The future of the NHS
The NHS is currently facing significant pressures due to various challenges which will further escalate in the future if unaddressed. Additional funding and evolving NHS services are necessary remedies, as are the greater use of technology and measures to retain staff. But it’s also important to take action on areas outside of the NHS’s control like social care and the social determinants of health. Policy-making for the NHS should adopt a long-term approach, grounded in evidence and incorporating the perspectives of patients, the public and NHS staff in a meaningful way, to ensure that long-term investments are sustainable.
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Kate Duxbury Research Director
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Interview with Tim Gardner, Assistant Director of Policy at The Health Foundation
The future of the NHS
There has been much talk in 2023 about the future of the NHS – with its 75th anniversary falling in a year where there has been little to celebrate. The NHS is under severe pressure, with long waiting lists, Accident & Emergency Departments that are overwhelmed at times, and mental health services that are particularly hard to access1 2. Despite GP practices delivering more appointments than ever before (with 27.8 million appointments in July 20233), they cannot keep pace with demand.
It is perhaps not surprising, then, that public satisfaction with the running of the NHS is at its lowest level in 25 years4 , and the public are pessimistic about its future prospects: over half (54%) think the standard of care the NHS provides will get worse over the following year, according to Ipsos polling with The Health Foundation5. This is the second highest proportion saying the NHS will get worse since 2017, second only to November 2022 at the beginning of a well-publicised difficult winter for the NHS.
The challenges that the NHS faces are considerable
And the public are right to be worried, as the challenges that the NHS needs to overcome are considerable. The NHS was under significant pressure even before the Covid-19 pandemic. There are many factors feeding into this, but three in particular to highlight are societal change, funding levels, and the NHS workforce.
The UK has a growing and aging population6. This puts our health services under an obvious strain. The NHS needs to care for more people, who are living for longer – meaning that demand for health services has been consistently increasing – and the numbers of older people are projected to grow even higher in the future. In our interview with Tim Gardner, Assistant Director of Policy at The Health Foundation, he points out that ironically, population trends mark a major success of our health service.
An aging population also brings with it a change to the very nature of illness, with more people living with complex, long-term conditions into their old age. And these challenges are not going away. The Health Foundation’s analysis suggests that 2.5 million more people are projected to be living with major illness in England by 2040 – a total of 9.1 million people7.
In the face of these external challenges, NHS funding has not kept pace with its growing and changing needs. Although the NHS did receive real term increases in its budget in the decade of austerity before the pandemic, this was still below its long-term average8. International comparisons show it has fewer doctors and nurses than in other European countries, fewer hospital beds, and less equipment like scanners9. Gardner explained in our interview that this left the NHS in a vulnerable position when hit by an unprecedented global pandemic.
Added to this, it is becoming much harder to retain a workforce that has also been deeply affected by the pandemic. Among nurses and midwives who have left the profession in 2022/2023, just over half (52%) say they left earlier than planned10, while among GPs we are seeing the largest rise in the under-30s leaving the workforce11. Although overall numbers of NHS staff are increasing, buoyed by international recruitment, the numbers of leavers mean this is a constant uphill battle.
What the NHS needs: funding and evolution
Part of the picture is the need for increased funding, a fact that the public recognise well: 80% think the NHS needs an increase in funding, while just 17% think the NHS should operate within its current budget12. But how that additional funding is spent is important as some commentators point to limited productivity gains for the NHS despite significant additional funding and increased staffing during the pandemic13.
So funding is not all that the NHS needs – with ever increasing demand, it needs to continue to transform services, or it will be unaffordable – in the UK as in other countries. And the public recognise the need for change. In our polling with NHS Confederation14 , 76% think the NHS needs to make big changes to the way it runs and provides services in order to improve – including 60% who assert that it also needs more money, and 16% that it needs to make changes but does not need more money.
However, the public do not want fundamental reform of the NHS – they still strongly back the model and its founding principles15. Gardner and other health think tanks agree with the public, arguing that there is no evidence that the NHS model itself – and the way in which the NHS is funded – leads to poorer outcomes.
“The changes that we need to see are more about evolution than revolution.”
- Tim Gardner, Assistant Director of Policy at The Health Foundation
What this means for policy makers
In this context, the NHS knows it needs to do things differently, and is actively looking to make changes. And some long-term solutions are being proposed.
Improved use of technology, data and AI can help ease some of the pressures. In our deliberative research with Imperial College Health Partners for the NHS in London16, patients and staff discussed how technological innovation can transform urgent care through new approaches such as ‘digital triage’ which asks patients to first input their symptoms online or over the phone and an algorithm determines the urgency and most appropriate service. There was a recognition that such tools could be useful in more efficiently managing demand, yet there is also concern about how they can be implemented and what it would mean for accessibility to healthcare for vulnerable groups.
