By Karen Taylor, Director Centre for Health Solutions

At the start of a new year, I am sure there are many, like me, who are hoping that this coming year will be a better year for everyone, including our NHS. I have reviewed and reported on the performance of the NHS for more than 25 years (1997-2022). I have also been a non-executive director of an NHS hospital trust (2011-2021) and now an NHS community trust. Throughout this time, I have seen tremendous innovation with staff going above and beyond to improve patient care, but I have also seen many challenges that have culminated in unwarranted variations in performance, waste and inefficiencies. I’ve also seen the pendulum swinging back and forth on policy, performance and people’s perception of the NHS. One constant remains, my belief in and support of an NHS free at the point of need, equitable and focused on delivering improved patient outcomes. Today, the challenges facing the NHS appear more significant than ever. My first blog of 2023 explores some of the complex drivers of these challenges.     

What are the challenges facing the NHS today?

For the past year, it’s been near impossible to read a newspaper or listen to a news report without hearing about healthcare’s multiple challenges; whether it’s the continuing high levels of NHS staff vacancies, increasing waiting times, unfavourable comparisons with other health systems, the impact of rising inflation on pay and running costs, or the decision by nurses and ambulance staff to resort to industrial action. However, this situation hasn’t happened suddenly. Our research shows that local services and frontline staff continue to struggling with the lack of:

• a fully funded national workforce strategy
• an adequate interoperable IT infrastructure
• effective clinical pathways that deliver outcomes in line with the best performing healthcare systems
• sufficient flexibility in bed capacity in line with our European counterparts
• an adequate resolution to the funding and support needed for social care.

Despite this, our research has identified multiple examples of the NHS identifying innovative ways of delivering services and working far beyond their conditioned hours or simply working differently to meet year-on-year increases in demand for services. Yet, as many of us know, the consequences of this unrelenting demand, is taking a toll on the physical and mental health of staff and leading to increasing levels of sickness absences and a serious decline in workforce numbers.

While the decline in numbers has been happening for several years, it is now exacerbated by the departure of clinicians who, having borne the brunt of the pandemic, are finding that the unrelenting pressures are leading to burnout.  resulting in them deciding to either reduce their hours or, in increasing numbers, leave the NHS. The high level of recorded vacancies has left an unsustainable staffing gap, and by necessity increased spending on temporary staff, which in 2021-22 exceeded the agency spending cap with total spending of £9.2 billion.¹This is also increasing still further the pressure on those who remain.

What impact are these challenges having on the NHS workforce?

Over the past decade there has been ample evidence of the NHS embracing innovations in science and technology, significantly improving the NHS’s ability to diagnose and treat patients more effectively. However, the NHS has also seen the funding available to maintain high quality services, and pay its staff a fair wage, eroded by increasing demand in the face of a relative reduction in the supply of funding and resources.

Since March 2020, the NHS workforce has also been at the heart of the response to the COVID pandemic, attracting continuous media and public scrutiny and comment. While this was initially overtly positive; latterly, media and public opinion has become increasingly negative and politicised as delays in accessing services have escalated.

One of the most challenging and high-profile issues has been NHS staff pay and conditions, which have decreased steadily over the past ten years.  The 2021 NHS staff survey, which predated the latest surge in inflation, found that only 31 per cent of staff said they were satisfied with pay, the lowest result ever. The most dissatisfied groups were nurses and healthcare assistants (only 17 per cent were satisfied), ambulance staff (only 23 per cent) and registered midwives (28 per cent).²

The NHS is unique in how it determines pay at a national level. It relies on two independent NHS pay review bodies considering evidence from UK governments, employers and trade unions before making their recommendations to government on pay increases, usually on an annual basis. A key function of these reviews is to provide big enough pay incentives to retain NHS workers while attracting more people to work within it. Pay is seen as both a major cost to the public purse but also an investment in supporting population health.³

However, after taking account of inflation, the mean gross weekly female full-time nurses’ earnings in 2019 were virtually the same as in 2008.⁴ The Health Foundation has calculated that between 2011 and 2021 NHS nurses average basic earnings fell by five per cent in real terms.⁵ Similar reductions have bene seen in many other Agenda for Change staff groups, including paramedics. Consequently, the 2022 recommendation of an average 4.5 per cent pay rise for NHS staff amounted to real term pay cut for many.⁶ While shift work and overtime provides opportunities to increase earnings for many, it also adds stress and increases the risk of burnout. Moreover, this year’s pay offer was set in March 2022, so didn’t take account of the unexpected rise in inflation. Meanwhile NHS staff sickness absence was nearly two percentage points higher from January to April 2022 than it was before the pandemic.

