2018–2027: The eighth decade

In the UK political sphere, the decision of the elecorate to leave the European Union in 2016 dominated the agenda, often squeezing out other issues. Within the NHS, however, the combination of the worst bits of Andrew Lansley’s reforms and the limited growth possible within a programme of austerity led to widespread dismay. The decision of the Prime Minister to retain Jeremy Hunt as Health Secretary and then appoint Matt Hancock provided a measure of stability. Neither was seen as a radical reformer, and both proved able to work with Simon Stevens, the Chief Executive of NHS England.

As a birthday present on its 70th anniversary, the NHS received a long-term financial settlement. Although less than think tanks such as the King’s Fund felt was necessary, at around a 3.4% real terms increase each year in England, it was only the second long term settlement in the history of the NHS. The need for security of resources had long been maintained. Here was something significant. As Gordon Brown, the then Chancellor of the Exchequer, was angry when Tony Blair made his long term funding commitment, so was Theresa May’s Chancellor Philip Hammond reportedly irritated by this new one.

A new coronavirus causing a condition the WHO called Covid-19 was identified in December 2019 in Wuhan, China. In a minority of people the new strain caused severe pneumonia and organ failure. Despite containment efforts across the world, it spread rapidly. By March 2020, Europe had become the epicentre of the outbreak and the WHO officially declared a pandemic.

The first death in the UK was recorded on February 28th. On March 23rd, the UK government implemented a far-reaching lockdown which barred people from leaving their houses for any reason except food, medicine, daily exercise, and helping people with health needs. Regulations under a quickly passed Coronavirus Act gave the police powers to enforce these provisions, as well as banning bars and restaurants from opening. By mid-April 2020, more than 15,000 people had died from Covid-19 in the UK.

The NHS responded with unprecedented actions to expand the capacity to deliver intensive care to Covid-19 patients. Student and retired nurses and doctors were brought onto the front line, planned care was cancelled, new hospital sites were opened, and the standards for discharging patients were lowered. The availability of tests and protective equipment for staff became a dominant political and operational issue.

Over the course of 2020 and 2021, the nations of the UK moved in and out of different levels of restriction on economic and social activity, aimed at controlling the virus, which surged repeatedly as new variants emerged to re-infect people with immunity.

From late 2020, the UK granted emergency use authorisations to Covid-19 vaccinations, and the NHS began a massive programme to deliver these. The UK initially achieved rapid coverage of first doses relative to other countries, at the expense of delivering second doses at the recommended time. By early 2022, more than 92% of UK residents over 12 had received a vaccine dose, and more than two-thirds had received three doses. While cases remained high, deaths fell markedly. Between February and May the UK governments removed most or all restrictions and requirements: hospital admissions briefly rose, but fell again by April.

Infection control measures in hospitals, cancelled procedures due to the pandemic, and patients avoiding care through fear or a sense of responsibility caused a widespread deterioration in NHS waiting times across the UK. In England, the number of people waiting more than a year for planned care rose from 1,000 before the pandemic to over 300,000 by early 2022. The British Social Attitudes survey showed an unprecedented collapse in the public’s satisfaction with the way the NHS was run in 2021. For the first time in twenty years, more people were dissatisfied than satisfied.

Organisational change

From 2016, on an essentially voluntary basis, Trusts, Clinical Commisioning Groups (CCGs) and local authorities had been encouraged to form 44 Sustainability and Transformation Partnerships (STPs). The 2019 NHS Long Term Plan called for the evolution of all of these into Integrated Care Systems (ICSs) by April 2021. The aim was for these combinations of commissioners and providers to take major decisions together about improving population health, introducing the new services outlined in the plan, and closing and redesigning existing ones. CCGs were supposed to merge until there is only one per ICS, able to act at a more strategic level. The plan also called for providers to group together into Integrated Care Providers (ICPs). These were to bring together hospital and community services, and in some cases general practice, to hold a single contract to deliver services.

Simon Stevens said that to deliver the plan every NHS organisation would need to intensify partnership and working with each other, including local councils and community organisations. One senior officer said that many performance ‘challenges’ could only be addressed across a larger population and ‘provider footprint.’

