“When you cut budgets, cut services, and cut staff, you are also cutting away care”.
There’s a medical staffing crisis in the NHS which has been intensifying in recent years. For over a decade there have been calls for the government to ensure that we have a robust and sustainable NHS workforce by providing more medical student training places, and tackle the specialist training pathways for qualified doctors. But despite the many ambitious promises from successive leaders, the picture remains dismal. There are now huge staffing gaps, bottlenecks that inhibit doctors accessing training to produce the specialists we desperately need, and NHS doctors have been treated very badly by the government for the past 13 years.
The workforce has endured pay freezes and squeezes which have seen salaries plummet in real-terms since 2010. There have been punitive pension changes which have had enormous and unforeseen impacts on some doctors and most excruciating of all, NHS doctors have become the victims of politicised rhetoric from a group of politicians who profess to love the NHS but have continually undermined its functioning.
As we emerged from the pandemic, waiting lists were growing fast, and NHS staff were doing everything they could to meet the needs of their patients. GPs, in particular, have absorbed a huge amount of the pressure as patients endured long delays and cancellations with their hospital treatment. In August 2021 alone, GP practices in England saw five million more patients compared to the same month the previous year. And while all this was taking place, the government were busy pushing a Bill through Parliament which has fractured the NHS in England by breaking it into smaller units, and at the same time appeared to be running a campaign of abuse against the doctors. Things intensified so much that, as the Guardian reported, “Sajid Javid’s criticisms of how GPs work have fuelled a rise in verbal and physical attacks on them and their staff, the leader of Britain’s family doctors has claimed.”
It has been extremely difficult for NHS staff to absorb rhetoric from politicians, and then to see it repeated in many privately-owned media outlets again and again until it takes on the impression of fact. Doctors have been accused of being lazy and work-shy, greedy or uncaring, and, of course, many patients are absorbing this rhetoric and sometimes repeating these lines back to their doctors. The public are deeply frustrated, often suffering, often anxious, and looking for someone to blame. Some politicians and media outlets have instructed them to blame doctors.
It’s ramped up recently, because of the widespread industrial action. But for most of the doctors I speak to, the strikes are not solely about pay; most are not striking out of personal interest alone. When they go to work it is an incredibly stressful place to be, because the service has been cut back so significantly. They lack the colleagues they need to make the service feel robust, and who made the care for patients feel holistic. When you cut budgets, cut services, and cut staff, you are also cutting away care. Everywhere in the NHS there is a background hum of pressure, and the NHS staff exist within this environment every single day. The waiting lists are inescapable and suffocating; they loom over so many people who are doing their best, but who are exhausted. Their efforts never feel quite enough.
Those who have worked in the NHS for a long time, who may have trained within the service, built the service, trained others, and been part of the fabric of this institution for many years, desperately want it to survive. They recognise its value as a fundamental part of our society, and they want working conditions to improve in order to attract more staff, build robust teams again, and provide good retention prospects to ensure sustainability within the service.
But staffing is threadbare and it’s getting worse. It can be difficult to reconcile this with the figures and spin offered up by the government themselves. In April 2023 they stated:
“There are a record number of doctors, nurses and other healthcare staff working in NHS trusts in England helping to deliver extra appointments, speed up diagnoses and tackle the Covid backlog…There are more than 1.27 million full-time equivalent staff working in NHS trusts in England. This is 51,500 more people compared to a year ago - an increase of 4.2%...There are over 5,300 more doctors and over 12,300 more nurses working in NHS trusts compared to February 2022.”
But these figures don’t tell the full story. The churn rate of NHS staff is alarming at the moment; with almost 170,000 leaving the NHS in England in just the 12 months to July 2023. We are currently missing 154,000 NHS staff in England alone. But it’s not all about numbers. If, as the NHS is doing, you lose many experienced staff - haemorrhaging doctors, nurses and other healthcare professionals who have dedicated long years to the system - you cannot hope to replicate their efforts by just ramping up recruitment. Newer, less experienced staff or those who have less knowledge of the healthcare needs of a local population won’t bring the same richness of understanding to their work. This is qualitative, largely unreported, and incredibly important given the government’s new NHS workforce plan. The plan has received incredible media fanfare, with bold plans to strengthen the NHS with “an extra 60,000 doctors, 170,000 more nurses and 71,000 more allied health professionals in place by 2036/37”
This workforce plan is long overdue and much needed, and yet it falls short in many ways. There isn’t enough focus on retaining the healthcare workers we already have - paying them properly, providing them support in other ways. And there are wider concerns too from many NHS campaigners; a growing concern that politicians are seeking to de-skill the NHS workforce in order to bring down the staffing bill and undermine the quality of our public healthcare system, in order to allow private healthcare to flourish in the UK.
