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Winter is always a difficult time for the NHS but, this year and last, COVID-19 has made these pressures more extreme than ever. With the backlog of care growing, unfortunately we are likely to see more broken records and longer waiting times.

Health and care services are looking after patients with increasingly complex care needs, under more and more difficult circumstances, alongside trying to plan for the future. As the REAL Centre enters its second full year, I wanted to reflect on the growing challenge of keeping one eye on the horizon while also grappling with the here and now.

Pressures on the NHS were severe even before the pandemic took hold. COVID-19 has compounded those challenges, as can be seen most clearly in the rates of burnout for the NHS workforce and the growing concern over the timely treatment of non-COVID-19 patients. In the UK, elective care waiting times are the longest they’ve ever been: in November 2021, just 66% of people waited less than 18 weeks for treatment (the target is 93%) and 5% of people have been waiting for more than a year. A&E and ambulance waits are also the worst they’ve ever been, and we are yet to see the full extent of the impact of the Omicron wave.

Our recent analysis on health and social care funding projections set out the resources required to deal with the immediate pandemic recovery while also building future resilience in the NHS. We estimated that stabilising the health system in the wake of the pandemic and keeping pace with underlying demand would require a spending boost of 3.5% per year, which equates to over £60bn by 2030. It was encouraging to see a significant funding injection as part of the Spending Review last year which was broadly in line with our projections but less than what we estimated could be needed to clear the backlog in this parliament.

These encouraging plans for investment have been made to the end of the parliament. However, they don’t account for the Omicron wave, which has piled more pressure on service delivery through increased demand and staff absences. While so many of these pressures are urgent, we must not lose sight of the need to build resilience in the health service through decision making that has a longer term lens. The REAL Centre has highlighted four key areas that desperately need attention: workforce, social care, capital and public health.


Even pre-pandemic, there was an understanding within government that we need to invest more in the NHS workforce. Targets were set for recruiting 50,000 nurses, 6,000 GPs and 26,000 other primary care professionals by the end of parliament. Meeting these targets is looking more and more difficult, especially given that since 2011 nurses’ pay has fallen by 5% in real terms. The pandemic has heightened concerns about workload, retention, motivation and the longer term supply of nurses.

The challenges facing the workforce were scrutinised during Sajid Javid’s recent evidence to the Health and Social Care Select Committee. He was pressed on how he would meet these recruitment targets, as well as deliver much-needed improvements to workforce planning. On this, we and 90 other organisations are supporting an amendment to the Health and Care Bill (currently in the House of Lords), calling for independent assessments of how many health and care staff the UK needs.

As the NHS focuses on how to ‘build back better’ from the pandemic, prioritising the wellbeing of the workforce is an absolute must.

Social care

While 2021 was a year many of us would rather forget, it did bring the first leap forward in social care reform after many years of ‘can-kicking’. This reform adds some much-needed protection against catastrophic costs. But there is still a lot of uncertainty over how much social care our society will need, whether we have enough staff and care homes, and how much care will be publicly funded.

We commented in November that last-minute changes to social care reforms have been a step in the wrong direction. For a decade, social care funding has barely risen in real terms. While the new levy will provide £5.4bn over 3 years to fund the new cap on care costs, this won't address the challenges in the existing system. We worked with the IFS to publish an independent assessment of the government's proposed reforms to the social care charging system, including the introduction of an £86,000 lifetime cap on care costs.

Investment in the long term

The REAL Centre and the Health Foundation have long been calling for investment in the future of health and social care to be prioritised. The UK’s historically diminutive capital budget and falling public health budget require sustained investment to prepare for future demand. As highlighted in the REAL Centre’s first insights report, the next 25 years will see the number of people aged 85 and older double to 2.6 million.

Despite a rising proportion of older people living with long-term conditions, older people are now more often able to live without help. This raises questions for how health and social care may be delivered in future. Better evidence and understanding of the drivers of inequalities and future pressures are vital to inform long-term policy decisions and resourcing.

Combining crisis management with sensible long-term planning and progressive public policy is going to be the big challenge in 2022. The REAL Centre’s research aims to help policymakers understand the issues more deeply and therefore strike the right balance.

What’s next for the REAL Centre?

Coming up for the REAL Centre this year is our workforce projections report. This will focus on identifying workforce shortages, in particular in nursing and general practice, presenting workforce supply and demand projections up to 2030/31.

Investment in health care capital, public health and wider social determinants of health will help the UK prepare for the changing burden of disease and better support our ageing population. Later this year the REAL Centre projections model will focus on better understanding the dynamics of ageing, improvements in treatment and how the health of the population is going to affect our need for health and care resources.

Watch this space for more information about our upcoming work.

Toby Watt (@tlswatt) is a senior economist in the REAL Centre.

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