Ahead of the general election, we're aiming to inform debate and help make sense of what the latest developments mean for health and social care.
Our series of long reads explores the big issues, outlining the evidence and highlighting the key priorities for any new government. But if you haven’t had time to read the detailed briefings, we’ve pulled out the key points below.
1. The nation's health
A healthy population is one of the nation’s most important assets. It is valuable in its own right and also creates value for society. It allows people to participate in family life, the community and the workplace.
Long-term improvements in life expectancy and mortality in the UK have stalled and are falling behind other high-income countries. At the same time the difference between the health of people living in the best- and worst-off communities is widening.
Action is needed across the whole of government to address these trends. Investment needs to be directed towards areas of public spending that create the right conditions for people to lead healthy lives.
Stronger measures are needed to ensure that government is held to account for the health of the population. This should include adopting a legislative framework, along the lines of the Welsh Wellbeing of Future Generations Act to encourage long-term action across government to promote good health. It should also include establishing an independent body to track and analyse trends in mortality and morbidity.
Similarly, the way success is measured nationally needs to change, moving beyond GDP to evaluating policy on the basis of health and wellbeing as a primary measure of successful government.
2. NHS performance and waiting times
Essential parts of the NHS in England are experiencing the worst performance against waiting times targets since the targets were set. This includes the highest proportion of people waiting more than four hours in A&E departments since 2004, and the highest proportion of people waiting over 18 weeks for non-urgent (but essential) hospital treatment since 2008.
The target for treating cancer patients within 62 days of urgent GP referral has not been met for over 5 years, and survey evidence suggests more people are experiencing lengthening delays in getting GP appointments.
Longer waits are a symptom of more people needing treatment than the NHS has the capacity to deliver. This reflects a decade of much lower than average funding growth for the NHS and workforce shortages, coupled with growing and changing population health needs. These pressures are exacerbated by cuts to social care and public health budgets, which make it harder to keep people healthy outside hospitals.
It will take sustained investment in the NHS and social care to reverse lengthening waits. This will include filling existing staff vacancies and growing the workforce, investment in buildings and equipment, and stabilising the social care sector.
If the NHS is to achieve its long-term vision of a service that can prevent ill-health, better manage long-term conditions, and treat people earlier, NHS staff will need time, space and skills to make change at all levels of the health and care system.
3. Health and social care funding
UK health spending has grown by 1.6% a year over the last 4 years. This is much less than half the historical average growth rate. Compared to similar countries, the UK’s day-to-day spending on health is around average, but capital investment is notably low.
In England, the strategy for the NHS – the NHS long term plan – is underpinned by a funding settlement up to 2023/24, with average annual increases of 3.3% a year, starting this year. But this is against a backdrop of significant hospital deficits, a maintenance backlog and workforce shortages – all flowing from previous inadequate investment.
The funding settlement doesn’t cover the full budget for the NHS in England. Budgets for workforce education and training, public health and capital continue to have neither a plan nor long-term funding. Without further investment in these areas, quality and access to care are at risk of deteriorating further. As things stand, the total health budget will increase by just 2.9% a year to 2023/24.
Maintaining current standards of care will require funding for these areas to increase by at least 3.4% a year – £3bn of funding in 2023/24 above current announcements. Investing in and modernising the health service as set out in the NHS long term plan requires around 4.1% a year – a further £4bn above that figure.
The focus on mental health, primary and community services in the NHS long term plan is welcome. But there remain real challenges to ensure that this is not undermined by staff shortages, which despite the extra funding will prevent the intended improvements to these services.
The greatest challenge lies in adult social care. Increasing numbers of people are unable to access social care, and care providers are at risk of collapse. Funding has not kept pace with demand, falling in real terms for most of this decade. Restoring access to 2010/11 levels of service, and investing to stabilise the social care workforce, would require an increase of £12.2bn compared to estimates of funding available in 2023/24 for councils to spend on social care.
4. Health and social care workforce
The number of people employed by NHS providers in England this decade has grown at just half the rate of the 2000s, despite growing need. As a result, the NHS reports a workforce shortage of around 100,000 staff.
The issues in social care are even greater and the outlook is concerning. Workforce shortages stand at around 122,000, with a quarter of staff on a zero-hours contract.
Our projections, with the King’s Fund and the Nuffield Trust, suggest that without concerted policy action and dedicated investment, NHS shortages could grow to up to 200,000 by 2023/24, and at least 250,000 by 2030. Nursing remains the key area of shortage (of over 40,000) – and this could double by 2023/24 and grow to over 100,000 by 2028/29.
The number of nurses has grown at just one-third the rate of both doctors and clinical support staff in the past 5 years. Within nursing, the number of nurses working in community and mental health services in 2019 remains below 2014 levels.
This is partly caused by a failure to train enough nurses. In 2011 the number of training places was reduced by more than 10%. The removal of the nurse bursary in 2017 was designed to allow higher education to expand places but it has had limited impact on the number of students in training. Numbers are far below the 25% expansion planned: one in four nurses don’t complete their studies in the expected time and there are fewer mature students training in areas of mental health and learning disability.
Cost of living is a significant barrier for many. Nursing students tend to be older, have more financial commitments, and NHS training precludes undertaking other part-time work. We have recommended offering ‘cost-of-living grants’ of around £5,200 a year to help this.
Despite a 2015 target for 5,000 additional GPs by 2020, the number of qualified permanent GPs has fallen. As a result, the number of patients per GP continues to grow, from 2,120 to 2,180 last year alone.
One consequence of the failure to train and retain staff is that the UK is heavily reliant on international recruitment. This needs to continue: at least 5,000 nurses sourced from abroad a year need to be recruited until 2023/24 to reduce shortages. In 2017/18, the latest data available, just 1,600 nurses from overseas joined English NHS trusts. We do know how many overseas nurses are registered in the UK and therefore potentially available to work in the NHS. There are 33,000 EEA nurses on the register. In 2018/19, 3,400 more nurses came to the UK from outside the EU than in 2017/18. This follows an 85% fall in the number coming to the UK from the EU in recent years.
The social care sector employs a quarter of a million people from beyond the UK. Some areas of the country are particularly reliant; 40% of social care staff in London are from overseas. International recruitment is vitally important for social care and a restrictive immigration policy will make this harder.
As a major employer, typically providing better pay, terms and conditions, and career progression than social care can afford, the NHS has a significant impact on the social care workforce. More must be done to support social care – for instance, matching pay increases in the NHS would cost £1.7bn by 2023/24.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.