Spending on hospitals increased in the past six years, but admissions grew even faster. Nearly 90% of hospitals now run high deficits. In 2013, people began routinely waiting longer for critical services such as A&E and cancer treatments. Patient satisfaction levels have been maintained, but this may not last if waiting times and performance continue to slip.
Spending on hospitals increased in real terms by 14.7% between 2009/10 and 2015/16.
In 2009/10, spending on the NHS was £113.5bn,* of which spending on secondary care commissioned by primary care trusts was £68bn (this primarily covers hospitals and community health). This increased by around £10bn to £78bn in 2015/16.
But so did activity – for example, A&E admissions rose by over 20% during the same period.
In the quarter ending June 2009, 829,000 people were admitted to A&E at major emergency departments in hospitals, referred to as type 1 admissions (there were nearly 3.4 million type 1 admissions throughout 2009/10). This rose to over a million in the quarter ending June 2016** (and over four million throughout 2015/16).
Once people do get through the doors, quality indicators suggest that the wards they arrive at are safer than ever. For example, the number of patients contracting bacterial infections (e.g. MRSA and Clostridium difficile) and developing pressure ulcers has been decreasing year on year, and hospitals are getting much better at reporting incidents that could cause harm to patients. These improvements are likely to be the result of sustained, targeted interventions over the past decade to drive up standards in these areas.
Nevertheless, pressures are clearly building as hospitals try to keep up with rising activity across a range of services, such as elective admissions, cancer treatments, outpatient services and diagnostic tests, as well as A&E (see Box 2.1). A composite index of all hospital activity, produced by researchers at the University of York, suggests that across-the-board activity in hospitals increased by 11% up to 2013/14.
This increase, combined with reduced tariff payments to providers, is placing hospitals under enormous financial strain, with the majority overspending in order to deliver essential services to more people. In 2015/16, acute providers overspent by around £2.6bn (compared with £421 million (m) in 2013/14) and nearly nine out of 10 ended the year in deficit.
Box 2.1: Hospital activity – key facts
Elective hospital admissions increased by around 23% from nearly 4.7 million in 2009/10 to nearly 5.8 million in 2015/16.
The number of people treated for cancer within two months from GP referral has increased by over a third from 84,218 in 2009/10 to 113,896 in 2015/16.
GP referrals for outpatient services rose by 19% from nearly 11.5 million in 2009/10 to over 13.6 million in 2015/16.
The number of diagnostic tests to identify a patient’s disease or condition increased by 40% from around 14.4 million in 2009/10 to over 20 million in 2015/16.
The total number of doctors and nurses is growing, but hospitals are relying increasingly on agency workers.
In September 2009, there were 92,503 full-time equivalent (FTE) doctors*** and 182,127 FTE nurses****. According to one estimate, clinical staff cost around £43bn each year to employ and account for around half of providers’ costs. Pay restraints and freezes were therefore introduced by the Coalition Government to keep staff costs down. The total number of doctors and nurses increased incrementally only between 2009 and 2012.
However, new National Institute for Health and Care Excellence (NICE) guidance published shortly after the Mid Staffordshire NHS Foundation Trust crisis and the subsequent Francis Review in 2013 highlighted that inadequate numbers of staff – particularly nurses – were compromising the quality of care. Since then, hospitals have been encouraged to bring in more clinical staff to ensure safe staffing levels. The number of doctors and nurses has been increasing; as of August 2016, there were 105,060 doctors (up 13.6% on September 2009 levels) and 197,458 nurses (up 8.4% on September 2009 levels).
However, efforts to recruit more staff have failed to meet growing demand. The National Audit Office (NAO) highlighted an overall shortfall of around 50,000 staff in 2014, with particular shortages of nurses, midwives and health visitors. Trusts are meeting this need by using more costly agency workers to fill long-term vacancies. Spending on temporary staff increased from £2.1bn in 2012/13 to £3.7bn in 2015/16, according to one estimate, which is adding to the size of acute trusts’ financial deficits.
Although there are now caps on the amount hospitals can pay agency staff, many providers are breaching this. The King’s Fund – the independent think-tank on health – the NAO and the Public Accounts Committee (PAC) have all concluded that this reliance on agency staff will not be tackled without first addressing the shortage of permanent staff. This challenge is likely to become more acute as a result of new policies (such as the proposal to introduce seven-day services across the NHS by 2020).
Patients are waiting longer for essential services, with standards now routinely missed.
The NHS Constitution was first published in January 2009 and provides a series of pledges on maximum waiting times for services such as A&E (maximum four hours’ wait from arrival to admission, transfer or discharge), diagnostic tests (maximum six weeks’ wait) and treatment for diagnosed cancer (maximum two-month wait from an urgent GP referral to first treatment, where cancer is suspected). These standards were generally maintained until 2012, but signs of slippage are now showing. The Health Foundation and Nuffield Trust have concluded that ‘when [the] pressures bite, the first thing to give is access to care’.
