As we head into 2019, the media coverage has intensified with stories of the ‘mayhem’ due to the coming cold snap and the looming crisis in the NHS and the race to combat the “toughest ever” winter crisis and the pressures on the hospitals to meet their targets. This comes on the back of the BBC story, asking public to check how their local hospitals are performing against some key targets . We are now also told that the ministers and the NHS England chief are at loggerhead over targets and demands for specific improvements linked to £20.5bn cash boost for the NHS.
The pursuit of efficiency and use of performance measures has been a hall mark of the NHS in the last few decades. The management by targets approach in the NHS has yielded some positive results but cases of ‘hitting the target but missing the point’ are also common. For instance, in my own research, I have systematically documented a range of unintended consequences of the ambulance response time targets and have found out that the targets continue to play a significant role in driving behaviours and cultural perpetuation of key values. In my recent opinion piece, I have shown how the ambulance services have been failing to meet their new performance standards faced with various other challenges.
Evidence from the last winter points out the difficulties in meeting the A & performance standards. Media stories highlighting delays on the part of ambulance crews arriving at the scene including deaths of the patient waiting for an ambulance further add to the narrative. Some of these arguments have been rehearsed earlier but in my view there are two key issues which need our attention. These include: the funding situation for the NHS organisations, and the worsening staff shortage exacerbated by the Brexit and current immigration policy.
Address the funding-demand gap
The sustainability of an underfunded and overstretched NHS has been a matter of much debate , analysis and scrutiny including emotive calls about unnecessary deaths caused by the funding crisis. The National Audit Office in its most recent report has concluded that “the additional funding, aimed to help the NHS get on a financially sustainable footing has instead been spent on coping with existing pressures”.
The funding crisis has also been the subject matter of media reports and an ongoing inquiry by the Parliamentary Select Committee. Different sectors of the NHS are facing specific issues. In my research, I have argued the case for the ambulance service that doing even ‘same with less’ is proving difficult for individual ambulance trusts.
The Carter Efficiency Review , published in February 2016, highlighted concerns about wastage and ‘unwarranted variations’ across different NHS organisations. While it identified areas of improvement and potential savings of £5 billion, it also raised fundamental questions over the need for significant investment in the sector. However, in the current climate of financial austerity, it is difficult to see how its fifteen recommendations can be implemented in order to achieve the desired savings. Notwithstanding any disagreements over the about the scale of the problem, it’s quite clear that the NHS is under serious strain.
Improve staff situation
The NHS Five Year Forward View made a categorical commitment to support a diverse, modern and healthy workforce. However there are huge challenges on this front, not least the additional uncertainty the Brexit ‘deadlock’ brings. A joint report by the Nuffield Trust, Health Foundation and The King’s Fund, published in November 2018, has issued a stern warning that the current staff shortages of 100,000 is likely to rise to 250,000 by 2030 and could be more than 350,000 if the “emerging trend of staff leaving the workforce early continues and the pipeline of newly trained staff and international recruits does not rise sufficiently. This should not come as a surprise since the staff shortage crisis was highlighted in the draft NHS Workforce Strategy published in December 2017 for the first time in twenty-five years on back of the worst NHS crisis. Again, if we were to look at the figures for the ambulance and allied services, out of the 17,000 nurses, midwives and allied health professionals (AHPs) who went on to the professional registers between 2015 and 2017, only 7,000 of them have joined the NHS. The Strategy sadly points out that the primary reason for staff leaving the NHS is the ‘growing pressure’ they are experiencing in the workplace. Shortage and retention of staff, accompanied by the highest sickness absence rates in the NHS, dominate the ambulance workforce agenda.
Media reports are on the rise highlighting cases of harassment and bullying of the NHS staff as a consequence of pressure of meeting performance targets with one in four staff have reported to have experienced bullying in some way, costing around £2 billion annually to the NHS. The latest NHS Staff Survey has revealed some shocking statistics about the ambulance staff showing them worst for discrimination and equal opportunities, worst for illness due to work-related stress, worst for team working and worst for staff engagement. Last year, Guardian reported a story that the hospital bosses felt ‘humiliated and bullied’ when they were forced to chant ‘we can do this’ over A&E targets by a senior NHS official in a performance review meeting. CQC Inspection Reports highlighting similar concerns for poor staff morale due to the pressures of meeting performance targets are also not very uncommon. The issues around dignity and staff retention are still significant owing to the continuing work intensity.
As we enter the cold winter period, there are further signs that the NHS is witnessing an all year round-365 day crisis and the pressures felt by the system are not confined to the busy winter months. A latest report by Nuffield Trust has suggested that it is “unlikely that this winter is going to be significantly better for patients and the NHS than last year”. NHS figures continue to show that hospitals in England are ‘badly missing’ targets despite mild weather and low flu levels. An independent analysis on the impact of the £20.5 billion extra funding to the NHS has reported fears that it is likely to be used-up by the on-going issues such as the ageing population, pay rises, hospital effects and the rising cost of drugs.
Additionally, the uncertainty resulting from the postponement of the vote on the Government’s EU Withdraw Treaty in the Parliament and the dangers of a ‘cliff-edge’ Brexit is making the already grim situation worse. Such an uncertainty at the onset of what many believe would be a worst winter for the NHS, coupled with the impact of a harsh Brexit on the NHS workforce is likely to have a devastating impact on staff morale.
It is thus becoming clear that the current approach to deal the crisis with emergency cash injection is proving ineffective. It is time to take a fresh look at the targets and to address the fundamental issues of the funding gap and workforce welfare if NHS organisations are to have a fighting chance to meet their performance targets. Unless that happens, it very much looks like a ‘mission impossible’!