The NHS is Britain's most treasured institution yet policy missteps have left it facing an existential staffing crisis

Since its creation, the NHS has been one of the most important issues for the public in every election for more than seven decades. With 87% proud of the institution, it’s second only to firefighters when it comes to the commitment Britons feel to protecting and supporting our NHS. However, the crisis that it currently faces is as dramatic as any it has faced in its history. The size of the NHS backlog, the number of people waiting to receive care, has been steadily rising as the health service struggles to tackle the chaos left in the wake of Covid-19 and in early September reached over 6.8 million, the largest in history.

The significant backlog affects not just operations needed to overcome physical difficulties but also mental health. There are about 1.6 million people waiting for mental health treatment, a towering figure that requires as much attention and concern as the record waiting lists elsewhere within the health service. Whilst clearly the scale of this pile-up is a Covid by-product, the inability to reduce waiting lists, and gloomy predictions of only reaching pre-pandemic waiting lists by the end of 2025, can be attributed to another crisis in the NHS: staff shortages. Recruitment and retention of staff is the paramount problem for the government to solve regarding NHS policy. The Health Foundation found that NHS England may be short some 38,000 nurses by 2024. There are already over 100,000 NHS vacancies while the parliamentary health select committee has found that in the next decade 965,000 more posts will be needed in the NHS and social care to deal with our ageing population.

This shortfall in NHS personnel isn’t just a figure for the ONS; it has a real impact on the service we all depend on. Since May, there have been 7,000 more non-Covid deaths than expected and hour-long waits to get an ambulance, let alone the time to get treatment, an operation, and access to the other services that the NHS should be able to deliver. In fact, after reaching A&E, over 24,000 people were forced to wait more than 12 hours. The record waiting times at every stage of our health service confirm the true scale of crisis that it faces. Not only is it clear that the NHS faces a shortage of workers now and into the future, just when our ageing society will need more staff tending to our elderly, but those still working in the public sector are being pushed to breaking point.

Faced with enormous challenges during the Covid-19 pandemic, nurses and doctors are suffering from anxiety, stress and depression which has seen the NHS lose millions of days in staff sickness. Not only is this a tragedy for the staff involved; it naturally impacts the level of service that the public can expect to receive. Moreover, NHS staff are deeply dissatisfied and angry for another reason that has flared up in the cost-of-living crisis. The Royal College of Nursing is balloting its nearly half-a-million healthcare workers on whether to strike in response to an average 5% pay rise offer when they had been pushing for 5% above inflation. Given the projections for inflation continue to rise, with some now predicting 22.4% inflation in the new year, 5% higher pay would represent the biggest single real-term cut to NHS pay in memory as price increases far outpace earnings growth.

This rare threat of industrial action in the NHS is a consequence of a pay emergency that has been simmering for years. Even before the cost-of-living crisis began to bite, even before the pandemic in fact, real average earnings were below what they were more than a decade prior, with NHS consultants and midwives seeing their real pay cut by 12% and 10% respectively. It would be damaging enough for living standards that wages have not risen in line with the pre-financial crisis trend but they also fell in real terms by staggering amounts even as the cost-of-living continued to climb. This problem of pay extends too to social care workers. The plight of social care workers was exemplified by Damian Green, former deputy Prime Minister, who stressed that many are paid less than dog walkers which, given the enormous challenges of the job both physically and mentally, explains why there is set to be a substantial staffing gap through to the foreseeable future.

There has also been a serious decline in UK doctors joining the NHS, with recruitment falling nearly 16% between 2015 and 2021, with an even greater fall for nurses. Yet, the dramatic staffing shortage is not just a result of fewer UK nationals staffing the health service. Since the decision to leave the European Union in 2016, immigration into the UK for work from the bloc has dramatically declined as a result of work visa requirements. The proportion of NHS recruits coming from the EU was as low as 2% this year, a far cry from the last few decades of close ties between Britain and Europe. This dual decline in EU and domestic staff entering the NHS for much of the last decade explains why Health Secretaries Hunt and Hancock - who had promised to increase GP numbers by 5,000 and 6,000 respectively - failed. They were unable to solve the problem of recruiting new doctors to our most sacred institution.

Retention has proven as problematic as recruitment, which has further endangered the ability of the NHS to meet the widening staffing gap. The primary problem raised by senior NHS staff as the cause for early retirement are the tax rules regarding pensions. As a result of existing lifetime limits on tax relief, doctors are in effect encouraged to reduce their workload and then retire instead of continuing to work, as much of that otherwise extra income would be taken away in tax. This limit has further exacerbated the crisis in the NHS over the past year, with the dramatic increase in inflation bringing real income down, causing doctors to face up to £35,000 in extra tax, thus explaining BMA reports that most staff fifty-five and over plan to retire by 2024. NHS Employers, representing nearly 1.5 million workers, has already sought assistance from the Chancellor of the Exchequer to remove this enormous disincentive for older staff to work longer and harder in the NHS.

The solutions to this crisis are simple to understand yet very challenging for the government to act on. In social care, lacklustre wages can be explained in part by the cuts to per capita social care spending by the government since 2009. Per capita social care spending fell by around 13% in real terms between 2009 and 2017 and, although it has risen since, it is still significantly below its level over a decade ago. With our ageing society, investment has to rise to deal with social care demand, much of which can go towards attracting new talent with more generous pay offers. Many health leaders have called for a £10.50 minimum wage for social care which, given the hundreds of millions being wasted by NHS trusts on desperate recruitment drives, is worth the cost if it can guarantee that social care vacancies are filled. Whether money is found from existing budgets or funded through other revenue, there needs to be cross-party understanding that salary costs must rise to tackle these problems in social care and the NHS. Fundamentally this isn’t partisan but simply driven by markets; with rising demand for healthcare the supply of labour capable of providing it must rise too. If current pay doesn’t attract enough staff, the free market dictates that pay must rise.

Regarding the pensions tax trap that senior NHS workers are facing, an immediate change should be unfreezing the lifetime allowance, which is set to remain at its current level until 2026. Increasing the lifetime allowance in line with inflation won’t solve all the problems facing staff but can alleviate the pressure currently threatening an exodus from the health service. Although this may lose the Treasury some money, the £6.2 billion currently spent on agency and bank staff, the former costing the NHS far more than the latter, is to some degree a consequence of failing to retain full-time employees. Again, changing the tax rules may cost the Exchequer, but with billions already being spent to paper over the cracks this money is needed regardless.

Ultimately, the present crisis of the NHS is the largest it has ever faced, particularly when looking forward to the next ten years. The crisis is primarily a result of years of lacklustre pay settlements that have now, in the midst of the largest cost-of-living crisis in a century, reached a threshold that threatens the very people who make the NHS the treasured institution that it has become. Sensible, modest changes to policy have to be made to rescue this public service and the money needed to fund these policies will have to be found regardless. A new long-term programme of reform will be needed to improve productivity and output whilst protecting staff salaries to bridge the chasm of personnel needed by the time of the NHS’s centenary. We need the courage to take action, be bold and, most of all, be honest with the public: without better pay funded by taxpayers, the NHS, that prized British service, is on its knees.