There are, according to the famous phrase “Lies, damn lies and statistics”, and the public is fed a diet of all, but amongst the most misleading government presentations are those on health spending.
Increases need to be understood in the context of the starting figure, funding needs to be assessed against needs and demands. ‘Record’ spending can still be inadequate – and in this case has been since 2010. High levels of taxation do not mean taxation is high enough to meet needs, or levied fairly.
How many times in the run-up to the 2019 election did ministers cynically misrepresent the scale of the funding settlement for the NHS that had been agreed by Theresa May’s Chancellor Philip Hammond at the end of 2018, quoting “an extra £33.9 billion” over five years in cash terms, rather than its real-terms value of just £20bn?
How many times have ministers used crude cash figures to claim “record” spending – when the real terms allocations since 2010 have been amongst the meanest since the NHS was established in 1948?
NHS Providers Chief Executive Chris Hopson calculated back in 2019 that if NHS spending since David Cameron first took office had just kept pace with the previous long term average annual increase, spending on health and social care would have been £35 billion per year higher than it was.
But year after year government and Conservative spin-doctors have successfully fed much of a poorly-informed mainstream news media with the illusion that the NHS has been lavishly funded under Johnson, so few of the assertions are seriously challenged.
The confusion was multiplied in September by the deliberate obfuscation over the Johnson government’s decision to push through a £36 billion 3-year package of National Insurance tax increases on the lowest-paid workers, allegedly to spend more on the NHS and social care.
In fact less than half of the £36bn, just £15.6bn over three years, is earmarked for NHS England. Another £6bn goes to the devolved governments (Wales, Scotland and Northern Ireland), £9bn is simply to be handed to the Department of Health & Social Care – and £5.4bn, again over 3 years, is reserved for social care – too little, too late, and without the necessary reforms to a crisis-ridden largely privatised system.
Ridiculous claims have been made over how much this extra money, which does not even begin to trickle through until next year, can achieve – and how much indeed is even allocated to England’s NHS.
Now these figures have been followed by the confusion of the Spending Review, which runs up to 2024-25. The Treasury’s Red Book shows that the new money increases the allocation to the Department of Social Care by an average of 4.1% per year between 2021 and 2025.
This appears to be close to the long run average increases prior to the Tories taking office in 2010. But the next column shows that the average increase from 2019 to 2025 would be much lower – at 3.3%.
Worse, by no means all of the money allocated to the DHSC goes to paying for NHS treatment. NHS England’s average increase in funding from 2019-2025 will be just 3.1% – well below the previous long run average.
This inadequate level of increase even to keep pace with cost and demographic pressures comes after the meanest-ever decade, in which government health spending grew in by an average of just 1.3% per year between 2009–10 and 2015–16, leaving it effectively frozen in real terms from 2010-2019.
Even if we accept that the specific added costs to the NHS of the Covid pandemic have been covered by additional allocations, these calculations take no account of the growth – by almost 5 million (7%) – of the UK population over the same period, bringing with it an increase in numbers of older people, whose health care on average is more expensive.
As a result of these factors, the gap between resources and demand for health care had already increased England’s NHS waiting list to more than 4 million before the Covid pandemic.
The combination of beds (and staff) tied up treating thousands of Covid patients with the reduction in bed numbers to ensure social distancing has left the NHS even further lacking in capacity to keep up with elective referrals or catch back up on a chronic problem of lengthening waiting times. The waiting list is now edging up towards 6 million, with over 200,000 waiting over a year – and growing numbers waiting over two years.
To make matters worse, NHS capital allocations have also been squeezed to unrealistic low levels for a full decade, leaving trusts lacking the resources required even to keep up with routine maintenance and the replacement of clapped-out equipment. The backlog maintenance bill has rocketed to £9 billion from an already unmanageable £6bn in 2017/18. This is work that should already have taken place, and does not include planned maintenance work.
Again the allocations are deceptive. While the DHSC was allocated £7.1bn capital in 2019-20, NHS providers’ share of that was just £4.5bn. This has risen from an even more inadequate £3.9bn in 2018-19 – but was just half of the backlog maintenance bill: the allocations are running well below the amount needed even to preserve standards.
Joshua Kraindler, economics analyst at the Health Foundation, warned in March 2019 that: “The capital budget is, in real terms, the same as it was in 2010-11 and as a result, capital investment per NHS worker continues to fall.”
So there is no capital for trusts to invest in re-planning the use of their clinical and other space to restore the near-15% loss of front line beds in use since 2019, or to invest in new and improved diagnostics or other services – let alone provide the extra resources needs for mental health, community services or primary care.
Instead NHS England has looked to spend up to £10bn over 3 years on treating NHS patients in private hospital beds – a short-sighted measure that will leave huge unresolved problems and the NHS chronically dependent on private providers.
