The government must tackle urgent NHS pressures while developing its 10 year plan

The forthcoming budget is an opportunity to make a start in filling the funding gap

The Darzi report into the current state of the NHS in England may have bought some time for the government to come forward with solutions, but time does not stand still. Work on the NHS 10 year plan for health is underway and publication of the government’s strategy has been promised for next Spring. In the meantime, NHS finances have deteriorated to the point where the planned deficit for the whole of 2024/25 was almost reached at the end of July.1

The immediate causes of NHS deficits can be found in the vanishingly small increase in the overall budget this year and eye watering efficiency savings that are widely considered to be implausible. These causes have compounded long term underfunding of the NHS and failure to keep pace with rising demand for care. NHS England’s requirement that integrated care systems sign up to unrealistic plans has had predictable consequences.

With pressures on emergency care increasing, and waiting lists for elective care stubbornly high, the government cannot afford to wait another six months before acting. Already the Royal College of Emergency Medicine has criticised NHS England’s winter plans and warned that patient safety will be compromised by “normalisation” of long waits in emergency departments.2 There have also been reports that the government wants the NHS to make greater use of private hospitals to deal with the backlog in elective care.3

Short term fixes like this may give the appearance that “something is being done,” and they will undoubtedly help some patients, but they are not consistent with the “big shifts” advocated by health secretary Wes Streeting. These shifts include moving care from hospitals to the community and giving priority to prevention over treatment. Neither can be delivered quickly and both require additional spending and, in some cases, legislation which will take time to put in place.

Both the prime minister Keir Starmer and Wes Streeting have argued that reform is necessary before additional investment in the NHS. Even if they believed that more resources were needed, they are hemmed in by the dire state of the public finances and election promises not to raise headline taxes. Whether they can hold the line on “reform before investment” remains to be seen, particularly as winter pressures increase in all areas of the country. Events as well as strategy seem likely to shape the direction the government takes.

The most visible events ministers should be concerned about are those at the front door of hospitals. Lengthy ambulance handovers, the persistence of “corridor care” because of bed shortages, and continuing risks of patients being harmed by long waits in emergency departments cannot be resolved easily. Pressures across the health and care system lie behind these challenges, including in social care where no relief is yet in sight as the government considers what to do in this area.

Additional capacity in the community and closer integration of hospital and community services have proved valuable in recent winters and are in line with the shifts outlined by Wes Streeting. So too are local initiatives like HomeFirst in Leeds where the emphasis is on supporting people in their own homes, timely transfers from hospital, and better coordination of care between hospitals and the community. Sharing and adapting initiatives of this kind should now be a high priority, learning from the work of the most developed integrated care systems in England.4

The government’s stated ambitions for a neighbourhood health service depend on well resourced and effective primary care led by staff who feel valued and supported. Agreeing a new contract that meets the aspirations of general practitioners, and is affordable, has never been more important. A lengthy dispute with the BMA risks undermining the foundations on which the NHS is built, as well as being harmful for patients and adding to the pressures on hospitals. The agility demonstrated by primary care during and after the pandemic must be sustained and supported.

With the clock ticking, the budget at the end of October offers an opportunity for the government to signal its intentions. A substantial downpayment on the capital investment needed to build resilient infrastructure and repair the crumbling NHS estate would be a good start, in primary care and other services. Extra funding for local authorities is another priority to support the shift to care in the community and shore up the threadbare safety net of publicly funded social care.

Resources are also needed to deal with this year’s financial pressures to avoid NHS leaders having to make the hard choices they are now confronting to balance their budgets. An example of these choices is funding to reduce long waiting times for mental health needs, including for people with autism. These waits attract less attention than those for people with physical health needs, but are at least as important, as are services for people with learning disabilities. Cuts in these less visible services should be avoided.

Greater honesty on these issues is overdue, starting at the top and recognising the time it will take to create a sustainable health and care system. The government must understand the urgency of tackling today’s challenges and ensure the actions they take are aligned with the 10 year strategy under development. Leaders within the NHS are experiencing greater pressures than a year ago and are concerned about their ability to provide safe care.5

Unless these leaders are given realistic objectives that can be delivered with available resources, their motivation to keep trying risks being undermined. Time is running out to avoid this happening.