One of the developments which is causing concern for many is the rise in the role of the physician associates (PAs) within the NHS. PAs work alongside doctors to help to diagnose patients and fulfil some of the same roles as junior medical staff. I don’t want to express criticism about PAs specifically; I have heard anecdotally that PAs provide much needed support to teams during this NHS staffing crisis. However, there are huge concerns now that patients may not understand their role, that the PAs themselves may struggle to define their own professional limitations in a system under so much pressure, and that this workplace pressure will mean they struggle to find the supervision they need to safely work within medical teams.
After all, when things are extremely busy in the NHS, senior doctors have less time to teach junior colleagues or medical students, and subsequently there has become a need for junior doctors to behave more autonomously. This has always been an enormously challenging compenent of work in a busy environment, for all members of a medical team. But at least doctors can rely on an established framework – they all have the same scientific basis to their understanding of disease, and they fit within an clearly understood hierarchy within the workplace; and so the carefully honed processes to ensure that information flows up and down the chain of command ensure a patient has the right care delivered, even at times of strain.
There are legitimate concerns about introducing new staff who don’t have the same background knowledge; concerns that there might be knowledge gaps, or gaps in communicating information, and that mistakes could be made. One tragic high-profile case has brought all of this to the fore recently.
But is this an isolated incident? Are the concerns unfounded? Is our reaction simply a natural resistance to change? Should we abandon these concerns, and simply try to raise awareness about the changing shape of the healthcare workforce, the roles within teams? After all, the rise of the physician associate is not the only change. Rishi Sunak hopes to swell PA numbers to 10,000 in the NHS, but he also hopes to train thousands of other staff in apprenticeship programmes too. Things are extremely bad now; we do need drastic solutions, change is necessary. Are we worrying about the wrong things?
I’ve asked myself this a lot over the last few months, reading the views of frontline doctors, think tanks and professional organisations, and I can’t help but conclude that these concerns are not unfounded. My fear is that politicians have intentionally damaged our public healthcare system to the point of desperation, and having done this successfully, are now pushing through suboptimal plans, which are gratefully received by people who have been so failed that they are now thankful for anything at all.
I think they intended to change the very nature of the NHS -from a robust service, serving every person in our country with the healthcare they need, into a just-enough backstop, a last resort which most people will not want to rely upon. Instead, they will take out healthcare insurance, they’ll go private, they’ll pay for healthcare because they’ll have to.
We needed new hospitals and they haven’t provided them, so some NHS hospitals are propped up with supports.
We needed new doctors, and they’ve inserted new staff in their place, who are cheaper to train and cheaper to employ.
Ten years ago we had the best healthcare system in the world. If we want that again, and I believe we do and we can, we need to fight for it. If we don’t, we’re going to lose it.
A few years ago HEE produced a forward look to 2027. Lots of assumptions you could disagree with but I thought it was quite good and could be updated as assumptions changed. Essentially it disappeared without trace and an almost mythical workforce plan was mooted before I retired. I've only seen the headline numbers and frankly, the idea of 60,000 extra doctors alone, is laughable. We are never going to fill these from our schools, so a huge proportion would have to come from overseas and we know how the Tories have weaponised immigration.
Moreover, if you are young and bright do you want the years and costs of training when you can earn ridiculous amounts in finance and tech? And not even touched on affordability. As for 170k more nurses - maybe with forced labour....
I think when PAs came in there was talk of them developing into a quasi-apprentice route to doctor level. Good idea perhaps? Not everyone goes to elite schools or universities. However, in Sunak's hands it does feel more like a Poundland approach to medicine.
Great stuff but it’s clear this government are intentionally running the service down just months from a general election and today reports of 7.8 million on waiting list for treatment in the NHS ! 7.8 million waiting ! This is only going to end one way! What a way to treat your own people !!..,