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Why is the NHS under so much pressure this winter?

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We look at the key crises facing the NHS – and the government’s proposed solutions to the increased strains on staff, beds and budgets

The NHS is facing the most intense strain on resources in decades as a result of flu, bad weather and an increase in patients suffering from breathing problems. Here we examine some of the key questions and discuss the government’s proposed solutions.

Q: What are the financial pressures on the NHS that have built up over the last decade?

A: Between 2010-11 and 2016-17, health spending increased by an average of 1.2% above inflation and increases are set to continue in real terms at a similar rate until the end of this parliament. This is far below the annual inflation-proof growth rate that the NHS enjoyed prior to 2010 of almost 4% stretching back to the 1950s. As budgets tighten, NHS organisations have been struggling to live within their means. In the financial year 2015-16, acute trusts recorded a deficit of £2.6bn. This was reduced to £800m last year, though only after a £1.8bn bung from the Department of Health, which shows the deficit remained the same year on year.

Q: What was the government’s response in the budget?

A: The chancellor, Philip Hammond, attempted to fend off a winter NHS crisis by handing the service an immediate £335m bailout and an extra £1.6bn from April to cover the 2018-19 financial year. Analysts believe it amounts to about half of what the service requires to keep up with demand. After the budget in November, the Nuffield Trust thinktank said that the amount pledged “was not set to keep pace with what patients need”. According to the health policy thinktank the King’s Fund, the money only makes up for higher than expected inflation and keeps the real-terms increase for the next three years at 1.2%, which “is not sufficient to cover growing demand”.

: Can the NHS remain within its new, slightly bigger budget?

A: NHS trusts have limited their deficits mainly by cutting back on capital projects. Reductions in spending on building and maintenance over the last seven years means many hospitals are in dire need of refurbishment if not replacement. In 2016-17 NHS managers asked for £4.1bn just to maintain the current establishment in a decent state of repair, but were forced to make do with £2.9bn. There will need to be a fresh Whitehall spending review to boost funding over the longer term, which appears unlikely. Treasury sources have indicated that with Brexit, the dominant preoccupation of most ministers, the capacity to revisit spending plans is limited.

Q: Do we have enough doctors and nurses?

A: The UK has fewer doctors and nurses than many other comparable countries both in Europe and worldwide. According to the Organisation for Economic Co-operation and Development (OECD), Britain comes 24th in a league table of 34 member countries in terms of the number of doctors they have relative to their populations. Greece, Austria and Norway have the most; the three countries with proportionately the fewest medics are Turkey, Chile and Mexico. Jeremy Hunt, the health secretary, regularly points out that the NHS in England has more doctors and nurses than when the Conservatives came to power in 2010. That is true, although there are now fewer district nurses, mental health nurses and other types of health professionals.

NHS unions and health thinktanks point out that rises in NHS staff’s workloads have outstripped the increases in overall staff numbers. Hospital bosses say that understaffing is now their number one problem, even ahead of lack of money and pressure to meet exacting NHS-wide performance targets. Hunt has recently acknowledged that, and Health Education England, the NHS’s staffing and training agency, last month published a workforce strategy intended to tackle the problem.

Q: Has there been a Brexit effect?

A: There is great concern within the NHS – which is hugely reliant on EU-trained staff – that over time fewer health professionals trained in the 27 other EU countries will come to work in the UK. NHS leaders are also worried that increased numbers of EU-trained staff already working in Britain – there are 54,000 in the NHS in England alone – will opt to go home or move to another country, and there are some signs that this is already happening a bit.

But NHS Digital figures show that the health service in England actually had more consultant (senior) doctors, more registrars (junior doctors), more trainee doctors, more midwives and more ambulance staff trained in EU countries at the end of June 2017 than at the end of June 2016, a week after the Brexit referendum. However, it has slightly fewer nurses and health visitors now than then – 20,618 compared to 20,907 in June 2016.

Q: What about social care?

A: Hammond said last March that he would pump an extra £2bn into social care to head off a crisis that meant thousands of elderly patients were recovering in hospital rather than returning to some form of care. Councils were able to bid for £1bn in the current financial year and the remainder over the following two years. There is evidence that the extra funding has allowed hospitals to transfer elderly patients back into long-term care and free up beds, although not enough to meet the government’s targets for the length of time patients stay in a bed. The Department of Health wanted to see a fall to an average of 3.5 days but was forced to settle for five days.

Q: What is the longer-term plan for social care?

A: The £2bn front-loaded financial package was supposed to be followed by the publication of a broader policy document explaining how ministers planned to cope with an estimated rise of 2 million in the number of people aged 75, many of them seriously ill, between 2010 and 2030. In its election manifesto, the Tories proposed a dementia tax to boost revenue. This plan was ditched after Theresa May’s failure to secure an overall majority in parliament. A revised plan is expected sometime this year.

Q: Why is it so bad this year in particular?

A: A combination of factors are at play. Hospitals have fewer beds than last year, so they are less able to deal with the recent, ongoing surge in illness. Last week, for example, the bed occupancy rate at 17 of England’s 153 acute hospital trusts was 98% or more, with the fullest – Walsall healthcare trust – 99.9% occupied.

NHS England admits that the service “has been under sustained pressure [recently because of] high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges, early indications of increasing flu prevalence and some reports suggesting a rise in the severity of illness among patients arriving at A&Es”.

Many NHS bosses and senior doctors say that the pressure the NHS is under now is the heaviest it has ever been. “We are seeing conditions that people have not experienced in their working lives,” says Dr Taj Hassan, the president of the Royal College of Emergency Medicine.

The unprecedented nature of the measures that NHS bosses have told hospitals to take – including cancelling tens of thousands of operations and outpatient appointments until at least the end of January – underlines the seriousness of the situation facing NHS services, including ambulance crews and GP surgeries.