Two and a half years ago, when an unknown virus swept the nation, I found hope in an unlikely place: the NHS. The doctors and nurses at the hospital were drawn to a spirit of camaraderie and can-do, in stark contrast to the exhausting burnout we see today. As the NHS approaches its midday, with the catastrophic combination of nurses on strike for the first time in a century and ambulance workers going on strike next week, I am reminded of that glimpse of a way to do things better. .
I had a rare and privileged experience in 2020, as a temporary advisor to the Department of Health. Sitting in the dysfunctional center of government, which had a vacuum where a prime minister should have been, I briefly witnessed a fragmented system come together to do what front-line staff thought was right for patients, freed from some of the usual protocols.
When Covid hit, dental hygienists, surgeons, and physical therapists retrained as ICU nurses. Health workers administered insulin injections and wrote death certificates. Even the BMA, that bastion of conservatism, had to abandon its attempt to stop medical students from caring for Covid patients. At a Zoom conference I attended, hosted by a surgeon, hundreds of GPs and consultants passionately said they no longer wanted to work in silos; that they were collaborating in new ways; they had been freed from the HR jargon and form filling.
“We must never go back,” was his refrain in the spring of 2020. But we have. In less than a year, the bureaucracy reasserted itself. Retired doctors who volunteered to help with the vaccine rollout were required to complete 18 training modules, including one on preventing terrorism.
The stun “guidance” spurts from the center as forcefully as ever. Nurses tell me that money is spent on “communications” equipment instead of medical care. Surgeons tell me they are doing fewer operations than before the pandemic due to infection control measures, faulty computer systems, and late-arriving operating room staff. Last year, 12,600 operations were canceled due to administrative errors. When professionals are burned out, faced with a backlog of 7 million patients, and wages are falling in real terms, it’s no surprise that so many are leaving or on strike.
Where has all the extra money gone? A new report from the Institute for Fiscal Studies finds that the NHS is treating far fewer patients than it was before the pandemic, despite having more staff and more money (its current budget is £180bn). The usual explanation for underperformance is that demand exceeds funding. But the IFS suggests that the money is being spent on the wrong things.
The last three years have seen large increases in the employment of consultants, junior doctors, nurses, and clinical support staff. There were 10% more consultants, nurses and health visitors in July 2022 than in July 2019. This does not seem to translate into higher productivity, partly because some patients are sicker and require more treatment, and partly because beds they are being “blocked” by older people who are able to discharge but cannot access social care.
However, the analysis also suggests that many of the new hires are in the senior or junior ranks, not in between. We risk losing the backbone of the NHS – the registered nurses who manage daily care. There are more specialists and fewer general practitioners and community nurses who can help patients at an earlier stage.
Even with all this additional staff, there are still plenty of openings. Why? An NHS member explained to me that when funding increases, so does the number of publications funded. Therefore, increasing resources automatically creates a shortage of labor. It has been shown to me that the number of “establishment” positions (required staffing levels) increased when the new funding was announced. This is crazy.
For decades, the debate over the number of employees has been the currency of politics. Successive governments have touted “more nurses, more doctors” as a panacea to avoid criticism. But when the NHS has 200,000 more employees than in 2012, and 1.2 million employees overall, it’s time to ask how staff are being used, not just how many. “Staff certainly feel stretched out,” the IFS authors write. “But it’s not obvious that adding more staff or money will immediately unclog the system.”
Here is an opportunity to change the conversation. Wes Streeting, Labour’s shadow health secretary, seems refreshingly ready to do just that. “I’m not afraid to take on vested interests,” he said recently, including in his own party.
If the NHS and its frontline are to go above and beyond for patients, we need a revolution in organizational management. General Sir Gordon Messenger, former deputy chief of defense staff, recently reviewed the state of NHS leadership and concluded that there has been an “institutional failure” in the way managers are “trained, developed and valued”. Even if the review is exhausting, the change now is vital to restore autonomy, respect and adequate support.
Covid posed an immediate threat that prompted NHS professionals to face the challenge of their calling. This crisis feels very different: a routine desperate to get through each day, where everything is urgent.
Nigel Edwards, CEO of the Nuffield Trust, used to joke in the NHS: “next week is strategic; the following week is the unimaginable future.” It’s not a joke anymore. Unless leaders can demonstrate that there is a better future, no amount of new staff will fix the problem.
