Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: Coffey’s inadequate plan for health and social care

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o2296 (Published 23 September 2022) Cite this as: BMJ 2022;378:o2296

Linked News

NHS plan will make “no tangible difference” to struggling patients, say GP leaders

  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter @mancunianmedic

Thérèse Coffey, England’s new secretary of state for health and social care, has set out the details of her plan to improve NHS performance. I tuned in to hear her statement to the House of Commons and was disappointed but not surprised by the empty, wholly inadequate, unrealistic nature of her proposals.1

Regarding the elective care backlog, Coffey at least admitted that the numbers of people waiting would rise before coming back down. She plans to accelerate some of the milestones and actions in the existing elective recovery plan from 2021, specifically mentioning an increase in community diagnostic hubs and new hospitals—although I’m not sure what part the latter will play in tackling today’s backlog. And there’s considerable doubt about the government’s pledge of “40 new hospitals by 2030.” Apart from a plan to review the pension tax rules that deter senior doctors from taking on additional clinical sessions, Coffey’s proposals had few details.

She told us that, in winter 2021, 45% of the longest ambulance handover delays were at 15 hospital trusts.2 Indeed, variation between providers and localities was a theme she returned to: she seemed to ask whether we could get the rest to be as good as the best and tackle these variations by copying practices at better performing sites—although there are wider structural factors behind the poor performance in some of these places. She reiterated the government’s commitment to the four hour waiting time target at emergency departments, despite the failure to meet it in England for several years.3

She promised more call handlers for emergency services, with no promise to recruit more paramedics or ambulance technicians, improve their terms and conditions, train more, or recruit more from overseas. However, many delays in emergency departments relate to patients who are sick enough to require admission but are delayed because beds are often (as Coffey acknowledged) occupied by people fit enough to leave hospital but awaiting social and community health services to help them return home.4

On this point, she pledged a £500m “adult social care discharge fund”5 for this coming winter to help people leave hospital sooner and “the equivalent of 7000 additional beds” by providing extra care capacity for when they do so, including support in their own home. (This merely restores what was in place from March 2020 to April 2022 with the relatively successful “covid discharge fund.”6) However, she gave no detail about how these extra care home places, community beds, or home support packages would be sourced. And the £500m announced is not new money but will come from reduced national insurance contributions by NHS staff and “savings.”7

Coffey helpfully acknowledged that the points based immigration rules affecting care workers needed to be relaxed to allow more to enter the country, with a recruitment campaign backed by an investment of £15m. There was no mention of increasing pay or improving terms and conditions to help recruit and retain care workers—nor any detail on longer term solutions for significant, sustainable increases in social care funding, beyond saying that this would be considered further in the future. So, any onus to improve terms and conditions would still fall on struggling care provider organisations. She placed faith in more digital investment (again, free of detail) to relieve pressure on care staff.

GP numbers

Then on to GPs. Coffey announced no plans to increase their whole time equivalent numbers (which have fallen since 2015 despite a rising workload)8 or to improve terms and conditions, beyond tackling the pension tax issues. On Radio 4’s Today programme earlier that day she had claimed that GP numbers were “pretty stable.”9 But the UK has among the fewest doctors and nurses per capita in OECD nations,10 and our GPs are far busier than those in comparable high income nations.11

Currently, 44% of patients12 are seen by a GP on the same day they request an appointment. Coffey now has an “expectation” that all patients will be seen within two weeks and that more same day appointments will be available. How? Apparently, by giving GPs “additional freedoms to recruit additional support staff”—which they already have, as part of government initiatives around integrated care systems.

But where will the extra general practice nurses or allied health practitioners come from? They too have workforce crises and unfilled posts.13 Coffey proposed “more use of community pharmacists,” including independent prescribers. All of this would provide an extra million GP appointments a year,14 she claimed. But with already over 300 million GP consultations a year,15 this was a big number soundbite used out of context. Setting targets doesn’t create more capacity, and in any case Coffey has said that the government won’t impose an official target on GPs.

We all know that the elephant in the room for health and social care is the workforce crisis, but apart from re-announcing an earlier government pledge to “recruit an additional 50 000 nurses,” all that Coffey could promise was that a workforce plan would be published soon. Serially anticipated but never arriving, the NHS workforce plan has become like waiting for Godot.

Ultimately, Coffey’s much trumpeted firecracker of a plan to improve the NHS and position herself as the “patient’s champion” was partly a rebadging of existing plans, partly a damp squib.

Footnotes

References