For example, in June 2009, 98% of patients attending major emergency departments in hospitals (referred to as type 1 admissions) were discharged, admitted or transferred within four hours of their arrival, meeting the government target at the time. This standard was lowered to 95% in June 2010 and was first breached later that year, in December 2010. The target has not been met since September 2012 and, in the quarter ending December 2016, nearly 700,000 people waited in A&E for more than four hours.
The variation in performance between providers is also striking. The Care Quality Commission’s report on the state of care in 2015–16 noted that ‘in July 2016, the percentage of patients spending less than four hours in major A&E departments ranged from 64% to 99%’. This decline in performance is usually associated with winter pressures, but has now worryingly become the norm across the year for NHS provider organisations.
This is because there are simply not enough beds to accommodate all the patients that need them. Bed occupancy levels are at their highest-ever recorded levels. A report by the Nuffield Trust found that 95% of hospital beds were occupied every single day last winter (December 2015–February 2016), well above the recommended level of bed occupancy (85%). This winter (December 2016–January 2017), bed occupancy only fell below 85% at Christmas, and quickly rose again. Higher bed occupancy makes it harder for A&E departments to admit patients within the four-hour target, resulting in longer waiting times. A&E waiting times and occupancy levels are a marker of stress across the whole system as service standards have begun to slip in many areas (see Box 2.2).
Box 2.2: Declining service standards
The target that 85% of people should start their first treatment for cancer within 62 days of an urgent GP referral was breached for the first time in March 2014 (84.4%) and has been declining since. As of December 2016, 82.2% of patients were treated within 62 days (with 6,489 patients still waiting for treatment). Other cancer waiting-time targets are being met.
The target that 92% of people should start treatment within 18 weeks from referral for non-urgent conditions (introduced in April 2012) was breached for the first time in December 2015 (91.8%) and has consistently been below the target since March 2016. As of December 2016, the recorded waiting list stood at 3.66 million people, up from 3.30 million at the end of December 2015 and 2.37 million at the end of December 2009.
The percentage of patients not treated within 28 days of a cancelled operation has been rising year on year. In June 2009, it was 3.9% (539 patients). This reached a peak of 8.7% in March 2015 (1,787 patients). As of December 2016, 7.3% of patients (1,551) whose operations were cancelled were still waiting longer than 28 days to be treated.
Yet patient satisfaction has held up and people would still recommend the services they have received to friends and family.
Despite the longer waiting times, NHS patient feedback suggests that satisfaction levels of those who do receive care have held up. Overall patient experience scores, which cover areas such as access to services, the quality of care and the information given to patients, have remained stable at around 75–77% over the past six years.*****
This is reinforced by the Friends and Family Test, which asks patients whether they would recommend the service they used to others. In April 2015, 96% of inpatients would have recommended the service (a level that was maintained in April 2016), while 88% of people using A&E would have recommended A&E services (with only a slight decrease to 86% in April 2016).
At the same time, there has been an improvement in how those closest to the service – NHS staff – perceive the standard of care provided in their organisation. In the 2012 NHS Staff Survey, 65% of respondents strongly agreed or agreed with the statement: ‘If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation.’ This increased to 70% in the 2015 Staff Survey.
It is encouraging that the NHS has been able to maintain positive feedback from staff and patients in the face of severe financial challenges. However, this shouldn’t give grounds for complacency. These surveys focus on the perceptions of patients who do eventually get into hospital (where safety standards and quality have been improving for some time, as outlined on p. 11). We know less about how those still waiting for services feel.
The wider public are also more concerned than ever about the challenges facing the NHS. In the 2015 British Social Attitudes survey, the percentage of people who were very or quite satisfied with the NHS decreased from 70% in 2010 to 60% in 2015, while the percentage of people who were very or quite dissatisfied increased from 18% in 2010 to 23% in 2015. Waiting times, staff shortages, underfunding and financial inefficiency were the top four reasons for dissatisfaction.
The critical question for politicians is whether further deterioration in access to care and in waiting times becomes the ‘new normal’ or whether there is a turning point at which the situation becomes intolerable to patients and the public more widely. The 2016 QualityWatch annual statement from The Health Foundation and Nuffield Trust concluded that we may be reaching that point, as longer waiting times increase the risks of patients’ preventable conditions not being addressed and minor ailments becoming major ones.
* The figure was converted to real terms at 2015/16 prices.
** The latest data for September–December 2016 shows 1,075,245 admissions, compared with 881,670 during the same period in 2009.
*** This includes consultants (including directors of public health), associate specialists, specialty doctors, staff grades, specialty registrars, core medical training doctors, foundation doctors year 2, foundation doctors year 1 and hospital practitioners/ clinical assistants.
**** This includes nurses (adults) and nurses (children).
***** Figures for ‘all trusts’. 60% of patients, on average, found the service ‘good’ and 80% of patients, on average, found the service ‘very good’. NHS England, Overall Patient Experience Scores: 2015 Adult Inpatient Survey update, June 2016.