It is 6am and a dozen ambulances are waiting to offload their patients, but the local NHS hospital is already full. Every bed in the emergency department is occupied. As well as the patients in ambulances, others lie inside on trolleys in corridors, some even on trolleys in cleared-out cupboards. In the waiting rooms, dozens more are in the long queues still to be seen.
“People are presenting with easily treatable conditions, but because it’s taken so long to get in, we’re already on the back foot,” says Robert, an A&E doctor at the hospital. (As he is discussing the poor quality of care at his hospital he does not want his last name, or the name of his hospital, to be published). “It’s terrible. It’s absolutely dire. We know patients deserve better.”
There are blockages on the way in to the hospital, blockages inside them, and perhaps most frustrating for healthcare staff and patients, blockages getting those who have been treated and have recovered out of the front door and home, or into the community.
It is this last problem that is proving hardest to crack. Despite promises from successive UK prime ministers to mend the broken social care system, it remains completely dysfunctional.
Robert says that, in some cases, patients who are fit to be discharged are remaining in hospital for months. Data for October showed that just 39.9% of NHS patients were discharged as soon as they were medically ready, with more than 13,000 beds on an average day occupied by patients who could have left, according to analysis by the NHS Confederation.
“The main reasons are that there just aren’t enough care home places or care staff,” he says. “Sometimes it’s to do with the right type of care home. There’s nowhere for them to go.”
Professor Martin Vernon, a consultant geriatrician in Greater Manchester and former NHS national clinical director for older people, tells a similar story. He has worked in the health service for three decades and cannot remember a time when things were worse. “The hospitals are effectively full, and the community is effectively full,” he says. “It feels like we’re constantly trying to catch balls and make sure we don’t make errors. But it’s a constant worry. We can’t see the light at the end of the tunnel.”
This country is by no means unique in its health and social care struggles. Even in nations often held up as having model healthcare systems – such as France and Germany – the combined pressures caused by ageing populations, financial constraints, recruitment problems, Covid-19 and flu have taken their toll.
On the issue of social care, French doctors and experts admit to shortcomings, though not on the scale of those in the UK. “It’s not that we don’t have problems, but things are organised differently,” said Blanche Le Bihan, a professor at the French School of Public Health and researcher at the Arènes scientific research centre in Rennes specialising in social care.
“The system is far too fragmented, that’s the main issue with social care in France – communication, coordination are always complicated,” Le Bihan says. “But while it’s far from perfect, it’s not a major factor in hospitals’ current problems.”
To ease the burden on its hospitals, France, which has markedly higher levels of taxation to fund its public services than the UK, has invested heavily over the past decade in both outpatient clinics and what is known as “home hospitalisation”: more than 7% of all patients formally admitted to hospital are now cared for at home, against 2% in 2006.
But this winter’s flu, on top of the bronchiolitis and Covid epidemics, have nonetheless exposed long-term management issues, staff shortages and low morale.
“We are more than full – patients are overflowing into corridors,” said Pascal Bilbaut, head of A&E at Strasbourg University hospital. “Young people are fine, but when you’re dealing with patients in their nineties, of course it’s more complicated.”
In general, however, France’s healthcare problems are less severe than those facing the NHS. According to OECD figures, France has 5.7 beds per 1,000 people, compared to the UK’s 2.4 and an OECD average of five.
The average wait for an ambulance last year was 14 minutes while in the NHS in England more than 40% of crews were forced to wait at least half an hour to hand over patients in the week up to 1 January. That is the highest level since records began a decade ago.
In France the waiting time for a hip replacement averages three to four months, while in England about 400,000 people are waiting more than 52 weeks for treatments such as hip or knee replacements. Patients with heart conditions are seen by a specialist within 28 days in Paris, with 70 the longest wait recorded elsewhere. In England, there are more than 340,000 people waiting for cardiology care, with about a third of those waiting longer than the maximum target time of four months.
In France, the time between a cancer diagnosis and the start of treatment averages less than six weeks, while patients with potentially life-threatening conditions are typically seen by a consultant within six days of referral, half within two days. In England, 18,600 people given an urgent referral for suspected cancer last year waited at least 100 days to start treatment.
Germany, meanwhile, has been tackling the joint health and social care challenges in a cross-party consultation process since the mid-1990s – an approach Westminster has never been able to follow, despite the obvious need. Berlin’s answer, which everyone admits is still far from perfect, is the Pflegeversicherung – or long-term care insurance scheme. It is funded by mandatory contributions from all employees, who pay about 3% of their salary into the system.
This funding mechanism is based on the solidarity principle of spreading the risk across society, ensuring that an individual’s burden, should they require care, is not overwhelming. The scheme focuses on keeping people out of hospital (currently four out of five of the 5 million people in care, two-thirds of whom are aged over 85, are looked after in their own homes), improving the home care they receive from mobile care workers and easing the burden on family carers.
