Hospital spending and staff numbers have continued to rise, but so has demand. In this challenging context, clinical standards and patient satisfaction are being maintained.
But queues for services are growing.
Spending on hospitals increased in real terms between 2009/10 and 2016/17.
Spending on hospitals continued to rise over 2016/17: day-to-day government expenditure on NHS providers (which are predominately acute providers), now stands at around £80.9bn. This means there has been a real-terms spending increase of around 15% – or £10bn – since 2009/10. However, The King’s Fund has noted that the front-loaded settlement of the 2015 Spending Review will mean that future funding growth between 2016/17 and 2020/21 will be low by historic standards.
In 2010/11 the provider sector reported a surplus of £0.513bn. Since then, spending has outpaced funding within acute settings, creating a provider deficit which peaked at £2.45bn in 2015/16 (with acute providers at £2.6bn). Over the course of 2016/17, steps were made to reduce this deficit. Through the front-loaded 2015 Spending Review settlement, a £1.8bn injection from the Sustainability and Transformation Fund and £3.1bn in efficiency savings, the provider deficit was reduced by a third to £0.791bn (with acute providers at £1.163bn).
Following the first quarter of 2017/18, the provider sector is forecasting an overall deficit for the year of £0.532bn, and an acute deficit of £1.245bn (slightly higher than the original forecast of £0.496 and £1.122bn respectively).
The upwards trend in activity is continuing at a significant pace.
Hospital activity has been increasing in order to meet rising demand. In the quarter ending June 2009, 829,637 people were admitted to Accident & Emergency (A&E) at major emergency departments in hospitals, referred to as type 1 admissions. These admissions first breached one million in the quarter ending December 2014, peaking at 1,078,329 in the quarter ending June 2017. This 30% increase is part of a much broader increase in hospital activity (see Box 2.3), which is feeling the impact of the growing population, as well as the growth of the ageing population and those with long-term conditions.
Box 2.3: Hospital activity – key facts
The total number of doctors and nurses is growing, but there are warning signs about the future of the workforce.
In June 2017, there were 96,748 doctors* and 199,738 nurses** (FTE), increases of nearly 12% and 10% respectively since 2009. A number of factors, beyond rising demand, have encouraged hospitals to maintain a steady pace of recruitment. Staff increases were incremental until the Francis Review into the Mid Staffordshire NHS Foundation Trust found that inadequate staffing compromised patient safety and the National Institute for Health and Care Excellence (NICE) published guidance on safe staffing levels.
Efforts to recruit enough staff to meet rising demand safely saw the increased use of costly agency workers. Spending on agency staff rose from £2.1bn in 2012/13 to £3.7bn in 2015/16. Hospitals’ focus on recruiting full-time staff and new measures introduced by NHS Improvement helped to reduce this figure to £2.9bn in 2016/17.
However, there are pressing concerns about the future of the workforce. After rising between 2013 and 2016, the number of nurses on the Nursing and Midwifery Council register declined between 2016 and 2017 (from 620,797 to 618,863). Meanwhile a Freedom of Information (FOI) request by The Health Foundation, a health think tank, determined that the number of new nurse registrants from the EU dropped from 1,304 in July 2016 to 46 in April 2017. This 96% decline was possibly the result of the Brexit referendum and new rules testing language skills.
Furthermore, Universities and Colleges Admissions Service (UCAS) figures reveal there was a 19% drop in nursing applications between 2016 and 2017, from 65,620 to 53,010. This drop is believed to be at least partially the result of scrapped NHS bursaries, with a particular reduction in applications from students over the age of 19. There was then a 3.8% drop in the number of nursing applicants placed 15 days after A Level results, from 26,920 to 25,900 (although numbers had been increasing between 2013 and 2016). Government has reacted to this warning sign, with Health Education England committing to funding an additional 1,500 clinical placements for 2017/18 – but it will not be possible to determine the full effects of this response before final figures are released.
Patients are waiting longer for essential services now than they did in 2009, with standards routinely missed.
The NHS Constitution provides a series of pledges on maximum service waiting times. These standards were generally maintained until 2012, after which breaches began to occur.
In the quarter ending June 2009, 98% of patients attending major emergency departments in hospitals (referred to as type 1 emergency admissions) were discharged, admitted or transferred within four hours of their arrival, meeting the contemporary target. The standard for all emergency admissions was lowered to 95% in June 2010, but type 1 admissions have not met this standard since the quarter ending September 2012. By the quarter ending June 2017, only 85.5% of type 1 emergency admissions were seen in four hours. This trend is also true across all emergency admissions, with the percentage of emergency admissions treated within four hours of arrival falling from 98.6% to 90.3% between the quarters ending June 2009 and June 2017. Queuing can also be observed across other elements of hospital care (see Box 2.4).
Box 2.4: Queuing in hospitals
Bed occupancy levels have been slowly rising in general and acute settings (from 86.3% to 89.1% in the first quarters of 2010/11 and 2017/18), which makes it difficult for A&E departments to admit patients within the four-hour window. Increased bed occupancy is usually associated with winter pressures, as cold weather and viruses both create new conditions and exacerbate existing ones, particularly among older people. However, all quarters in 2016/7 saw higher bed occupancy figures than winter 2010/11, suggesting that this reduced performance may be becoming the norm.
The 2017 Conservative manifesto restated the party’s commitment to NHS targets, including for elective treatment for non-urgent conditions within 18 weeks. However, there are signs of a quiet acceptance of queuing within hospitals. NHS England’s Next Steps on the Five-Year Forward View, published in March 2017, conceded that “median wait for routine care” might increase slightly, in what Simon Stevens later described as a “trade-off” in the light of “restrictions on funding and the demand… rising all the time”.
Despite queuing, patient satisfaction and clinical indicators suggest that quality is being maintained.
Despite the challenges hospitals face, patient satisfaction has been stable or slightly rising. Overall experience scores have remained high at 76.7% in 2016/17, compared with 75.6% in 2009/10 (although this does not include those still waiting for admission to hospital). Similarly, the July 2017 Friends and Family Test found 95.9% of inpatients would recommend the hospital service and 85.9% of people would recommend the A&E service (comparable to scores of 94.0% and 87.8% in July 2013).
The 2016 British Social Attitudes survey found that public satisfaction with the NHS and hospitals has largely been maintained; 63% of people were satisfied with the NHS (compared to 64% in 2009) and 60% were satisfied with inpatient services (compared to 59% in 2009). However, there were areas of greater concern; for example, satisfaction with A&E services had dipped to 54% (down from 59% in 2009). Furthermore, there was significant public concern with the future of the NHS during the 2017 general election; the final Ipsos MORI/Economist Issues Index of the election found that 61% of Britons considered the NHS to be one of the biggest issues facing Britain (the highest level of recorded concern since April 2002).
However, clinical indicators have demonstrated that hospital wards are generally maintaining or even improving the quality of patient care despite present pressures (see Box 2.5).
Box 2.5: Clinical quality indicators suggest that patient safety is steady or improving slightly
* This consists of consultants (including directors of public health), associate specialists, specialty doctors, staff grades, specialty registrars, foundation doctors and hospital practitioners/clinical assistants.
** This consists of nurses (adults) and nurses (children).