However, with no supporting explanation, the Red Book declares that with the minimal increases just announced, the government expects the NHS to deliver a 30% increase in elective treatment by 2024-25. It also lists a series of ways in which the same money is supposed to be spent:
- £4.2 billion by 2025 “to make progress on building 40 new hospitals by 2030 … and to upgrade more than 70 hospitals”. Everybody knows £4.2bn is nowhere near enough. In fact all of the prioritised new hospital projects are at a standstill, with new limits on spending causing chaos. The invitation for bids for an additional eight new hospital projects to bring the total to 48 has resulted in an additional barrage of hugely expensive, unaffordable schemes. And a string of 1970s-built hospitals across the country are increasingly unsafe as concrete planks crumble, requiring hugely expensive stop-gap measures, and threatening to collapse on patients and staff.
- £2.3bn by 2025 to “transform diagnostic services with at least 100 community diagnostic centres …”. However the first such community diagnostics centre, recently opened in Somerset, turns out to be yet another project reliant on the private sector. It is being run by Rutherford Diagnostics Limited, in partnership with Somerset NHS Foundation Trust. Peter Lewis, chief executive of Somerset NHS Foundation Trust, told the local press: “We entered into our partnership with Rutherford Diagnostics Limited in June 2020 because, despite our investment in MRI and CT scanners, and our continued use of mobile scanners, we were concerned that our trust would not keep pace with demand for diagnostic tests in the future.” For similar reasons it’s likely most if not all of the new centres will also expand the use of private companies.
- £2.1bn by 2025 for “innovative use of digital technology” – another door opened for expensive whizz-kiddery and unproven apps and systems, with control divided between NHS Digital, NHSX and NHS England.
- £1.5bn by 2025 for “new surgical hubs, increased bed capacity and equipment.” This sounds a lot but is equivalent just over £3mn per year per acute trust: and new beds and equipment beg the question of where the staff can be found to allow them to operate properly.
- £450m by 2025 for projects in England’s 54 mental health trusts, allegedly to replace dormitories with single en-suite rooms, and invest in new facilities linked to A&E and “to enhance patient safety” – again a pathetically inadequate amount to pay the rebuilding and other costs involved.
For mental health as much as acute services the key issue that is taken for granted, and for which no real changes are in hand, is the dire workforce shortage. The Red Book declares, with absolutely no explanation or detail, that the Spending Review settlement “will keep building a bigger, better trained NHS workforce,” and reaffirms “the government’s existing commitments for 50,000 more nurses”.
The facts are very different. No appropriate funding has been allocated to pay an additional 50,000 staff. The 50,000 target included an ambitious number of overseas recruits – many of whom, especially from the EU, have been deterred by Priti Patel’s ongoing ‘hostile environment’. It also included retention of 19,000 existing staff – while anecdotal evidence suggests demoralised and burned-out staff are leaving.
The most recent workforce statistics (July 2021) show that while nurse numbers have increased overall by 11% since July 2010, and midwife numbers by 13%, health visitor numbers are down by 19%.
Mental health nurse numbers are down by 2,350 (5.6%), despite the promise by Theresa May’s new government in July 2017 that 21,000 new posts would enable the mental health workforce to treat an extra million patients a year. In 2013 there was 1 mental health doctor for every 186 patients accessing services: by 2018 this had fallen to 1 for every 253 patients. No wonder NHS England admitted last month that 1.5 million patients need mental health treatment but cannot currently get it.
The most recent figures, to June 2021, show a total of 94,000 (7.2%) unfilled posts in England’s NHS: of these almost 39,000 are nursing posts, with vacancy rates ranging from 8.4% (South West) to 12.5% in London. Almost 10,000 medical posts are vacant. Almost 10,000 medical posts are vacant.
But the stress on the staff still in post has also been massively increased by the high level of sickness absence, worsened by Covid and the stresses and strains it has put on exhausted teams: anxiety/stress/depression/other psychiatric illnesses is consistently the most reported reason for sickness absence.
As Roy Lilley recently pointed out in his critique of the Spending Review:
“There are three NHS issues that must be resolved before anything else can be done, developed, extended, organised, planned, expanded or improved … workforce, workforce and workforce.”
But with no investment to pay for recruitment of extra staff, a miserly 3% pay award this year effectively cutting the pay of existing staff, and an empty promise of lifting the freeze on public sector pay … next year, with no commitment to fund any increase, it’s quite clear ministers haven’t got the message.
Empty boasts of more and better trained staff, new hubs and centres, new hospitals and increased levels of elective treatment therefore stand in jarring contrast to the dire state of today’s NHS, with ambulance services stretched to the limit while crews queue for hours to hand over emergency patients to rammed-full A&E departments; hospitals with sharply reduced capacity grapple with emergencies, Covid and the waiting list backlog; staffing levels often plunge below safe limits – and primary care services, mercilessly attacked by ministers, right wing news and social media, somehow manage to deliver record numbers of consultations despite reduced numbers of GPs and years of broken promises.
Yes the NHS is spending record amounts; yes there have been increases – but it’s facing record levels of demand, and the increases are not enough.
Until enough NHS managers pluck up the courage to speak truth to power, and opposition MPs, campaigners and unions mobilise to publicise the dangers – and force enough back bench Tories to recognise the real state of play, it won’t get any better. NHS patients need staff, quality care and support, not lies, damn lies and statistics.
By John Lister, The Lowdown, 1 November 2021