A Paradigm 'BlueSky' Ideation Laboratory
Articulating A Vision for
Transforming the Culture of Care
Objective
The objective of this section is purely to lay the foundations for purposes of level-setting everyone around a common understanding of the basic issues impacting the NHS and health systems globally, and in order to lay the groundwork upon which to build our forthcoming research and ideation. It is by no means intended to be exhaustive. (So essential for the purposes of our mutual understanding, but nothing particularly ground-breaking here, just yet!)
The Challenges for
Healthcare
The Challenges for Healthcare
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Technology & Integration
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Public Health Challenges
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Policy & Governance
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Research & Innovation
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Outliers /Other
#theideatory
The Challenges In Snapshot
01
Public funding for health services in England comes from the Department of Health and Social Care budget. The Department’s spending in 2022/23 was £181.7 billion. The vast majority of this spending (94.6%, or £171.8 billion) was on day-to-day items such as staff salaries and medicines. The remainder was largely capital expenditure on long-term fixed assets such as new buildings or equipment.
Limited Funding and Resources: Public healthcare systems are often underfunded, and private systems face limitations due to high costs, creating barriers to accessing necessary care and impacting overall quality and availability of service
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Health spending growth has been below average since 2010, resulting in a cumulative underspend of hundreds of billions of pounds. In the decade preceding the pandemic, its understood that annual spending increases were significantly below the long term average for nine subsequent years which has resulted in a cumulative underspend of £362 Billion since 2009/2010. Sir Michael Marmot adds in his report: Health Equity in England: The Marmot Review 10 Years On :
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​​‘In 2009/10 public expenditure was 42 per cent of GDP and by 2019 that had become 35 per cent. That is significant. And that reduction in public spending was done in a very regressive way, and this gets us closer to our lack of preparedness for the pandemic.’ Sir Michael Marmot
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Although health spending has increased year on year over the decades, this is due to a range of factors, including population growth, aging populations living longer with complex co-morbidities or medical conditions, increasing costs in relative costs of treatments moreover health spending has increased over the decades in all comparable european countries.
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Future Growth: Under current plans, the average real-terms growth in health funding will fall to 3.0% per year between 2024/25, as it did 2019/20. This is below the pre-COVID long-term average of 3.8%.
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Austerity Measures: Long-term austerity measures have led to tight budgets and underfunding, impacting service delivery. However, its had a wider deleterious effect. As Sir Michael Marmot landmark report in February, 10 years on from the Marmot review of 2010, said: ‘From rising child poverty and the closure of children’s centres, to declines in education funding, an increase in precarious work and zero hours contracts, to a housing affordability crisis and a rise in homelessness, to people with insufficient money to lead a healthy life and resorting to food banks in large numbers, to ignored communities with poor conditions and little reason for hope… Austerity will cast a long shadow over the lives of the children born and growing up under its effects.’ Sir Michael then went onto point out, that it was against this backdrop, that the response to the greatest public health threat in living memory was to be framed. ‘We were in a very bad state – and then came the pandemic,’​
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Rising Costs & Inflation: The cost of medical advancements, new technologies, innovations in medications, and complex treatments continues to rise, in line with patients expectations for ever more innovative (in some cases border-line experimental) treatments (especially for some acute and or rare terminal conditions), is driving up demand in some cases, for ever more new innovative and costly treatments. In short, patients have a reasonable expectation that the NHS will modernise, and offer the best latest treatments. These factors put additional strain on financial resources.
In 2024/25, the DHSC’s total budget is set to increase to £192 billion, an increase of £1.1 billion on 2023/24, but inflation means that, on current plans this only equates to a small increase of 0.6% in real terms compared with 2023/24. This represents a real terms reduction in funding compared with 2022/23.
