James Carville coined the phrase “It’s the economy, stupid” in 1992, while working as Bill Clinton’s presidential campaign adviser. Carville sought to make the economy the clear focus of Clinton’s pitch to voters. By all accounts, the slogan hung on the campaign headquarters’ wall.
On this side of the pond there isn’t a general election. But following the reshuffle and with an Autumn spending review fast approaching, the question of what to prioritise looms large. What sign should be hanging on the wall in the office of Sajid Javid, the new secretary of state for health and social care?
Javid was appointed in June, taking on what is a huge portfolio at the best of times—and these are anything but. Covid-19 isn’t over and the NHS is bracing itself for an incredibly tough winter. The waiting list for planned hospital care like hip and knee replacements is already at 5.6m—and expected to grow even longer. But it’s not just hospitals that are feeling the strain; general practice, mental health and social care are all reporting exceptional challenges.
Where should Javid start? For the NHS and care system, whatever the specific policy ambitions, success or failure ultimately depends on having enough skilled staff. The common issue facing general practice, social care, A&E and mental health is that there is a big gap between the demands facing the service and the staff available to provide care.
Without more staff, it’s hard to see how health and care services can break out of the current vicious cycle of having to focus resources on the “rescue” end of care, at the expense of the early, upstream interventions that would be more efficient and better for patients. The result is unhappy staff, patients and taxpayers.
There are few, if any, countries in the world that had the capacity and workforce to manage Covid alongside wider health services. But England found it particularly challenging. This is symptomatic of a wider issue across the economy: the search for ever greater efficiency has resulted in too little resilience. We are seeing the impact of vulnerable supply chains at work today: just-in-time deliveries and low storage capacity meant we ended up with the lowest gas reserves for a decade in the midst of a global energy crisis.
In the health system, prioritising efficiency over resilience manifests itself in a service that runs on the edge of capacity, with fewer beds, doctors, nurses and scanners than comparable countries.
New research from the Health Foundation finds that even as the pandemic subsides, demand pressures across health and care will continue to grow. The population is ageing, there are rising numbers with long-term chronic health problems, and the virus leaves backlogs coupled with new health problems from long Covid and pandemic-related mental illness. That means more money and more workers are needed in both the NHS and social care.
Overall, the research finds that even if Covid quickly becomes a more routine endemic disease, the NHS will need annual increases in funding which significantly outpace economic growth and inflation. For the rest of this decade, funding would need to grow at twice the rate of the last decade. The majority of the money raised by the new Health and Care Levy up to 2025 is going to the NHS, but this leaves open the big question of how spending in the second half of this decade will be resourced.
For social care, between 2010 and 2020 funding didn’t increase, despite an ageing population and more younger people with disabilities. That legacy leaves the system on the edge. Many people who need care can’t access it. Those who provide care are in a precarious position, really worried about how they are going to get the staff to maintain services. Putting social care onto a sustainable footing is going to cost considerably more than the £5.4bn the chancellor has currently earmarked from the Health and Care Levy. Any solution is about a lot more than capping care costs, welcome and important though that is. It will take many years of extra money, coupled with a vision for care and a package of reform that tackles poor pay, terms and conditions.
Social care has always been the Cinderella service compared to the NHS—even in the good times, funding for social care never matched that for the health service. But the Health Foundation’s analysis shows that over this decade the social care system will need larger proportionate increases.
In some ways this young decade is not so different to the past. Barring occasional one-offs, throughout its history NHS spending has grown as a share of national income, as we live longer and medical advances mean we can do more to treat disease. How well that extra funding is used depends on whether it’s matched by the skilled staff needed to provide care. Our work suggests that by 2030/31, the NHS and care system will need more than a million extra staff. That’s double the growth in workforce numbers over the last decade in the NHS—and four times the growth in social care staff.
Planning for the workforce of the future has traditionally been the Achilles’ heel of UK health policy, with international recruitment the “get-out-of-jail-free card” to manage shortages. But globally, demand for health and care staff now exceeds supply. The UK needs to invest in training, pay, terms and conditions to secure the workforce we will undoubtedly need. Javid would do well to follow Carville’s example and put a sign up in the Department of Health and Social Care: “It’s the workforce, stupid.”
Now read Madeleine Bunting on the precarity facing care workers