Later in 2019 NHS England published a set of proposals for legislative change. These included provision for the merger in practice of NHS England and the trust regulator NHS Improvement, the removal of competition and procurement laws from NHS bodies, and new abilities for NHS trusts and commissioners to pool powers and appointments. These directives and ambitions were given legal backing by the 2022 Health and Care Act. This abolished CCGs and passed their powers on to Integrated Care Systems run by Integrated Care Boards. The representation of NHS trusts on these boards marked the end of 30 years during which a split between purchasers and providers of care was intensified. Reinforcing this, the Act included powers to change procurement rules, making it easier to justify not putting contracts out to the market. Responsibilities and budgets were not pooled across health and social care, although a White Paper described aspirations for this to happen more locally.

The Act also strengthened the control of the Secretary of State over the more autonomous NHS created by the 2012 reforms. Politicians could now direct NHS England to do as they wished, merge and restructure the arm’s-length bodies that ran services, and take over decisions on local service changes.

In response to the growing threat of Covid-19 to the UK population, NHS England and NHS Improvement declared a Level 4 National Incident on January 30th 2020, allowing them to directly order trusts and commissioners to cancel elective care and immediately discharge all patients medically fit to leave hospital.

The NHS and armed forces worked together to create a set of “Nightingale” hospitals on new sites across England, including London’s Excel centre and the Manchester Central Convention Complex. These sites opened during April 2020. They were overseen by local NHS trusts and staffed by NHS workers, with logistic support from the Armed Forces.

Finance and funding

As the number and complexity of people needing care outstripped funding growth, NHS trusts began this period with a large underlying deficit, spending more than they received each month and year. The regulator NHS Improvement formally acknowledged this for the first time, putting the gap for the 2018–19 financial year at over £4 billion.

In 2018, Prime Minister Theresa May marked the service’s 70th anniversary by announced a funding increase of £20.5bn to the annual budget of NHS England by the year 2023–24. This marked a significant departure from the previous decade of historically low budget growth, to growth of around 3.4% per year. As with other recent spending announcements, this related only to the NHS England revenue budget, with other budgets like medical training and capital which had fared worse under austerity not included.

The 2018-19 financial year marked the fifth in a row that the NHS had gone back to Parliament part-way through the year to ask for capital spending to be redeployed to day-to-day expenditure. The emergence of this practice was an indication of financial strain, and associated with a rising “backlog maintenance” bill for outstanding repairs.

The Government announced extra in-year funding from reserves for the NHS and other public services to support their response to the 2020 coronavirus outbreak. By mid-April, the health service, public health initiatives such as testing, and logistics supporting it had been allocated £6 billion.

Normal NHS financing rules were suspended in March 2020 due to the coronavirus outbreak. National guidance told trusts and commissioners to arrange block grants to cover all the income usually paid across, and committed extra funding to cover costs incurred in dealing with the pandemic. NHS England ordered trust finance directors to submit claims for these extra costs on a monthly basis. Trusts were still expected to break even across a quarter.

In 2021, the Chancellor announced a “Health and Social Care Levy” – a  hypothecated 1.25% increase to most rates of National Insurance. The Health and Social Care Levy Act 2021 requires the proceeds to go to health and social care, though this is only a part of their budgets and the ability to increase and decrease other funding means there is no particular relationship between health budgets and the amount raised. Despite a suggested connection to a cap on social care charging, the majority of the additional money was directed to the NHS and not social care. This resulted in somewhat more generous funding for the health service in the medium term, though this was limited by the ending of separate funding for Covid-19 and a tighter settlement in 2024/25.

General practice and primary health care

Partly under central encouragement, the organisation of primary health care began to change. Underlain by the belief that services could be improved (and cost savings might result), practices increasingly established federations, group practices and networks. In general they did not affect the day-to-day work of a practice, but they might assist in the joint provision of more specialised services, or out of hours cover and emergency surgeries.

