What does the future hold for the NHS?
Urgent and emergency care situation reports show how the NHS almost ran out of critical care beds during the second wave of the pandemic. Hospitals in London reached 95% of their capacity by January 2021, closely followed by the South East and the East of England.
The situation was perilously close to being an unmitigated disaster as the second national lockdown began across the UK. Yet many of the pressures faced by the NHS were predicted in advance.
Five Coronavirus spikes piercing the NHS
In early 2020, a study by the Health Foundation predicted five distinct areas of impact linked to the pandemic.
Severe illness & Death
The authors considered how the direct impact of Covid-19, measured in terms of severe illness, hospitalisations, and deaths, would almost break the NHS. The latest data back up their grim forecast.
Dr Alex Stockdale, NIHR Academic Clinical Lecturer in Clinical Infection, Microbiology & Immunology at the University of Liverpool, who worked on Covid wards during the first wave, said:
“Everybody was really afraid. Non-infection specialists particularly, because they hadn’t really dealt with infectious diseases. All of us had quite profound insomnia, lying awake at night worrying ‘is it going to be me next’?”
Existing socioeconomic inequalities were also exacerbated by the pandemic, with black and minority ethnic communities disproportionately affected.
Acute system shake up
Acute care was also expected to suffer from decreased capacity, caused by the massive surge in demand of Covid-19. This transpired as thousands of people were discharged to free up beds for Covid patients, staff were redeployed en masse, enormous numbers of operations were cancelled, and GP appointments increasingly took place remotely.
Non-covid related hospitalisations fell dramatically during the first lockdown, with accident and emergency admissions dropping by 31.4% overall compared to 2019, according to a recent data release by NHS Digital. Around 45% fewer Children aged 0-4, and 21-27% fewer young adults aged 18-25 were admitted to hospitals than the previous year.
Non-acute care and GP clinics
Non-urgent, routine healthcare normally dealt with by GPs was also dramatically impacted by the pandemic. Cancer Research repeatedly raised concerns about the relative lack of early cancer diagnoses, which is likely to lead to adverse outcomes.
Dr Stockdale echoed their concerns:
“What we’re seeing now is lots of late diagnoses of cancer. That’s going to be the biggest shadow: Cancer related death over the next 24 months.”
Cancer surgery has also dropped since the first lockdown, meaning that many urgent referrals received alternative treatments like radiotherapy.
Remote GP appointments increased significantly during the pandemic. According to NHS data, between May and July 2020 almost 50% of all appointments were conducted by telephone, exceeding the number of face to face appointments. Previously, from October 2019 until March 2020, in-person appointments accounted for 80% of the total.
A GP from Kent, who spoke on condition of anonymity, said:
Remote appointments can actually take longer than seeing someone face to face, because…you can’t pick up…non-verbal cues and use your intuition.”
“There is…technology to ask patients to send images…for example of a rash. Sometimes this can be a real time saver, but other times…you have to [see them] face to face…to get a clear view.”
They also worried about elderly, deprived, and vulnerable patients “missing out on access because of digital exclusion.”
A report by Health Watch concurred that “many people [were] struggling to access care”, and found the lack of clear communication about changes to the appointments system “frustrating” and “confusing”.
Delays and failures
Research by the British Medical Journal showed a “record high of 4.46 million” patients were awaiting planned treatment in November 2020, and “2.3 million people” were still “waiting for surgical care” earlier this year.
Repurposed wards, operating theatres and outpatient clinics, staff redeployment, absence due to sickness or self-isolation, protective protocols slowing down hospital treatment, and “delays or failures in patient testing”, were all cited as possible contributing factors to increased waiting times.
A decimated & demoralised workforce
A report by the Health Foundation examined how perennial staff shortages hampered the NHS’ pandemic response. Despite a recruitment drive there were over 80000 staff vacancies in June 2020. Almost 50% of these were nursing jobs, keeping the UK below the OECD average for nurses per capita.
Evidence also suggests that NHS staff have increased levels of anxiety, depression, stress, and PTSD. Female nurses and ethnic minority workers were particularly affected, with the latter having “50% greater risk” of “high PTSD symptoms”, and being significantly more worried about getting Covid-19 than their white counterparts.
The NHS Staff survey 2020 provided a parallel perspective. Overall, 44% of staff reported “feeling unwell” due to “work related stress” during the pandemic, an increase of 10% from 2019.
Post-pandemic recovery in the shadow of Brexit
A report by the Nuffield Trust outlined the complexity of Brexit for the NHS. From the prospect of investor-state dispute clauses in the controversial Trans-Pacific trade deal allowing private companies to challenge public health regulation, to rising medicine prices, changes in the mutual recognition of qualifications affecting NHS recruitment, UK immigration rules ensuring that social care applicants cannot pass minimum “salary or skills thresholds” for visas, foreign nurses finding it harder to accept jobs, data sharing disruption, and the burgeoning crisis in Northern Ireland, the future looks fraught with problems.
Alongside issues related to Brexit, the NHS is on the verge of integrated care systems reshaping the current model of healthcare. New partnerships between NHS providers and local government are set to be fully operational by April 2022. The proposed changes have been met with scepticism.
What next for the NHS?
Coronavirus shows no sign of disappearing in the near future. A “chronically underfunded” and understaffed NHS and social care system looks likely, at the very least, to have to maintain a delicate balance between:
- Fighting Covid-19,
- clearing the backlog of patients waiting for elective operations and treatments,
- catching up on cancer diagnoses,
- facing the social care crisis,
- addressing the mental health burden bearing down on staff and the public,
- dealing with a post-Brexit world,
- recruiting five thousand new nursing staff per year,
And much more besides.
As the pandemic ebbs and flows these challenges represent the tip of an increasingly unfathomable iceberg. The question is whether the British government, healthcare providers, and key stakeholders can work together to steer the NHS Titanic through the tumultuous, storm-tossed waves threatening to sink the ship before any lifeboats can be released.