A new plan is needed for the NHS, says the Royal College of Physicians

The NHS in 2016 is clearly in a difficult position. Quite how difficult was laid bare recently in a new report by the Royal College of Physicians (RCP). 

Its Underfunded, Underdoctored, Overstretched report makes it clear from the title alone where it sees the pressure points. And, given the current climate of junior doctor strikes and the government's preference for efficiency savings over more funding for the NHS, it should not surprise anyone that the report paints a grim picture. 

The NHS is, the physicians' body says, struggling to cope under the increasing pressure of rising demand and inadequate funding, with resulting workforce pressures threatening patient safety. 

What's notable about this report over a lot of the other warnings about the state of the health service is that it draws on the experiences, views and concerns of consultant and trainee physicians. 

Rising Demand 

The report first takes issue with NHS funding, saying the health service's budget has not kept pace with rising demand for services, with the latter increasing by four percent every year but government spending set to rise by just 0.2 percent in real terms in the years to 2020 – money that will have to go a lot further than it would have in the past. 

In fact, the health service ended 2015/16 with the largest aggregate deficit in its history, according to The King's Fund, with a threefold increase on the previous year bringing it in at some £1.85 billion. The respected healthcare think tank looked at NHS deficits in July and noted the scale of the problem "signifies a health system buckling under the strain of huge financial and operational pressures". 

For the RCP the situation has recently been seriously compounded by hospital deficits, which are hitting £2.45 billion. Attempting to deal with the deficits means that money earmarked for the transformation of services "risks being sucked into a financial black hole". 

Meanwhile, cuts to social care have been piling on further pressure. It's estimated that some £5.5 billion has been cut from services for older and disabled people since 2009/10, despite rising demand for health and care services from an ageing population. Particularly worrying is the 400,000 people that The King's Fund estimates have been denied access to the care they need over the past five years because of the cuts. 

Surveying the level of services cuts and their impact, the England's care regulator the Care Quality Commission (CQC) said this month the measures had placed A&E services at a 'tipping point' and that hospitals are dangerously full. It comes against a long-term trend of rising A&E attendance, which has gone from 17.8 million visits in 2004/5 to over 22.3 million in 2014/15, having increased every year since 2001/2. Its State of Care report, which is based on inspections and ratings of more than 21,000 services, raises concerns about the fragility of the adult social care market and how that is now beginning to impact both on the people who rely on these services and on the performance of NHS care. "The combination of a growing and ageing population, more people with long-term conditions, and a challenging economic climate means greater demand on services and more problems for people in accessing care," the CQC said. 

CQC chief executive David Behan warned: "Unless the health and social care system finds a better way to work together, I have no doubt that next year there will be more people whose needs aren't met, less improvement and more deterioration." 

According to the RCP pressures on the NHS are putting patient safety and recovery at risk "every day of the week", with patients facing longer waits for treatment, and the number of patients stuck in hospital because of delays in being discharged having increased by 80 percent over the past five years.  

Staffing shortages 

One of the report's criticisms is that the NHS is 'underdoctored', with fewer doctors being trained in the NHS and a shortage of those training to be medical specialists. 

This may be eased in time with the announcement by the health secretary at the Conservative Party conference earlier this month of a 25 percent increase in medical school places (see page 34). But doctors' leaders quickly pushed back, saying Jeremy Hunt's plans don't go far enough. 

In the meantime the RCP says: "NHS staff increasingly feel like collateral damage in the battle between rising demand and squeezed budgets. Four in five physicians-in-training report that their job causes them excessive stress; three-quarters go through at least one shift a month without drinking enough water. When NHS staff well-being suffers, patient safety and experience suffer too." 

The RCP adds that 95 percent of physicians-in-training report that poor staff morale is having a negative impact on patient safety in their hospital. 

RCP registrar Dr Andrew Goddard said: "It is clear to all of us working in the NHS that we are at a point of no return and the NHS in its current form is unsustainable without a significant increase in funding. We can't continue to provide ever-more-expensive treatments to an ever-increasing group of patients and not expect the system to collapse. 

"As doctors, we see the problems this creates on a daily basis, be it at the front door of the hospital, in A&E or in outpatients. Patients can see it too and realise that the NHS is no longer theenvy of the world and isn't fit for our changing world." 

For Dr Goddard the solution involves some big decisions for society to make and requires political parties to "stop blaming each other for where we are and work together to build a health and social care system that is fit for the UK in the 21st century". 

In response NHS managers' body the NHS Confederation cautiously welcomed the RCP's report on workforce. Its director of policy Dr Johnny Marshall said: "Further growth in the numbers of doctors is currently necessary but it will become unaffordable if allowed to continue indefinitely – putting healthcare at risk." 

The answer to this, he said, was for the development of new roles, such as that of physician associates, and new models of care that are "more in-tune with patients' needs", such as moving services from hospital settings to community settings. 

"If the RCP could expand its focus in one area, we believe it could further encourage the expansion of community services and better coordination between GPs, pharmacists and other local care – making it more fully aligned with patients' needs. We must move care and treatment closer to people's homes," Dr Marshall said. 

A future prescription 

Optimistically or not, the RCP wants to see a new NHS budget that meets demand for health services, sets realistic targets for efficiency savings, protects funds for transformation and invests in the long-term sustainability of the NHS. 

Alongside the pressing need to ease staffing gaps in the number of doctors, the RCP wants improvements for the working lives of NHS staff and later this year will launch a new campaign to help ensure NHS doctors are valued and supported. 

RCP president Professor Jane Dacre said: "As a doctor, I realise that this is a tough diagnosis for the NHS. However, a diagnosis is the first step towards working with colleagues to find solutions. We are keen to find the best treatment for the NHS over the coming weeks, months and years." 