NHS crisis: How did we get here and is there a potential route back?

December's NHS figures made for truly shocking reading.

People who had heart attacks or strokes waited more than an hour and a half for an ambulance to arrive, on average - the longest ever by more than half an hour. People in life-threatening conditions also waited longer than any time on record.

More than half of people attending major A&Es waited more than four hours to be seen and assessed, again for the first time ever.

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And once they had been assessed, almost 55,000 people waited a further 12 hours in A&E to be admitted to hospital.

This is not just an all-time record, but is higher in one month than the total recorded over 11 years from August 2010 to September 2021.

These delays could be responsible for hundreds of unnecessary deaths every week.

Pandemic vs general decline

But how much of this poor performance - the backlog of operations, exhausted staff and sicker patients - can be put down to the pandemic?

And how much of it is part of the general decline in the health service over the past decade and its inability to keep up with the demands of an ageing population?

Throughout the 2010s the number of people assessed in A&E within four hours remained fairly static each month, despite more people attending.

Demand rose while treatment capacity didn't, so waiting times went up.

Since the pandemic, there have been fewer people attending A&E than before (on average, it's risen more recently), but fewer still are being treated within four hours.

Demand is actually down but capacity is down more. Despite the different demands, waiting times have risen at a similar rate.

It's a similar story with the waiting list.

The number of people starting treatment each month rose gradually throughout the 2010s, but the number of people being added to the list was consistently higher.

Demand was rising but capacity wasn't at the same level.

Now, the number being referred for treatment each month is lower than it has been for at least six years, but the number of treatments starting is also down.

The pandemic is one reason for this difference - staff sickness and absence reduces the amount the NHS can do, and sicker patients take longer to treat. But the problem was already very much present before.

Tim Gardner, senior policy fellow at the Health Foundation, said the recent data showed that "the NHS is facing an emergency, but the roots of it lie in political choices made over the last decade, not the cold weather or seasonal flu".

"The pressures on the NHS result from a decade of underinvestment in the NHS and other public services, a failure to address chronic staff shortages, raiding capital budgets and the longstanding neglect of adult social care."

Shortages in staff, money and resources?

As the population increases, the number of staff looking after patients must increase too, to keep up.

The population of England grew by 6.5% between the 2011 and 2021 census, but that doesn't tell the whole story.

The number of people aged between 20 and 50 fell slightly, while the number of over-65s grew by almost 20%. There are 40% more over-90s.

An ageing population is a victory for public health in general, but comes with the responsibility to service an increased demand.

Older people generally have higher healthcare needs. They get sick more often and when they get sick it takes them longer to recover.

Funding, staffing and resources need to rise at the same level as the older part of the population just to maintain previous standards of care, before thinking about improvements. Even if the patient/staff ratio is maintained, the endurance and experience of those NHS staff is also critical - something which appears to be at risk at the moment.

Andy Curran, consultant in emergency medicine for Lancashire Teaching Hospitals NHS Foundation Trust, told Sky News that he fears for the future as staff drop out or are working less to protect their own wellbeing: "I've struggled with it (my mental health) personally. But a lot of colleagues who have been working full-time have had to reduce the hours they do just to maintain their own wellbeing.

"We see junior members of staff coming through who are leaving us earlier than ever before, to go and work elsewhere.

"If we're not careful, we'll make it such an unattractive place to work that we won't have anyone to come through to care for us when we're in crisis."

Overall, the number of NHS doctors and nurses has grown by more than the ageing population over the past ten years, thanks mostly to sharp rises in recent years. So that's some rare good news. But the number of managers has not kept pace.

The Institute for Fiscal Studies says this could be contributing to a slowdown in healthcare efficiency.

"The whole system could be functioning less effectively because of insufficient or ineffective management. To simplify enormously, managers can improve productivity by taking on operational tasks, leaving clinical staff to focus on treating patients: their comparative advantage," the IFS says.

"Managers, in turn, can stick to what should be their comparative advantage: planning staffing schedules, for instance, or scheduling operating theatre use."

Healthcare funding

Funding has increased over the past ten years, but not at a level that responds to this growing and ageing population.

Data from the Nuffield Trust, an independent UK healthcare research group, shows how spending halted in 2010 - relative to the changing population - having grown through the 2000s and before.

Nuffield's John Appleby and Sally Gainsbury said that even if the latest spending pledges are delivered, "it will still only bring the average annual increase between 2009/10 and 2024/25 to 0.5%".

"This is far below the long-run average of 2.6%, and comes against the backdrop of the health service trying to recover from a pandemic."

So while the number of doctors has increased with time, the efficiency of their work appears to be being hampered by a lack of managerial direction and a lack of funds and equipment.

Hospital beds

One of the most striking examples of this lack of resources is beds.

In 2012 there were 99,562 beds available across English hospitals on average every day in December. By 2022 this had increased by less than 500, to 99,927.

Along with social care, the lack of beds could be one reason why A&Es are not able to discharge patients into different parts of the hospital. Hence, the long waits in A&E and ambulances being unable to offload their patients.

Is there any way back for the NHS?

We're seeing the first signs of a turnaround in fortunes for the waiting list. It went down in October for the first time since May 2020, from 7.21 million to 7.19 million. The number waiting over a year, over 18 months and over two years all came down - but there's still a long way to go.

Over 200 times more people have been waiting over a year for treatment compared with when the pandemic began.

These longest waits have been targets for the NHS for several months now, and Prime Minister Rishi Sunak said cutting the list was one of his top five priorities for 2023. He also announced £250m of extra funding to the health service.

It seems a tough challenge, but there is a precedent.

In August 2007 when figures first started being collected, 4.2 million people were on the waiting list and almost 600,000 of them had been on there over a year - more than even at the worst stage of the pandemic.

In just two years, the waiting list had almost halved, to 2.3 million. The number waiting longer than a year was 18x lower than it had been, at just over 30,000, and would be below 1,000 before the end of 2012. As the spending data from Nuffield in the chart above shows, however, it didn't come cheap.

In 2003 the Labour government increased National Insurance by 1% to help pay for a £6.1bn spending increase, dwarfing the £250m currently committed by this government. Even then it took years before the waiting list started to fall.

A spokesperson for the King's Fund, an independent charitable organisation working to improve health and care in England, welcomed Mr Sunak's recent announcement of more funds, but said it has to be sustained to see the same levels of success as his now fairly distant predecessors from the 2000s: "Given the crisis at hand, this week's emergency £250m cash injection from the government will be welcomed by the health care system, but real concerns remain that this short-term boost comes so late into the winter and will take time to reach frontline services and improve care for patients.

"Ultimately short-term fixes won't solve long term challenges. A timeline on the upcoming workforce plan would be a good starting point to signal longer term thinking from the government.

"Waiting times can be reduced, as seen in the early 2000s, if services have a clear focus and the right levels of investment and staffing. Without these conditions, it is unlikely that sustained pressures across the system will ease."

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