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Hannah-Rose Douglas, deputy director for the Health Foundation’s REAL Centre, commenting on the governments allocation of an additional £3.4Bn in 2024 Spring Budget, earmarked for AI & Digitisation said:
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‘While the additional funding for the NHS in the recent spring Budget is welcome, when the impact of a growing and ageing population as well as inflation is taken into account, the value of the NHS England’s spending pot will decrease in value by 1% in 2024/25, compared to the previous year. This underlines the challenges for the NHS to improve care when faced with these ongoing funding and demand pressures.​​
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02
Workforce Shortages & Productivity
As well as recruitment, holding on to existing staff has been an issue for the NHS, with 10.7% (154,000) leaving their NHS roles in the year ending September 2023, and 28.3% (390,000) leaving their social care roles in 2022/23.
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Workforce Deficits: One of the main challenges for the NHS from perspective of its workforce is just from its sheer scale and size.
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The NHS is the UK's largest employer, with the NHS in England employing over a 1.7 million staff, (equivalent to 1.5 million full-time staff), with employee costs accounting for around two-thirds of NHS providers’ expenditure.
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The NHS is estimated to be the sixth largest employer in the world, behind the Indian Ministry of Defence, US Department of Defense, the People's Liberation Army of China, Walmart, and Amazon​
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The vast majority of NHS staff – 1.4 million people – work in ‘hospital and community services’ as direct employees of NHS trusts, providing ambulance, mental health and community and hospital services.
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There were 125,572 vacancies (9%) in the NHS between March and June 2023.
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According to the NHS Long Term Workforce Plan, the projected demand for staff by 2036/37, will be in the region of 2.3-2.4 million and, if this is met, an estimated 1-in-11 of all workers in England will work for the NHS, compared to 1-in-17 now.
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There are significant shortages of doctors, GP nurses, and other healthcare professionals, this has also been exacerbated by Brexit and had an impact on EU nationals working in the NHS as well.
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​Challenging working conditions, and insufficient recruitment and retention strategies.
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Published data suggests that the NHS may have some 1,400 unfilled doctor vacancies and around 8,000 to 12,000 unfilled nursing vacancies on any given day.
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Stress, Burnout and Morale: High levels of burnout and low morale among healthcare staff due to increased workload and pressure.
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According to the results from the NHS Staff Survey 2023, 30.38% of NHS staff said they felt burnt out because of their work. This is down from 33.97% in 2022 and 34.49% in 2021.
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​Productivity Growth: Also significant were the challenges the NHS experienced in recovering activity, and clearing the backlogs incurred during the pandemic, which has proven extremely difficult, despite the NHS being given more money and staff? The NHS found itself in the position of doing 'less for more'
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And then subsequently found itself at serious risk of running out of money despite funding being increased substantially post- the pandemic
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While the NHS has almost a fifth more staff now than 4 years ago, the amount of hospital care it provides is broadly no higher than pre-pandemic levels.
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Figure 1 shows how NHS funding, staffing and hospital admissions have changed in the years pre pandemic, and (since 2019/2020.
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GP appointments: patient satisfaction with access to general practice has severely plummeted in recent times, with patients expressing dissatisfaction in their experiences of accessing appointments, waiting times to be seen, and the types of appointments offered. Added to which the ongoing GP crisis, or shortfall in the total numbers of GP's, despite government promises to recruit more GP's, has actually seen the numbers of fully qualified permanent, full-time GP's progressively fall since 2015.
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Hospitals services, (due to the Hospitalisation treatment model being the main mechanism of care delivery) remain the main component of the care the NHS provides, and
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NHS constitution Standards: The latest research by the Nuffield Trust has revealed that nine of the eleven waiting time targets as set out in the NHS's Contract with patients are currently not being met​
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Health Inefficiencies and Waste: Inefficiencies, such as administrative waste, preventable hospital readmissions, and unnecessary procedures, contribute to high costs without improving patient outcomes, impacting the overall sustainability of healthcare.