While its own system is under a degree of pressure, the German media of late has been full of stories of the NHS’s struggles, which it sees as on a different scale altogether. On Thursday Die Welt ran a story entitled “Grossbritannien: Ein Gesundheitssystem vor dem Kollaps (Great Britain: a health system facing collapse)”. The piece highlighted a centralised and bureaucratic system that was no longing coping, adding: “Perhaps the British should move to [adopt] the German health system.”
In the UK, the wave of strikes by nurses and ambulance workers over pay, which will probably soon be followed by action by junior doctors, adds to the sense of decay and demoralisation.
Money is clearly part of the problem. The Westminster government put huge extra sums into the system during the Covid pandemic. Spending on the NHS totalled 12% of GDP in 2020, compared with the average among all OECD countries of 9.57% and an average among the 14 longest-standing EU member states of 10.62%.
But before the pandemic spending had lagged way behind other leading economies, leaving the NHS creaking and ill-prepared. Analysis by the Health Foundation of OECD data shows that average health spending (not including social care) in the UK between 2010 and 2019 was £3,005 per person – 18% below the EU14 average of £3,655.
The analysis also shows that if UK spending per person had matched the EU14 average during that decade, then the UK would have spent an average of £227bn a year on health between 2010 and 2019 – £40bn higher than the actual average annual spending during this period of £187bn.
Over the same decade, the UK also had a lower level of capital investment in new buildings and equipment for health care compared with the EU14 countries. Between 2010 and 2019, the average health capital investment in the UK was £5.8bn a year. If the UK had matched other EU14 countries’ average investment in health capital (as a share of GDP) it would have invested £33bn more between 2010 and 2019 (about 55% higher than the actual investment during that period).
But the problems of the NHS and the social care system here, say experts, are not just about money. They are also cultural, political and structural.
Sally Warren, director of policy at the King’s Fund, who previously worked at senior levels in government on health and social care policy, says that conservative attitudes to health care can obscure the need for fresh ideas and thinking. Local campaigns opposing hospital closures, for instance, even if what might replace the old hospital could be better, are examples.
“One challenge we face in the UK when it comes to reforming the NHS is the extent to which the public and politicians consider our heath to be about what goes on inside an NHS hospital,” Warren said. “This focus on one aspect of healthcare can get in the way of changes which are needed to both shift care outside hospitals into local community settings, and to wider changes which can support our health, be that around diet, activity or quality of housing.”
Dr Dan Poulter is a Tory MP and former health minister who works part-time as an NHS psychiatrist. As a result he has an almost unique insider’s vantage point of both the UK political system and the NHS.
Poulter says narrow political arguments and disagreements have too often blocked reform. Unlike the cross-party approach adopted in Germany, parties here have refused to join forces to determine the best way forward – and have instead shot down the other’s ideas for party advantage. Examples include plans for funding social care put forward by Labour before the 2010 election and others floated and then abandoned by Theresa May and the Tories in 2017. The Tories dubbed Labour’s plan a “death tax”, while May’s policy was called a “dementia tax”.
“Reforming the health and care system is hard,” Poulter says. “It is a 10-year project and the UK has a five-year electoral cycle. It is difficult to achieve reform because there is always politics to be exploited in any argument over reform.” Labour politicians reject the idea of working with the Tories on social care, and will privately admit that if they did so they would lose arguably their strongest political card – the ability to attack the Tories on the NHS and social care.
Poulter also points to structural flaws in the UK health and social care systems, which are now comprised of too many different parts operating in “silos” with their own budgets to protect – the legacy in part of trying to bring more business discipline into the system.
“You have GPs working in small- or medium-sized business, mental health, community care run by local authorities, hospitals … They all have their own budgets to protect. The system is fragmented. There is no financial incentive in the system for these parts to work together. Instead the reverse is often the case. There are competing priorities. If a local authority running social care invests in grab rails (to help people return home faster from hospital) that local authority doesn’t benefit from the savings. The savings accrue to the NHS.”
Attempts to come up with a funding solution for social care have met endless delays as politicians have balked at the costs and complexities of reform. Most recently chancellor Jeremy Hunt delayed for a further two years the implementation of the Dilnot report on social care funding that was published in 2011 – a decision that infuriated Andrew Dilnot himself.
Former Tory cabinet minister Damian Green, who chairs the all-party group on social care and who took charge of the reform agenda in May’s cabinet, says there is not yet sufficient recognition among a wide enough cross-section of the population of the urgent need to reform social care. Green, who lost his own father to dementia and saw the problems in the system, says that while many “baby boomers” recognise systemic shortcomings, the subject still fails to excite sufficient passion in the population at large to raise the issue to the top of the political agenda.
Warren says the challenges are daunting. “There is no immediate or easy fix to the current challenges facing the health and care system, which is the result of a decade of underfunding health and social care. What is needed is a comprehensive workforce plan that looks at both recruitment and retention of staff, a serious reform of social care which can boost capacity and quality so more people can be supported, and finally a shift to models of care that support prevention, earlier intervention and living well with long-term conditions.”
She adds: “While some of this is undoubtedly about funding, it is also about taking decisions which are not just about the short term, but about the resources and services needed over the medium term to meet the health and care needs of our population.”