In 2019, a five year contract framework was agreed between the Government and the British Medical Association. This committed £1.8bn to flow through a new ‘network contract’ for geographically-mandated networks of practices across England covering 30,000-50,000 registered patients called primary care networks (PCNs). PCNs are meant to be sufficiently large to gain economies of scale, but small enough to still provide the personal care valued by patients and practices. The network contract aims to encourage the 80 per cent of practices that are already collaborating to formalise their membership, nominate a clinical director, and jointly with community services, deliver new services specified by NHS England and local commissioners. By mid-2019 1,300 networks had been formed across England.

The contract also sets out expanded plans for mixed professional teams, starting by reimbursing practices for employing pharmacists and social prescribing workers. The most visible change to patients will be increased access via digital technology. Practices will need to make 25 per cent of appointments bookable online, improve their online presence and give new patients access to their digital records as standard. Patients will have a right to request an online and video consultation by 2021.

Certain terms of the GP contract were suspended during the 2020 coronavirus outbreak, with practices no longer required to conduct health checks or reviews. Practitioners were asked to receive all patients via online or telephone-based remote triage, and undertake all possible care remotely. A cohort of 1.3 million people especially vulnerable to Covid-19 was identified nationally, and GPs were told to review their care plans and manage them. All Care Quality Commission inspections were cancelled.

NHS England ordered all routine dentistry, including orthodontics, to be stopped in March 2020.

Following a political and media backlash against the widespread move to telephone and online access, NHS England was encouraged to issue new guidance in 2021 emphasising the need to allow patients to choose appointments in person. This resulted in an outcry from some of the leaders of the profession, who felt that the media narrative was unfair given the situation and continued provision of many appointments in person: the BMA GP committee passed a vote of no confidence in NHS England.

Medical education and staffing

By 2018, a chronic shortage of GPs existed, with numbers having declined relative to the size of the English population for several years. Several hospital specialties also faced shortages, especially psychiatry.

This was part of a wider workforce gap across many professions, with total NHS trust vacancies rising to around 100,000. In response to these problems the interim People Plan was published in 2019. It called for an improvement in NHS culture and regional workforce planning. As Health Secretary, Jeremy Hunt also announced in 2018 an increase of 1500 in the number of medical school places with five new universities offering places.

In March 2020 the General Medical Council automatically granted emergency registration to 15,000 doctors who had given up their registration or license in the last three years in an attempt to expand the workforce in response to the coronavirus pandemic. Revalidation checks, which doctors ordinarily have to undergo every five years to continue practicing, were suspended.

In 2021, the government relaxed the cap on medical and dental student places to reflect a surge in people meeting the grade requirements of their offers due to the suspension of exams, and the deferral of many students from 2020. This resulted in a sudden increase of more than 1,000 student places, taking the total above 9,000.

Nursing

The NHS faced a serious shortage of registered nurses by the beginning of this period, with more than one in ten posts vacant. The move in 2017 from giving nursing students bursaries to requiring them to take out loans for study did not have the anticipated effect in encouraging universities to open new places, and the number starting fell. A sharp drop in recruitment from the European Economic Area following the referendum and a new language test added to the pressures. However, migration of nurses from elsewhere in the world began to rise again.

The interim People Plan contained measures to address this including spreading ways to reduce nurses leaving the workforce early and dropping out of training. It also looked to expand routes to becoming a registered nurse for those already working for the health service as nursing associates.

In April 2020 the Nursing & Midwifery Council opened voluntary emergency registration to all nurses and midwives who had left its rolls in the past five years, using new powers under the Coronavirus Act. Overseas candidates who were fully qualified except for the requirement to pass a clinical examination set by UK universities were also invited to register.

The NMC and NHS England wrote to student nurses in their second and third years giving them the options to spend all of their time in clinical practice for nurses within the last six months of their course, or 80% of their time for others. There was no option to consider training as normal due to the impact of the pandemic. By mid-April, around 12,000 nursing and midwifery students had taken up these options.

By 2021, the new Health and Care Visa and expanded recruitment campaigns saw nursing recruitment from countries outside the EU reach very high levels. 38% of all nurses joining NHS trusts in England came from abroad, far higher than the 23% who came from domestic training. This marked a historic shift back to periods of intensive recruitment from Africa, Asia and the Caribbean which have featured throughout the life of the NHS.