In September 2022,  the number of NHS vacancies stood at a record high, with more than 133,000 full-time equivalent posts unfilled – a 29 per cent rise in vacancies in twelve months (47,500 of the vacancies are for nurses, an average of almost one in eight posts).⁷There is an increasing body of research that shows these levels of staff shortages and increasing evidence of staff burnout have serious implications for patient safety (equally as serious as the impact of strikes).^{8 9 10 11}

Meanwhile the crisis is equally challenging in general practice. ONS data shows that since 2019, GPs’ workloads have increased by 18 per cent and the full-time-equivalent (FTE) workforce has fallen by nearly 700 with each FTE GP now caring on average for an extra 120 patients with little expectation that the manifesto promise of hiring 6,000 more GPs will be realised. Nevertheless, a record 36.1 million appointments were delivered in October alone, with almost 40 per cent delivered on the same day as booked. ¹²However, there was also a consensus that the increased workload expected of GPs and their teams, coupled with the chronic shortage of GPs, is unsustainable.  Consequently, increasing numbers are now leaving the profession in higher numbers that are joining it and escalating pressures are driving the remaining workforce to the brink of exhaustion and burnout.¹³

What can be done to help resolve the situation?

This blog set out to provide a brief snapshot of some of the facts and figures underpinning the current challenges facing the NHS. There can be no denying that since the onset of the pandemic the NHS has been tested as never before. In that time, we've seen the extraordinary sacrifice and commitment of staff, and the dedication and resourcefulness of leaders, innovating, problem solving, and working in new ways. However, the underlying pressures haven't gone away and indeed have increased. Social care remains in crisis, and funding for health and social care is severely stretched.

Yet, the evidence is strong that carefully planned and effectively delivered investment in health and social care and especially in the workforce can bring measurable benefits that both improve the health of the population and the resilience, quality, sustainability and cost-effectiveness of the heath system. Such spending should not be seen as a cost to the economy but an investment in its future, helping to build social, intellectual as well as economic capital for the economy while nurturing the aspiration and ambition of what is the largest workforce in the country.

In our next report, which is a follow up to our Time to Care report published in 2018, we explore these very real challenges facing the NHS and evaluate the effectiveness of various solutions to help tackle the workforce pressures being faced by the NHS and build a sustainable future for the NHS. ¹⁴We will also be considering what lessons could be learned from other European countries’ responses to similar challenges.

Karen Taylor - Director, UK Centre for Health Solutions

Karen is the Research Director of the Centre for Health Solutions. She supports the Healthcare and Life Sciences practice by driving independent and objective business research and analysis into key industry challenges and associated solutions; generating evidence based insights and points of view on issues from pharmaceuticals and technology innovation to healthcare management and reform.

Email | LinkedIn

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¹https://www.bbc.co.uk/news/health-63588959

²https://www.nhsemployers.org/articles/nhs-staff-survey-2021-results

³https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/National-State-of-Patient-Safety-2022.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1092270/NHSPRB_2022_Accessible.pdf

⁴https://reader.health.org.uk/nurses-pay-over-the-long-term/executive-summary

⁵https://www.health.org.uk/publications/long-reads/where-next-for-nhs-nurses-pay

⁶Nurses’ and paramedics’ pay fact sheet - The Lowdown (lowdownnhs.info)

⁷ https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey/april-2015---september-2022-experimental-statistics

⁸https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/National-State-of-Patient-Safety-2022.pdf

⁹ https://www.bma.org.uk/news-and-opinion/stress-and-burnout-warning-over-covid-19

¹⁰https://www.gmjournal.co.uk/one-third-of-doctors-at-high-risk-of-burnout-finds-gmc-report

¹¹https://uk.news.yahoo.com/gmc-warns-high-risk-doctor-230100925.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuYmluZy5jb20v&guce_referrer_sig=AQAAAMooFHtDhPYCaJOMBT3J9dP4qa7IEPnhFMH4WALV2RIqIBS6TphTZeN2rZ7Xk-Ybl1mkLmHaDxZI56_F-GH3onadQDqjJLX0hhD9TcLkr_7_-eQIfOMohAEU8VeEsfN18Iwe-rCtjKLOv2i-8mhJ_WusoybGZnbEMMcaSmGbweSt

¹²https://www.rcgp.org.uk/News/Workforce-ONS-GP-Patient-Ratio

¹³https://www.bma.org.uk/bma-media-centre/declining-number-of-gps-shows-no-signs-of-abating-without-a-workable-plan-to-recruit-and-retain-nhs-staff-says-bma

¹⁴https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/time-to-care-uk.html