But there’s no doubt that technology has the potential to revolutionise the way our healthcare system works, not just through managing demand, but also in achieving productivity gains. For example, Dr Jonathan Bright from the Alan Turing Institute points in our interview to the potential of complex language models used by generative AI to reduce the burden on GPs by aiding with note taking and updating patient records, freeing GPs to see more patients. And indeed, workload and time spent on ‘unimportant tasks’ are key reasons quoted by GPs considering leaving their practices[3]. These sorts of interventions may therefore be beneficial in improving workforce retention, allowing healthcare professionals to spend more time on more rewarding aspects of their jobs.
Pay features in this as well, as recent strikes have shown. And our polling shows that the public broadly support striking medical staff and think they are paid too little [4], while also being understandably worried about the standard of care provided during strikes[5]. Without action to solve issues related to retention, of which pay is just one, the NHS we need for the future will be built on shifting sands. Therefore, it is vital for policy makers to put NHS staff, front-line staff and managers alike, at the centre of the NHS’s evolution.
Some of the solutions to the NHS’s challenges don’t lie within the gift of the NHS, as also highlighted by Gardner: “The NHS was never set up to go it alone. Many of the solutions lie outside the boundaries of the health service.” There are multiple cases where action elsewhere could help the NHS address its challenges, a key example being investing in social care services. In December 2022, of the circa 100,000 hospital beds in England, around 13,000 were occupied by patients who were well enough to leave but couldn’t be discharged17. Patients waiting for social care services are part of the reason for the challenges facing the NHS, albeit not the main cause: around one-third of patients in hospital who didn’t need to be there were waiting for social care. Developing a long-term funding plan for social care, along with addressing other issues such as the social care workforce shortage, will benefit the NHS.
As well as social care, there are a raft of other policy areas that can affect demand for health services in the longer-term. The social determinants of health have far more impact on the health of the nation than the NHS. A nation in which we all have access to things like good quality employment, housing, education and a high standard of living in general will lead to a healthier population with fewer demands on our health service.
Evidence-based and inclusive policy-making
Some of these solutions that have been proposed for the NHS will take time to filter through, which means it’s also important to think about how they are delivered. Ipsos’ research and evaluation within the NHS points to the need for policy makers to approach ‘change’ systematically to prepare the NHS for the future.
Firstly, changes to NHS services need to be made with due consideration for the evidence – evaluating the impact of its interventions to understand what is working, how, and in what circumstances. This is critical for ensuring the NHS pound is spent where it will make the most difference, but also for understanding the potential unintended consequences such as making sure that health inequalities are not further exacerbated.
Secondly, it is vital to involve patients, the public and NHS staff in developing solutions. They can be a source of inspiration, a sensible sounding board, and make the difference between an idea working or not on the ground. At a time when difficult decisions need to be made about where and how to invest the NHS pound, this simply cannot be done without wider involvement. Deliberative research by Ipsos and Imperial College Health Partners for the NHS in London on public and staff expectations of urgent care have demonstrated the value of this approach in informing policy and service design18.
Policy-making for the NHS requires a long-term approach
As Gardner notes at the end of our interview, there is reason for optimism: “We have got the fundamentals of what could be a very high performing health system”. But while the NHS is likely to be a key battleground in the run up to the general election, the improvements that are needed will take more than an electoral cycle to bear fruits. Actions that will future proof the NHS require long-term vision and patience, beyond an election campaign.
This is why Ipsos is working with The Health Foundation this autumn to engage in deliberative discussions with the public on ‘the future of the NHS’. By sharing information and exploring complex topics such as funding models, we can gain valuable insights and feedback from the public, including on what will help to instil confidence that the NHS is moving in the right direction.
We – the public, our politicians, the wider political system, the NHS, and the media – must come together to find ways to make better decisions on long-term investments in our NHS. By doing so, we can ensure the NHS remains sustainable and fit for purpose in the future. Otherwise, we risk having to make even more significant and unpopular changes.
References
1 Nuffield Trust (2023). Quality Watch
2 Bagri, S. (2023). NHS mental health services: what's changed?, Nuffield Trust
4 Morris, J. et al (2022). Public satisfaction with the NHS and social care in 2022, The King's Fund
5 Ipsos & The Health Foundation (2023). Public perceptions of health and social care (May 2023)
6 Census (2021). Living longer: how our population is changing and why it matters
10 Nursing & Midwifery Council (2023). The NMC register
11 The Institute for Government (2023). Performance Tracker 2022/23: Spring update
12 Ipsos & The Health Foundation (2023). Public perceptions of health and social care (May 2023)
13 Freedman, S. & Wolf, R. (2023). The NHS productivity puzzle, Institute for Government
14 NHS Confederation (2023), Understanding public perceptions and attitudes to the NHS
15 Buzelli, L. et al (2023). How the public views the NHS at 75, The Health Foundation
16 Ipsos & Imperial College Health Partners (2023). Urgent care in London engagement programme
[4] Ipsos (2023). Public attitudes towards strike action by Junior doctors
[5] Ipsos (2023). Public attitudes towards proposed strike action by NHS nurses
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