Clearing the NHS backlog

Winter crisis in the NHS. 2023 began with renewed media attention on the crisis in the NHS. The Royal College of Emergency Medicine’s Dr Adrian Boyle warned that delays in A&E are causing between 300 and 500 deaths each week. Matthew Taylor, chief executive of the NHS Confederation warned that staff pressures are becoming “unbearable” and “the next three months will be defined by further critical incidents needing to be declared and the quality of care being compromised.” Excess deaths are at a 50 year high (9% more than 2019). 

• The backlog is at an all time high. In addition to the crisis in A&E and ambulance waiting times, the latest data from the British Medical Association shows a record high of ~7.21m people are waiting for treatment in elective care. This is not a recent problem. In August 2022 National Audit Office found that there were ~2.75m patients waiting more than the legal standard of 18 weeks. Before the pandemic NHS England had not met elective waiting time performance standards for 4 years. (The King’s Fund’s Saoirse Mallorie explains what being on waiting lists actually means.)
• Causes of the bottleneck. The King’s Fund’s written evidence to an inquiry into NHS backlogs and waiting times argued that the root causes for longer waiting times were workforce shortages, funding shortfalls between 2010 and 2019, reduced numbers of beds relative to comparable countries’ health systems and a rising demand for care services due to an ageing population. 

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History of underinvestment in capital. The FT’s John Burn-Murdoch explains how the Government has decreased spending on the NHS as a share of GDP relative to comparable economies since 2010, and how this has led to a squeeze on staff pay and a “dearth of [capital] investment” so that “the NHS finds itself hamstrung by acute shortages of beds and the equipment that gets people out of beds faster.” (The NHS required an extra £33bn capital investment between 2010-2019 to catch up to the EU14 average.) The government’s answer to this was the 2019 election pledge to build 40 new hospitals by 2030, however the latest information is that work has only begun on 7 of the hospitals with other projects well behind schedule.

• Day-to-day spending. Further, average day-to-day UK government spending on healthcare between 2010 and 2019 was 18% below the EU14 average. Matching spending per head with France and Germany would have led to an additional £40bn and £73bn (respectively) in total health spending each year in the UK. (See the Nuffield Trust’s explainer on The past, present and future of government spending on the NHS.)
• Staff shortages. Total NHS vacancies now stand at 133,446, an increase from 7.9% in 2021 to 9.7% in 2022. The King’s Fund found that shortages are increasing due to a lack of long-term planning by the government and NHS over training and migration policy not being set with the “NHS’s interests in mind” (see a study from the Nuffield Trust on how Brexit affected the UK’s medical workforce).
• Retention and pay. Junior Doctor Jatinder Haryre notes that 89.7% of doctors who have already left the NHS to work abroad blame dissatisfaction with pay in the UK. The Institute for Public Policy Research’s Parth Patel explains that pay increases are crucial for maintaining NHS performance in an interview with Sky News. (See the TUC’s analysis of how much NHS staff have lost from a “brutal decade of lost pay” and our previous Digest for more on the impacts persistent pay constraint has had on public sector recruitment and retention.)
• Political implications. The FT’s Stephen Bush argues that “what would worry me were I a Conservative strategist is that the post-2019 increases in funding will start to actually have an effect on NHS performance, ooh, about a year after the next election, exactly in time for Labour to take the credit and to deepen voter anxieties about my party and the health service.“ Further, an Opinium poll commissioned by Compassion in Politics has shown that Conservative voters “overwhelmingly believe their party has failed in its management of the NHS during their time in Government”.

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The emergence of a two-tier healthcare system. More of the population are resorting to using private healthcare as an alternative to long waiting lists and declining quality of care. Persistent strain in the NHS has led some (e.g. from David Davis and Sajid Javid) to position insurance-based healthcare systems that utilise the private sector as solutions.  (See the Nuffield Trust CEO Nigel Edwards’s critique of social health insurance based systems.)

