005/06 to 2012/13, the number of people aged 65 and over in receipt of social care services dropped by 27.2 per cent.  Current estimates suggest that 800,000 older people living in England are not receiving the care and support they need to stay living at home independently.

The consequence for the NHS is people being admitted to hospital unnecessarily because of inadequate support in the community and two fundamentally different systems (one free at the point of use and one means tested) unable to properly integrate around the needs of the patient.

3. Five years of flat growth in NHS spending

The final pressure facing the health system is trying to respond to the problems set out above during a period of flat growth.  The NHS’s budget might have been (partly) protected but, like other public services, has had to find new ways of doing more with the same and make savings in the process of responding to rising demand.

Since 1948, NHS expenditure has grown on average 4 per cent every year in real terms, with growth of on average 6.4 per cent a year during the last Labour Government.

However, NHS spending for this Parliament has effectively been frozen at the same time the system is being asked to find £20 billion of savings as part of an efficiency programme – the so called ‘Nicholson Challenge’, initiated in 2009.

The savings achieved so far have largely come from “big ticket items” such as a freeze on NHS staff pay and reductions in management costs.  However, making the next wave of savings, without impacting on patient care, is becoming harder to achieve.

Published last week, the Department of Health’s annual accounts for 2013/14 revealed that for the first time since 2006 the NHS spent nearly its entire budget for the year – a real-terms growth in spending of 2.6 per cent.  Critically, this rise in expenditure was not the result of substantial investment to improve services but, overall, a response to the growing demands referred to earlier.

The current level of demand is likely to continue to grow for the foreseeable future. However, based on current budget projections the NHS cannot afford another huge increase in spending.  For the next year or so, it must try to live within its means.

If the NHS is not yet in crisis then it is certainly suffering from a crisis of confidence over how it is performing.  The next year will be pivotal for the NHS.  The country needs, just as Andy Burnham said yesterday, “a proper debate at the 2015 election [about] what kind of health service it wants in the 21st century”.  At the heart of this debate will be a question of funding and how we can continue to provide a service free at the point of use but in an age of austerity.

Labour has started this debate, but as the party of the NHS we must provide the solutions too.