NHS in crisis: Is the health service as we know it over?

Don't expect some sudden, overnight collapse though; if the NHS fails, it will be the result of a steady, but accelerating, process of erosion and decay.

Plenty of people will tell you that that is exactly what is happening.

Things are not dramatically worse now than they were a year ago, but they are much worse than they were four or five years ago.

Turnaround times show that one in 10 ambulances arriving at A&E departments in the week beginning December 4 had to wait two hours to offload patients and get back on the road.

That means some 750 patients in need of emergency medical care spent two hours in the back of an ambulance instead.

At Aberdeen Royal Infirmary it was considerably worse, with handover times of over five hours for one in every ten ambulances arriving at its front door.

These are shocking statistics, but they are in danger of becoming the norm.

During the same week in December 2022, a tenth of ambulances waited over one hour 48 minutes, up from one hour 23 minutes in December 2021.

The trend goes hand-in-hand with A&E gridlock.

Back in 2018, just 80 patients turning up at Scotland's emergency departments in the first week of December spent over 12 hours there. In 2015, it was just 12.

Fast-forward to the same week in 2022 and suddenly that figure had ballooned to 1,300. This year it was 1,233.

The number of people going to A&E has not increased compared to pre-pandemic levels (Image: PHS)Waiting times in A&E began rising sharply from mid-2021 onwards, including unprecedented numbers of people spending over 12 hours in emergency departments (Image: PHS)

This has nothing to do with attendances, which remain lower than they were before the pandemic, nor has there been a notable increase in the percentage of patients being admitted from A&E onto hospital wards.

The problem is a lack of available beds.

NHS Scotland has roughly 270 fewer acute beds than it did a decade ago, but the bigger issue is that one in six of them is now occupied by people well enough to leave but stranded in hospital waiting for social care - either a care home place (we have 2,259 fewer registered places than we did in 2013) or a home care package.

Forecasts estimate that the UK needs to expand its adult social care workforce 25% by 2035 - equivalent to an extra 440,000 care workers - just to meet demand.

Yet care providers are already struggling to recruit and retain enough staff as a result of Brexit, Covid-related burnout, and comparatively poor pay and conditions.

While health and care workers are exempt from the UK Government's planned hike in the salary threshold for a skilled worker visa from £26,200 to £38,700, there are concerns that a new block on non-NHS overseas workers bringing dependent relatives will deter applicants with potentially "disastrous" consequences for the care sector.

READ MORE: 

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• Trade union warns social care 'at risk of collapse' as talks falter on sick pay and maternity leave
• Fears women's health ward could be closed to ease pressure on Forth Valley A&E

A parallel crisis is also unfolding in general practice, where figures this week revealed that the number of GPs by headcount increased by just 89 between 2017 and 2023.

Back in December 2017, then-health secretary Shona Robison pledged that the Scottish Government would increase GP numbers by 800 within the decade.

The baton since has been passed, via Jeane Freeman and Humza Yousaf, to Michael Matheson who this week insisted that the ambition remained "broadly correct" once you include GP trainees (a bit of statistical jiggery pokery which inflates the increase to 271).

This is unlikely to wash with Audit Scotland who warned in February that the 800 target is "not on track" and including trainees is "misleading".

There are several reasons for this: GP registrars need supervision, some will never qualify, many of those who do won't actually stay in Scotland, and they spend a large chunk of their training period based in hospitals - not GP practices.

Worse still, in real-terms (after adjusting for part-time work) the size of the GP workforce has actually shrunk by 5.4% over the past decade while the number of patients registered has swelled by 7%.

This simple maths goes some way to explaining why it is getting harder and harder to see a GP.

So what's the solution?

Labour's Shadow health secretary, Wes Streeting, has been jetsetting to Australia and Singapore in search of answers, which - should his party form the next UK Government - he wants to put into action in England, which is beset by all the same problems.

Yet - as think tank after think tank - has hammered home, we don't actually need to reinvent the wheel, or adopt some other country's model.

As the Nuffield Trust points out, there was virtually no growth in healthcare spending in the decade leading up to the pandemic after adjusting for changes in the population size and demographics, meaning that new drugs, technology and staffing have been paid for by cuts elsewhere in the system which "cannot be sustained indefinitely".

Investment in healthcare was flat in real terms in the decade leading up to the pandemic (Image: Nuffield Trust)

Health spending per capita in the UK is also lower than average for Western Europe.

When the King's Fund compared the UK against 18 other wealthy, developed nations we had the lowest number of CT and MRI scanners per million people; 2.5 beds per 1000 people compared to an average of 3.2 per 1000; fewer doctors and nurses per head of population; and, jointly with Greece, the second highest avoidable mortality rate. Only the US was worse.

However, it also stressed that there was "little evidence that one ‘type’ of health care system or health care financing model achieves consistently better results than another".

CT and MRI scanners per million head of population, 2019 or nearest year (Image: King's Fund)Mortality rates from avoidable causes, 2019 (age-standardised per 100,000) (Image: King's Fund)

Even high-performing healthcare systems like Germany and Singapore are straining from the pressures of growing and ageing populations.

The root of the problem for the NHS is chronic underinvestment, in the health service as well as social care, exacerbated by wider issues of ageing, obesity, and inequality - all of which are increasing.

It is difficult to escape the feeling that we may have finally dug ourselves into a hole that is too deep to climb out of - and it's not just for Christmas.