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Hospital Backlog: The latest performance figures, published since the recent election - have revealed that the hospital backlog now stands at 7.6 million, having risen yet again for a second consecutive month.
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Struggles to Improve Productivity: While a handful of hospitals have experienced success in tackling their backlogs through weekend working, and high intensive use of their operating theatres, the NHS overall has struggled to improve productivity, despite allocations of additional budget and more staff being employed. Returns on investment have been poor, revealing a total disconnect between money spent and outcomes achieved. ​
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However, looking at treatments is only one aspect of productivity, this is a far more complex issue.
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The IfG Analysis published last year, conducted an analysis of the problem, and concluded that the NHS actually started becoming less productive in the late 2010s, after having had a 15 year prior run of improving productivity. The COVID pandemic was acknowledged to have exacerbated the crisis.
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Population Growth & Aging Demographic
'For a significant number of older people, advancing age is associated with frailty. In medicine this is often defined as a reduction in physical capacity: a group of older people who are at the highest risk of adverse outcomes such as falls, disability, admission to hospital, or the need for long-term care.' Catherine Thompson, Head of Patient Experience for Acute Services, NHS England.
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Population Growth and Urbanization: Rapid population growth, especially in urban areas, increases the demand for healthcare services. Urbanization can lead to overcrowded healthcare facilities and increased rates of infectious and non-communicable diseases.
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Increased Demand: England’s population is ageing. In the next 25 years, the number of people older than 85 will double to 2.6 million. The Health foundation were keen to point out that, the assumption that this will result in an increased requirement for health and social care services is a bit more nuanced. The proportion of older people in need of social care support has actually fallen, although having said that, the proportion of people over 75, with a serious, long-term condition has risen, and will likely become more complex over time, which does imply a knock-on effect, or an increase in demand for NHS services ultimately. suggesting that people are living with longer term conditions, managed with the NHS. The aging population leads to higher demand for healthcare services, particularly for chronic and complex conditions/ multi-morbidity)
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The COVID pandemic has had an impact on life expectancy which will also put additional strains upon the NHS and Health care systems in the long-term.
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The Silver Tsunami: The ONS recently revised upwards its population estimates and the population of England is now projected to be 8% higher in 2024/25 than in 2013/14 (0.7% growth per year), with a rising share of the population above retirement age. Adjusting for population increases, spending per person in real terms rises by 1.9% per year between 2013/14 and 2024/25. Further adjusting for ageing in the population, it will rise by just 1.6% per year over the same period.
When assessing the long-term financial pressures facing the NHS, the Office of Budget Responsibility’s (OBR) central estimate for health care in the UK shows funding pressures growing by over 4% a year, (in part to account for increases in aging population) accounting for inflation, between 2021/22 and 2031/32 – significantly higher than their projection for UK economic growth – requiring an extra £68bn investment.
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Resource Allocation: The need for more geriatric care and long-term care facilities increases financial and staffing pressures.​
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Reducing elective waiting times from ‘18 months to 18 weeks’ was one of NHS England's major achievements in the 2000s. In January 2020, before coronavirus (COVID-19) began to impact on the UK, more than one in six patients were waiting more than 18 weeks for routine treatment. To free up NHS capacity, non-urgent planned care was postponed for 3 months from 15 April 2020.
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The rates of spending growth, set out in the NHS Funding Bill in February 2020, will not be sufficient to cover the cost of meeting the 18-week standard by March 2024, even before any additional costs and demand arising from COVID-19. The Health Foundation estimates that spending growth would need to increase by a further £560m a year – assuming the NHS can prioritise patients to make the most effective use of available capacity.
04
Infrastructure & Capacity
Weak investment has contributed to constrained capacity across the health system. The overall result has meant a severe paring back of Infrastructure and Capacity, and this has contributed to the Health Sector's vulnerability to shocks.
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Hospital Capacity & Overcrowding: Many hospitals face overcrowding, with bed shortages and long waiting times for patients.
