Nightingale investment before pandemic would have made NHS resilient

England’s NHS would have been in far better shape to cope with the coronavirus crisis if the £1.5bn spent on creating the field-style Nightingale hospitals and discharging people into care homes to clear space for Covid-19 patients, had instead been invested earlier in community care, a think-tank has argued.

The Institute for Public Policy Research said the taxpayer-funded health service had entered the pandemic in a deeply fragile condition, after years of cuts that prioritised efficiency over resilience.

The institute’s data showed that more than four out of five English hospitals had “dangerously low” spare capacity on the eve of the crisis. A hasty search for extra beds as the virus took hold, meant the government had to provide more than £1.5bn in emergency funding to create the Nightingales, and discharge patients into the community. Many who left wards for care homes unwittingly spread the virus.

If the same sum had been invested before the crisis, it could have funded an additional 86m hours of community care within people’s homes, or 10.3m nights of care in residential nursing homes, easing pressure on hospitals and creating the equivalent of 28,331 extra beds in 2019, the IPPR concluded.

Chris Thomas, senior research fellow at IPPR, said that since the 1980s, there had been a growing focus on efficiency in the NHS “which narrowly defined value around short-term cost, rather than long-term quality, outcomes and sustainability”.

To strengthen the NHS, the institute is calling for a series of new “resilience rules”, based on the idea of fiscal regulations and financial stress tests after the 2007-08 financial crash. These should include a “capacity rule”, ensuring no hospital is more than 85 per cent full, with at least an additional £8bn invested in community care this parliament, to ease pressure on ward beds.

Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, said: “There is no doubt that we did not have an adequate bed base at the start of the pandemic. Our bed occupancy rates were too high, in places dangerously so, we had far too few [intensive care] beds and we lacked diagnostic capacity.”

The NHS, he added, “has been ‘running hot’ for years”.

Chart showing that bed occupancy in England has increased. % of acute beds occupied (rolling four-quarter average), 2011 - 2020.

The IPPR suggests this overstretched service struggled to cope when the pandemic struck. The NHS “had to withdraw services from huge cohorts of people”, cancelling 2m non-urgent operations; meanwhile urgent cancer referrals from GPs fell by 75 per cent.

The think-tank said these figures “are indicative of why the UK has experienced significant numbers of excess deaths not directly caused by Covid-19, as the outbreak took its toll on health and adult social care”.

The impact of the NHS’s comparatively low staffing levels was also apparent through the pandemic, according to the IPPR. “The UK has one of the smallest health and care workforces in the world — particularly given the size of our health system and our overall economy”, it said.

Chart showing that the number of UK doctors is low when  compared with other countries. Number of doctors per 1,000 residents

David Wrigley, a GP in Lancaster who is deputy chair of the British Medical Association’s ruling council, said that staffing levels were insufficient to support the goal of moving care out of hospital. The rationale for reducing the number of beds was “‘we can do things more quickly now and we can transfer care to the community’. It never really washed with doctors because to do things well in the community you need additional capacity — GPs, nurses — and that didn’t happen,” he said.

The IPPR report urges the government to commit to recruiting at least an additional 250,000 people into the NHS, and 400,000 people into social care, by 2030. 

The think-tank highlighted data showing that the UK spends more than the G20 average on healthcare but less than many comparable countries. It also has relatively low capital expenditure on buildings and equipment compared to its OECD peers.

Chart showing how UK long-term care workers compare with other countries. Per 100 people over 65

Mr Dickson said that a Confederation report commissioned from the Institute for Fiscal Studies think-tank and the Health Foundation two years ago suggested “we need 4 per cent real terms growth [in funding] a year every year for the next 10-15 years to deal with current and future demand”. Now, with the pandemic, “the task is even more formidable,” he added. 

Dr Wrigley is in no doubt about the impact on the frontline as the NHS struggles to restore normal services after the crisis. “We’ve got inadequate funding, inadequate staffing and a waiting list that’s going through the roof. The waiting list figures are real people in pain and discomfort who are trying to get on with their lives,” he said.

The Department for Health and Social Care said: “The government committed to giving the NHS whatever it needed to respond to this pandemic and the prime minister recently announced a further £3bn winter funding for the NHS to relieve winter pressures on A&E and provide additional capacity for the NHS to carry out routine treatments and procedures.

Chart showing that the UK spends more on healthcare than the G20 average. Percentage of GDP

“This is on top of the record cash funding boost of £33.9bn extra by 2023-24 we are already providing.”

Saffron Cordery, deputy chief executive of NHS Providers, which represents the leaders of hospital, ambulance, community and mental health services, suggested there were “lessons for a future inquiry in terms of the capacity and resourcing needed to both run the NHS, and to ensure it can adequately prepare and respond to pandemics”.

She highlighted the IPPR’s findings that more needed to be invested in public health and prevention. 

Yet, she added, over the past few months, trusts and their staff had “navigated the most challenging period of the NHS’s history” to care for people in a way that was “nothing short of remarkable”.

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