Parliament returned after the summer break earlier this month, and since then debate has been dominated by the NHS and social care. As COVID-19 moves from pandemic to an endemic disease, politicians and service leaders are wrestling with the long-term consequences for the health and care system.   

The scale of the challenge 

Across the NHS and social care, services are disrupted and facing increased demands, which show no sign of abating. For the NHS that means growing waiting lists and major pressures on emergency services and primary care.  

The big development in September was the announcement of a new levy to fund reform of social care and to support NHS recovery. The levy raises £30bn for England over the next few years, of which £5.4bn is earmarked for social care and £15.8bn for frontline NHS services. These are big sums of money and increasing tax rates is a bold development. But, as I wrote for a piece in Prospect magazine, the scale of pressures on the system means there is a very real risk this funding will fall short of what is needed.  

The Health Foundation’s REAL Centre today publishes our Health and social care funding projections 2021 report. This sets out the long-term funding requirements for health and social care in England to 2030/31. Alongside the funding requirements, it highlights that the NHS and social care system are going to need many more staff over the next 10 years; almost a million more workers in total.  

Clearing the backlog of care and delivering the NHS Long Term Plan 

Our evidence to the Health and Social Care Select Committee and new analysis on the waiting times backlog highlighted that there are now over 5.6 million people currently waiting for care. A third have been waiting for longer than 18 weeks, 300,000 for more than a year. But this is just the tip of the iceberg with 7.5 million ‘missing patients’ since the start of the pandemic (this refers to the number of patients that would have been expected to be referred for routine hospital care in this period based on numbers prior to the pandemic). The health impact of the backlog was outlined in our new analysis of hip replacements and diabetes care.  

But the challenges facing the NHS are not confined to elective care, they are system-wide. As my colleague Ruth Thorlby explains in this interview for the newsletter, the Foundation’s new report on how COVID-19 has affected progress with the NHS Long Term Plan found that no part of the plan has been unaffected. Previous national targets – such as expanding access to mental health services – will need to be revised to account for greater need. It's clear that COVID-19 has exposed and widened existing inequalities in health and care in England. And in primary care our evidence to SAGE on the scale of disruption to services through the different waves of the pandemic shows the ongoing challenge to recover services.  

What can be done? 

The government’s Health and Care Bill, designed to formalise the structure of Integrated Care Systems (ICSs), is currently at committee stage in the House of Commons and we have submitted evidence as part of this process. While new partnership structures have been developed to help local agencies improve care, the pandemic has held back the broader process of redesigning care to improve health and reduce inequalities. The new ICSs need to hit the ground running with reducing inequalities at the heart of their work.  

Our analysis of the backlog of elective care shows that staffing will be a key constraint shaping the pace of recovery. We estimate that eliminating the backlog in care and delivering the 18-week target by 2024/25 would require 4,400 more consultants and more than 18,000 more nurses. This is in addition to the current workforce shortages. Finding those extra staff will be very difficult and is a textbook example of why workforce planning needs to be improved.   

In social care, providers are also reporting major challenges in recruiting and retaining staff. The Health Foundation has been working with organisations across the health and care system to argue for an amendment to the Health and Care Bill to strengthen workforce planning. The amendment would place a duty on the Secretary of State to publish regular, independently verified projections of workforce demand and supply for both health and social care.  

Grasping the opportunities ahead 

The challenges ahead for the health and care system are daunting but there are also opportunities. Some commitments in the NHS Long Term Plan have been accelerated by the COVID-19 response, such as improving access to remote consultations in primary care and outpatients. While these changes will need careful monitoring and evaluation, opportunities to work differently need to be grasped. Our evidence to the Health and Care Select Committee showcased some of the excellent, innovative work going on across the NHS as part of backlog recovery plans, and we’ll be publishing a long read on productivity very soon mapping some of the key opportunities in this area. You can also sign up for our webinar on this topic in October: NHS Recovery – how do we ‘build back better’? 

A bigger plan 

But while funding and legislation are important, they need to be part of a much bigger plan. The health system needs an updated strategy for delivering the NHS Long Term Plan and a focus on recovery which addresses the backlog in elective care without compromising interventions to prevent disease and reduce inequalities.  

We also need to remember that the NHS cannot reduce inequalities on its own. October’s spending review will set out the government’s funding plans for wider public services. Increased investment in the NHS must go alongside investment in public health, the means tested adult social care system and a broader range of policy interventions to give more people the opportunity to live a healthy life. We are hosting a range of events at the party conferences to debate many of these issues and raise awareness of them among politicians and decision makers. 


Anita Charlesworth (@AnitaCTHF) is the Director of Research and the REAL Centre at the Health Foundation 

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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