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Performance: The NHS is under intense pressure with performance standards across the board being missed – ambulance response times, A&E waiting, cancer referrals and waiting times for surgeries ​
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Maintenance and Modernization: Aging infrastructure requires significant investment for maintenance and modernization to meet current healthcare standards.
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Underinvestment: Weak investment has contributed to constrained capacity across the health system
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The overall result has meant a severe paring back of Infrastructure and Capacity, and this has contributed to the Health Sector's vulnerability to shocks. ​
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The European Observatory on Health Systems and Policies defines a shock as “a sudden and extreme change which impacts on a health system”,
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and has resulted in Volatility, a health system, prone to chronic overcrowding, bed shortages and long waiting times for patients​​
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Going into the pandemic, the NHS in England had lower numbers of hospital beds per person than most comparable countries (2 beds per 1,000 people) – similar levels to Canada and Sweden, but lower than countries like France (3 beds per 1,000) and Germany (6 beds per 1,000)
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The NHS also had much shorter lengths of stay in hospital and higher bed occupancy – running the system ‘hot’- The Health Foundation
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The Volatility of Capital Spending
Capital spending has long been much more volatile than day-to-day health spending. After being cut back sharply in the 2010s, capital spending has increased in recent years – though in 2023–24, the capital budget in England was raided to fund day-to- The past and future of UK health spending. The Institute for Fiscal Studies, May 2024 3 day pressures, returning to the bad practice of the late 2010s.​​
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Deterioration of the NHS Estate (In England): One consequence of low capital spending is the deterioration of the NHS estate in England, where the maintenance backlog has more than doubled.
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Looming PFI Crisis: This may also be further exacerbated by a looming PFI crisis. This has led to a bill for backlog maintenance in the public sector of at least £37bn. Some £10bn of that is in the NHS. As a result, areas involving patient treatment are being closed ‘all the time’, NHS England told MPs recently. ​
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Capital funding is used to finance long-term investments such as buildings and medical equipment. The planned capital budget for health is £11bn in 2023/24 (£11.1bn in real terms), up from £9.9bn in 2022/23 (£10.6bn in real terms), a 4.3% real-terms increase.​​
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The 2023/24 capital budget is £1.1bn less than was announced in the Autumn Statement following in-year transfers to other budgets, and moreover though generous will unlikely be sufficient to address both the PFI backlog and current capital plans.​
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On current plans the capital budget will rise to £12.6bn in 2024/25 (a 13.6% real-terms increase compared to 2023/24). £3.4bn in capital funding between 2025/26 and 2027/28 was also announced at Spring Budget 2024, for digital and technological transformation and to support an NHS productivity plan.
05
Accessibility of Services
The waiting list for elective care in England has now reached 7.6m. Behind these numbers are people in avoidable suffering and pain, and lives put on hold. Reducing the NHS waiting list remains a top priority for the government and health service alike.
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Waiting Lists: Currently there are record numbers of people waiting for planned care and treatment, with over 7.6 million people on elective care waiting lists as of April 2024. Though this is slightly down from October 2023, when NHS waiting lists rose to their highest record yet (since records began in 2007), with nearly 7.75 million people awaiting treatment.
- with new NHS data suggesting that 70,000 were added to the NHS waiting list in August 2023 alone
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with over 302,000 people waiting more than a year.
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The waiting list has been growing since 2013, and the pandemic caused a sharp increase
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The median waiting time for treatment is 14.4 weeks, which is nearly double the pre-COVID median wait of 8.0 weeks in August 2019.
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The NHS has missed targets to eliminate waits longer than 65 weeks by March 2024, and to have 92% of patients receive treatment within 18 weeks of referral since September 2015.
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The waiting list is expected to continue to grow was feared that it might peak at more than 8 million by summer 2024, which fortunately wasn't realised, (but only by a slender margin).
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However, its believed the true number of people waiting, could be much higher, as some people who need treatment are struggling to get a referral from their GP's (in certain localities).
