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The NHS in England is under extreme pressure. The number of people waiting for routine hospital treatment is now 5.8 million and could grow much larger. Ambulance response times are increasing and A&E waiting times are the worst since records began. GP consultation numbers are now higher than before the pandemic. And COVID-19 is likely to have created additional health care needs, such as for mental health support.  

The NHS is trying to deal with these pressures with a staffing gap of more than 90,000 – a gap that could grow significantly over the next decade, according to our latest REAL Centre analysis. The current workforce is exhausted. The day-to-day experience of these pressures in general practice is described by my colleague Becks Fisher in her interview this month. 

The adult social care system is also on its knees. Staffing gaps stand at around 105,000 and many people go without the care they need. Reliance on unpaid carers in the UK is high – higher than in most comparable countries – but the number of carers accessing support has decreased. COVID-19 appears to have made these longstanding problems worse, such as unmet need for social care. 

Government policy is falling short 

Over the last year, the government has announced a mix of policy changes and investment for health and social care, including NHS legislation, a cap on social care costs, and a health and care levy to fund additional spending. And more policy change is coming: further white papers on social care reform and health and care integration are promised. The government is also due to publish its white paper on ‘levelling up’, which will affect health and health inequalities.  

But – so far – the policy changes announced fail to match up to the challenges facing the health and care system. This autumn’s Spending Review and the Health and Social Care Bill provide two examples. 

A closer look at plans for spending 

In last month’s Spending Review, real-terms increases in funding for most public services were announced. This is welcome. But only three departments – Health and Social Care, the Home Office, and Education – will have higher spending than in 2010. Austerity is far from undone, and the effects of a decade of underfunding on people and public services will be felt for many years.  

Day-to-day NHS spending will increase by 3.8% between 2021/22 and 2024/25. The NHS has been prioritised over other public services, and will make up nearly half of day-to-day government spending by 2024/25. But our analysis on the impact of the Spending Review on health and social care shows that the extra investment may still be insufficient to address the backlog in unmet health care needs and recover services. And more money is not much good without more staff. The Spending Review failed to provide details on long-term investment in the NHS workforce. 

Social care fared far worse. For core services, the amount made available for spending on social care is expected to increase by around 2% a year. This is barely enough to meet demand for care, and will not even begin to tackle the other pressures in the system – including unmet need, staff shortages, poor pay and conditions, and more.  

The government has announced some reforms to the social care system, including a cap on how much people will have to pay towards care over their lifetime. But these changes are not enough to provide care to everyone who needs it and improve quality of services. We’ve set out the benefits of further investment for reform in adult social care with colleagues from the Nuffield Trust and The King’s Fund.  

Government also announced last minute changes to the planned reforms last week, making them less fair and less generous to people with low to moderate levels of wealth than they originally appeared. Capping care costs makes sense, but these changes are a step in the wrong direction.  

Public health was also overlooked. The Spending Review committed to maintaining the public health grant for local authorities (which funds services like smoking cessation and children’s services) in real terms. But the budget has fallen by 24% per capita since 2015/16. This means that the government is choosing to underfund local services that can prevent ill-health and reduce health inequalities.    

For this month’s newsletter we summarise different perspectives on what the Spending Review means for the NHS, social care and public health, following our recent webinar on the topic. 

A legislative shake-up 

A second example is the Health and Social Care Bill currently being debated in parliament. The bill is the biggest legislative shake-up of the NHS in a decade, and – as we wrote in the BMJ recently – is a story of two halves.  

The first is a set of changes to promote collaboration in the health system, including by establishing new integrated care systems in 42 areas of England. Encouraging collaboration to improve care makes sense, and goes with the grain of recent NHS policy. But the benefits of the changes should not be overstated and there is a risk that the new NHS structure is complex, vague, and fragmented. The changes may also distract local agencies as they try to recover services. The second is a set of changes to increase political control over the day-to-day running of the NHS. These changes lack clear rationale. You can find our overall assessment and analysis of the changes here

The bill will create new NHS structures, but it will do little to address the fundamental challenges facing the health and care system. For example, staffing shortages are the biggest short-term issue. Yet measures in the bill to improve workforce planning are limited and weak.  

That’s why we, along with 60 other organisations, supported an amendment tabled by Jeremy Hunt MP to ensure that independent projections of workforce supply and needs in health and social care are produced and published regularly. We’ve also argued that the bill could do more to strengthen action to reduce vast health inequalities. The government did not adopt critical amendments on workforce planning when they were debated this week, but the bill could still be amended as it travels to the Lords. 

An unsustainable approach 

The health minister has said that current pressures in the NHS 'are sustainable’. But it would be extraordinary to look at what’s happening in the health system right now and claim it is sustainable.

Millions of patients and staff are already feeling the negative effects of a health system struggling to cope with demand. The combination of investment and reform announced by government so far fails to match up to these pressures.  

There are no quick fixes. But there are some obvious gaps – the most gaping being the lack of a fully-funded strategy for recruiting and retaining enough staff for the NHS and social care over the long term. The flurry of white papers and organisational changes will be little good without one. 


Hugh Alderwick (@hughalderwick) is Head of Policy at the Health Foundation.

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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