London CNN –
Most winters the headlines warn that Britain’s National Health Service (NHS) is at ‘breaking point’. The alarms go off again and again and again. But the current crisis has alarm bells ringing louder than ever.
“It looks different this time,” said Peter Neville, a doctor who has worked in the NHS since 1989. “It’s never been as bad as it is now.”
Scenes that were unthinkable until recently have now become commonplace. The capacity of the hospitals is quite overcrowded. Many patients are not treated in wards, but in the back of ambulances or in corridors, waiting rooms and cupboards – or not at all. “It’s like a war zone,” an NHS worker at a Liverpool hospital told CNN.
These stories are borne out by the data. In December, 54,000 people in England had to wait more than 12 hours for an emergency appointment. The figure was virtually zero before the pandemic, according to figures from NHS England. The average waiting time for an ambulance to attend a ‘Category 2’ condition – such as a stroke or heart attack – exceeds 90 minutes. The goal is 18 minutes. There were 1,474 (20%) more deaths in the week ending December 30 than the 5-year average.
Ambulance staff and nurses have staged a series of strikes over pay and working conditions, with the latest walkout by ambulance staff taking place on Monday. More are planned for the coming weeks. The chief executive of the NHS Confederation, which represents NHS organizations in England, wrote to the government in the run-up to last month’s ambulance strike to warn of NHS leaders’ fears they “cannot ensure patient safety” that day . In response, a government health minister advised the public to avoid “risky activities”.
While the NHS has suffered crises before, this winter has brought a new reality: in Britain, people can no longer rely on receiving healthcare in an emergency.
Founded shortly after the Second World War, the NHS is treated with almost religious reverence by many. Britons danced for him during the 2012 London Olympics and applauded him during the pandemic. “Our NHS” is a source of national pride.
Now it’s coming off. There has long been an implicit contract between Britons and the state: pay taxes and national insurance contributions in return for a health service that is free at the point of use.
But with the tax burden about to reach its highest sustainable level since the NHS was founded, Britons are paying more and more for a service they increasingly cannot access as quickly as they need it.
Some of these strains can be seen elsewhere in Europe. Doctors in both France and Spain have gone on strike in recent weeks as many countries face the same problems of providing care for an aging population – when inflation is at its highest level in decades.
Yet there are concerns that the NHS is in worse shape than its international counterparts, and CNN spoke to experts who said they feared they were witnessing a “collapse” of the service.
So how did Britain get here?
When Covid-19 hit, the NHS went into full crisis mode, diverting staff and resources from across the organization to care for patients with the disease.
But for many in the NHS, Covid-19 remains a crisis they are yet to emerge from.
During the height of the pandemic, many common practices were put on hold. Millions of operations were cancelled. The NHS ‘backlog’ has grown. Figures from November show there are more than 7 million people on hospital waiting lists in England.
This winter, the “twin epidemic” of Covid and flu continues to put additional strain on capacity.
Explanations of the current crisis “have to start by looking at Covid-19,” Ben Zaranko, an economist at the Institute for Fiscal Studies (IFS) whose work focuses on Britain’s health care system, told CNN. “There is the simple fact that there are beds in hospitals occupied by Covid patients, which means those beds cannot be used for other things.”
Covid has also put a strain on the amount of work the NHS can do. “If you add up all the time staff spend on infection control measures, donning protective equipment and separating wards into people with and without Covid … it can hamper the overall productivity of the system,” Zaranko said. Sickness rates for NHS staff are also significantly higher than they were before the pandemic, according to the IFS analysis.
But, again, Britain was not alone in its fight against the pandemic, but it appears to have been hit worse than comparable nations.
This is despite there being more doctors and nurses in the NHS now than before Covid. According to an IFS report, even after adjusting for staff sickness absence, there are 9% more consultants, 15% more junior doctors and 8% more nurses than in 2019.
However, the NHS is treating fewer patients than before the pandemic.
“It looks like parts of the system don’t fit together anymore,” Zaranko said. “It’s not just about how many staff there are and how much money there is. This is how it is used.’
Even with increased funding since the pandemic, the UK is still catching up after what critics say has been more than a decade of underfunding the NHS.
Neville, a hospital consultant, described 2008 as “the best” he had seen in the NHS in more than 30 years working in the NHS. At the time, the NHS had enjoyed almost a decade of significantly increased investment. Waiting lists have decreased significantly. Some even complained about the appointment of a doctor too quickly.
“When the Labor government came in in 1997, they injected significantly more money into the NHS. This allowed us to adequately staff and get on the waiting lists,” Neville told CNN.
But this level of investment did not last. In response to the financial crisis of 2007-2008, the Conservatives, elected to the coalition government in 2010, embarked on a program of austerity. Budgets were slashed and employee salaries frozen. For Neville, the decade that followed saw a gradual “erosion” of the system: “Slowly, subtly, but it’s happening nonetheless.”
According to analysis by the health charity the Health Foundation, average daily healthcare costs in the UK between 2010 and 2019 were £3,005 ($3,715) per person per year – 18% below the EU14 [countries that joined the EU before 2004] average £3,655 ($4,518).
During that period, capital expenditures — the amount spent on buildings and equipment — were particularly low, according to the Health Foundation’s analysis. The UK has far fewer MRI and CT scanners per person than the Organization for Economic Co-operation and Development (OECD) average, meaning staff often have to wait for equipment to become available.
Hospital beds are particularly scarce. Over the past 30 years, the number of beds in England has more than halved, from around 299,000 in 1987 to 141,000 in 2019, according to analysis by the King’s Fund, an independent think tank.
Siva Anandichiwa, principal analyst at the King’s Fund, told CNN that this decrease is partly due to “the changing model of care.” As technology and treatment improve, people spend less time in hospital, reducing the need for beds. The last Labor government, in power from 1997 to 2010, also cut the number of beds, despite increasing investment elsewhere.
“You can continue to reduce the length of stay of patients in a hospital,” Anandaciva said, but eventually “you get close to the bottom line. If you then continue to reduce the number of beds … then you start to run into issues like efficiency.”
During years of austerity, the number of beds continued to fall, leaving the UK with fewer beds per head of population than almost any developed nation, according to OECD figures.
“We knew for a long time that we just didn’t have the bed capacity,” Anandaciva said. But the cuts continued in the name of “efficiency,” he added.
While the low number of beds was seen as a “success” marker showing that the NHS was working effectively, it left the UK woefully underprepared for a shock like Covid-19. The same factors that made the NHS “effective” in one context made it grossly ineffective when that context changed, according to his analysis.
The bed shortage is made even more acute by the fact that many of the hospitals no longer need to be there – they simply have nowhere else to go.
“The longest period I’ve had a patient who was physically and medically ready to go home but was sitting around waiting to be discharged was four weeks,” said Angus Livingstone, a doctor based at John Radcliffe Hospital in Oxford.
The problem is caused by a crisis in another sector: Social care. Patients who could leave the hospital end up staying there because they do not have access to more modest care in a home environment and therefore cannot be safely discharged.
Health and social care are separate sectors in the UK system. Health care is provided by the NHS, while social care is provided by local councils. Unlike the NHS, social care is not free at the point of use: it is allocated and means-tested.
There have long been calls to integrate the two systems, as a crisis in one system spills over into the other.
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