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Insufficient capacity in adult social care: Financial and staffing pressures in residential and community services is continuing to have an ongoing impact on the quality of patient care, contributing to delays in discharging people from hospital, with some at greater risk of not receiving the care they need, and also contributing to the issue of bed blocking.
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In the Community, many face ongoing difficulties in getting GP and dental appointments. This results in some using urgent and emergency care services as their first point of contact, or not seeking help until their condition has worsened.
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Regional Disparities: Different regions experience disparities in access to healthcare services, with rural areas often facing more significant challenges. For example, their are fewer GP's per patient in more deprived areas, consultations are usually shorter, and also continuity of GP care is worse.
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GP practices: The more deprived regions of England are comparatively underfunded, under-doctored, and perform less well on a range of quality indicators, when compared to practices in wealthier areas.
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This is the 'inverse care law,' which was first identified by GP Julian Hart 50 years ago, who coined this term to explain that perversely – people who most need medical care are least likely to receive it.
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Past governments have used a range of approaches in an attempt to make access to primary care in England more equitable – including changes to GP funding, contracts, buildings, staffing, amongst other things.
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The GP sector in England began its journey to digitise in the 1980s, and was almost 100% complete by the mid-2000’s. By comparison, in 2002, secondary care embarked upon an ambitious programme to digitise, namely – the National Programme for Information Technology (NPfIT), however it was shut down in 2011 not having attained its goals.
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Digital Transformation: Integrating digital health technologies and electronic health records (EHRs) effectively is a complex and ongoing challenge.
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The National Programme for IT in the early 2000's has impacted the confidence of the NHS in it's Digital Transformation journey. Retrospective analyses of NPfIT criticised the programme for being too centralised, for not engaging with trusts and their healthcare professionals, and for trying to accomplish too much too quickly.
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Digitisation: Furthermore the Government announced in the 2024 Spring Budget, that it is to earmark a further £3.4m for 'digitisation', yet despite significant expenditures to date in various business, health-IT, and digital investments/ initiatives, the sector as a whole is yet to 'transform'
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Healthcare is also facing something of a crisis or 'lag' technologically in digital innovation, especially as compared to other sectors of the economy.
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Datafication
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NHS Digital and NHS England merged on 1 February 2023, to enhance focus on design and operating national data infrastructure and digital systems.
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'The 4th Industrial Revolution': In addition to which we've also been looking at the fact, that we are now at the inception of the 4th Industrial Revolution and is being driven by increased interconnectivity and innovations in smart automation​​
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An Era of Exponential Technology: In addition to which we are essentially poised to repeat all the innovations, and technological advancements supposedly from beginning of time to the present day in next 13 – 14 yrs.
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Digital (Knowledge) Deficit: This transpires for the health sector as a whole, against the backdrop of their being somewhat late adopters, and still in many cases being in the process of grappling to implement many of the technological advancements of the old or previous era, whilst now being also required to negotiate implementing the technologies of the new.
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The UK's AI Regulation Bill: This lateness in digital adoption does have potentially serious repercussions including for patient care in areas like the adoption of AI for instance, which is further compounded by the lack of legislative direction in relation to its use. The EU's AI Act came into force on 1st August 2024.
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However, the UK is lagging somewhat behind, having only introduced it's AI Regulation Bill to Parliament in November 2023, the detail of which is still being worked through. However, there were a number of concerns with the provisions of this bill, added to which it was also introduced to Parliament as a private members bill, success of private members bills actually being passed is about 5%, so that in reality the UK could be some way away from implementing its own AI regulation/ Act.
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Cybersecurity: Cyber-attacks in the UK are increasing with most industry experts thinking it is not a question of ‘if’ but ‘when’ the next large scale cyber-attack will occur.
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Ensuring robust cybersecurity measures to protect patient data in an increasingly digital environment.
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Technology & Integration
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