The NHS - Staffing Crisis

Recent conservative policies including efficiency savings, the withdrawal of nursing bursaries in 2017, prolonged wage freezes and an uncompromising attitude to the working conditions of junior doctors have resulted in an unprecedented crisis in NHS and social service staffing levels:


Facts:
There are currently 100,000 staff vacancies comprising 9% of all NHS posts, most are in nursing. 

Kent has the second highest rate of vacancies in the country

There are currently 122, 000 staff vacancies in adult social care (9% of care worker posts are unfilled)

Despite government promises nursing staff levels grew by only <1% between 2009 and 2018 despite a larger population growth and increase in proportion of those over 75.
Again despite government promises to increase GP numbers by 5000 by 2020 GP numbers have actually fallen

This is accentuated by a fall of thousands of GP's between 2015 and 2018 if you take into account the greater numbers of part time equivalents.
The UK has lower levels of nurses per head of population than France, Germany, Belgium, Ireland and the Czech Republic, approximating levels seen in Lithuania
Despite an increase in hospital medical staff numbers, 53% of consultants report gaps in medical cover, this situation is critical in accident and emergency

Projections:

  • By 2030 the projected deficit in NHS staff is 250,000. 
  • Because of the age demographics the fall in staff numbers is likely to increase as a result of retirement.  
  • Brexit will make the situation worse.  5.5% of the NHS workforce are from the EEA.  EEA nurse registrations in the UK are down 91% since the referendum. 
  • Kings fund indicates that 5000 nurses per annum need to be recruited internationally to prevent staff shortages worsening

Local Impact:
The 2019 Care Quality Commission report on the Princess Royal University Hospital rated Urgent and Emergency services as inadequate.  Amongst the reasons given were

  • Staffing levels and skill mix were not sufficient to meet the demands of patients
  • Patients could not access care and treatment in a timely way
  • UK GP waiting average waiting times continue to rise to over 14 days

Issues relating to the 2012 Health and Social Care Act

There were a number of areas focused upon in the act􀍘 It is complex I􀍛m afraid􀍘
Those sensitive areas relate to the commissioning of services. Over the past 3 decades successive
conservative and labour governments have promoted the concept of an internal market of health care
where health care providers (GPs and Hospital Trusts) commission services from a variety of providers.
The Act extended this and placed greater commissioning power in the hands of general practice􀍘 GP􀍛s
created GP commissioning groups ort CCG􀍛s to replace the primary care trusts􀍘 In theory this was to
increase the level of control over budgeting by primary care􀍘 In parallel the CCG􀍛s were required by law
to put out to tender contracts on the basis that there should be a level playing field between existing
NHS services and private contractors.
In addition Hospital trusts were encouraged to generate income from using their facilities and staff for
private treatments. The proportion of revenue that Trusts were able to generate in this way was set at
50% of their total revenue budget. The creating of foundation trusts was encouraged on the basis of
proven fiscal (but sadly as Stafford confirmed) less stringent quality of care guidelines. These Foundation
Trusts were able to raise funds independently of direct supervision by the Secretary of State for Health.
Consequences:
􀁸 A very elaborate system of commissioning was needed requiring additional staff and retraining
of GP􀍛s who has no experience in this area􀍕 many did not want this responsibility
􀁸 A rift was created between secondary care which tried to raise revenue by increasing the level
of services provided to general practitioners and CCG􀍛s who were endeavoring to keep within
budget and (as was also promoted in the 2012 Act) to transfer services from expensive hospitals
to the community.
􀁸 Increasing revenue from private resources created friction in NHS trusts between centrally
funded NHS services and more lucrative private sector use which could provide revenue to
offset budget deficits.
􀁸 Private contractors cherry picked low risk high turnover contracts such as cataract surgery and
diagnostic and radiological tests. This made NHS services less efficient by reducing the
economies of scale and many of these services are entirely in the hand of the private sector.
􀁸 More complex contracts such as the provision of end of life contracts in Staffordshire and
Community Care for the Elderly in Cambridgeshire failed to get beyond the negotiating phase
having consumed much in the way of time and effort by the commissioners
􀁸 Undercutting by private providers in an attempt to gain contracts had dire consequences, the
best example was the Hinchingbrook Hospital managed by Circle which had to be handed back
to the NHS.
Current levels of private funding:
􀁸 Despite the implementation of the act NHS commissioners allocate only 7.3% of the NHS budget
to the private sector and this has not risen significantly between 2017 and 2019.
􀁸 The total private sector budget is in fact much larger if you regard GP􀍛s who are in fact self
employed (contracted by NHS) and pharmacists and amounts to 25%
Impact of Brexit and the impact of US trade deals
􀁸 Although much has been made of the impact of Brexit on US involvement in the NHS through
trade deals it has to be remembered that the US sector currently operates many contracts
within the UK and has had that access for many years.
􀁸 There are two possible interventions which may prove harmful
o Drug procurement regulations that limit the use of generic pharmaceuticals in favour of
their more expensive branded equivalents.
o Access by US companies to those NHS services currently used by Trusts to generate
revenue through private work. This process which was seen by many as privatisation by
stealth could account for as much as 50% of the revenue of NHS trusts. It is possible to
envisage that US companies would seek to tender to run these services and expand
them at the expense of the public NHS services.
Other Impacts of Brexit
􀁸 RESEARCH
o The Russel Group Universities report that in the year after the referendum the was an
11% increase in academics leaving the UK.
o Between 2007 and 2013 the UK received 8.8 billion euros in research and development
funding, even allowing for the UK contribution to the EU, the net gain was 3.3 Billion
Euros. This funding will be lost.
􀁸 REGULATORY BODIES
o The UK is governed by EU regulations concerning
􀂃 The supply of medicines and devices
􀂃 Working time directives
􀂃 Competition law
􀂃 Medicines regulation
o With the advent of Brexit the UK will need to replicate these regulatory bodies.
o The consequences may be of reduced priority access to new drugs and treatments
Conservative election funding pledges
􀁸 Perhaps not surprisingly it is difficult to get much detail on these what is however clear is
o Expenditure and a % of GDP on the NHS is around 7% and less than in 2014
o Increased spending now is unlikely to reverse the effects of 22 billion pounds of
􀍚efficiency􀍛 savings in the 􀏱 year plan
o 47% of trusts are currently in the red
o Capital expenditure on hospitals is window dressing, the real deficit lies in revenue
funding.
o Despite pledges of increased funding the current staff shortages cannot be corrected in
the short term by expanded training places in the UK, the situation will get worse before
it gets better, this is further hampered by the Tories immigration policy which will
greatly hamper hospital trusts attempts to recruit nurses from abroad.

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