• “Exploiting the managed decline of the NHS?” A report from the IPPR explains how underfunding and persistent structural pressure has led to more increased direct utilisation of private healthcare services as more individuals are resorting to self-funding their own care. Keep Our NHS Public “condemns the underfunding of NHS services, particularly when done to cynically promote the unnecessary need for privatisation of services.” The Centre for Health and the Public Interest’s David Rowland argues that the growth of the for-profit healthcare sector in the UK is largely driven by government support. One example he gives is by exploiting access to a highly trained, expert workforce, as private providers contract NHS staff to deliver services without contributing to training.
• Outsourcing staff. Keep Our NHS Public notes outsourcing of staff as a key mechanism being used to drive privatisation. Professor Neena Modi, ex-president of the British Medical Association explains that sending NHS patients to private hospitals will worsen staff shortages within the NHS and erode health budgets as the public sector foots the bill for higher prices in the private sector.

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Labour’s solution sparks row. Sir Keir Starmer has said Labour would use the private sector in the health service more “effectively” if elected prime minister, which has attracted criticism from some on the left who  have accused Starmer of “ditching [his] pledge to end NHS outsourcing”. In the longer term, Labour has pledged a massive expansion in the NHS workforce, paid for by ending the non-dom tax status, but this would take years to bear fruit and would not help to deal with the immediate backlog.

• Clarifying Labour’s position. Labour wants to use spare capacity within the private sector (e.g. rooms and beds) to help clear the NHS backlog. Shadow Health Secretary Wes Streeting clarified that this treatment would still be “provided free at the point of need” and that this principle “will be erased over my dead body”. He proposed that “the next Labour government will agree a 10-year plan of change and modernisation”, which includes reform of how the NHS uses the private sector.
• Will it work? CHPI’s Director David Rowland argues that Labour’s proposals won’t work because “private hospitals do not have any additional doctors to assist in reducing the NHS backlog – in all the private hospitals operating in the UK, the doctors are NHS doctors, working in their spare time”. Further, workforce shortages are particularly acute amongst consultant level doctors that are critical for the delivery of the types of healthcare provided by the for-profit sector. Private hospitals can’t do anything to ease the staffing pressures currently driving the backlog, may deepen funding issues and expose patients to a greater risk of harm.

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Ultimately, clearing the backlog requires more funding. As Stephen Bush noted, “A good gauge for deciding how seriously you should take [either political party] is if their reforms are related to either of these two things: investment in healthcare capital and increasing bed capacity.” 

• Poor health is costing the government... The Times’ Health Commission found that rising levels of ill health are costing the economy £150bn a year in lost income tax, benefit payments and larger NHS budgets. Health inequalities were estimated to cost the UK £31bn to £33bn in productivity losses before COVID-19. However, the number of working age people suffering from chronic illness has significantly increased since the pandemic. The FT’s John Burn-Murdoch argues that “Britain’s healthcare crisis, with tens of thousands waiting over a year for hospital treatment, is directly contributing to the UK’s exceptional rise in economic inactivity."‍ The OBR recently predicted that up to 14% of the working age population will be in receipt of disability benefits by 2027-28 due to declining public health, which will increase government spending on welfare. 
• …holding back growth…Andy Haldane, Chief executive of the RSA and former governor of the Bank of England, has said that “more than a century of progress on health and wellbeing was going into reverse, with a direct impact on the economy and the cost of living emergency.” He said that the UK “sits towards the bottom of the pack” in the G7 on spending on healthcare, which is holding back the economy as the workforce has been shrinking since the pandemic. The Commission on the Future of Employment Support’s first report found that the “UK is one of only five countries in the industrialised world with a weaker labour market than before the Covid-19 pandemic and is on course to have the worst record by next year.”‍
• …and investment is politically popular. Those who want to increase taxes and spend more on health, education and social benefits has been climbing since 2017. More of the public want the government to “increase taxes and spend more” than those who want it to “keep taxes and spending at the same level as now”. Half of the public say they would support increasing the basic rate of income tax from 20% to 21% and using the money raised to increase spending on the NHS. Less than a third are opposed.