Election special: NHS strikes, A&E pressures and raising taxes to fund the NHS
- 27 June 2024
- 25-minute listen
Authors
During the 2024 general election campaign we'll be examining the key debates and exploring the big issues in health and care. We'll also be answering your listener questions and highlighting some of the important issues that are missing from the national debate.
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A week before the election, Sally Warren, Siva Anandaciva and Dan Wellings sit down to talk about what the public want from the next government, how industrial action might disrupt plans to improve health care and the recent Dispatches episode, which revealed the harrowing human consequences of A&E performance pressures.
Plus, they answer a listener question on ways to approach delivering NHS improvement at a national and local level.
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Key:
SW: Sally Warren (Host)
SA: Siva Anandaciva
DW: Dan Wellings
SW: Hello, and welcome to this latest episode in the King’s Fund General Election 2024 podcast series. I am Sally Warren, the Director of Policy here at the King’s Fund, and I have been given the keys to be the host of the Fund this week because Andrew is taking a well deserved break. I am joined by two wonderful colleagues from the Fund, our Chief Analyst Siva Anandaciva. Hi Siva.
SA: Hi Sally.
SW: And our equally wonderful Senior Fellow Dan Wellings. Hi Dan.
DW: Hi Sally.
SW: You are making your debut on the podcast election special series Dan, so thank you very much for joining us. As I hope listeners have started to understand, we always ask ourselves three questions in these election podcasts. The first question is what has been the big health and care story of the week? Secondly what hasn’t been, but really should have been a story of the week? And then finally we pose a question from you, our listeners. The first question then, what has been the biggest health and care story of the week? Well, if I just take a brief step back. We are now a couple of weeks beyond the manifesto, just one week to polling day, and normally in elections this is the period where one of two things happens. It becomes really very, very much about the personalities of the political leadership, or events happen and derail campaigns.
At a big political level, clearly Gamble-gate is a really good and current example of something that absolutely wouldn’t have been at any election (inaudible 00.01.24), would not have been a plan, but is really kind of setting the scene for the final weeks of the election. And in health and care it’s no different, and many of us would have seen on Monday the really harrowing reports from Despatches with some undercover filming in A&E that really brought home the human consequence of performance in the NHS. This definitely feels to me like it has been the big story event for health and care. So Siva, I wonder if you could talk to us about what did we see in Despatches, and what does it tell us about the current performance in the NHS?
SA: Thanks Sally, and if you haven’t seen it already, try and watch the programme. This is going to sound like quite a crass phrase of cut-through, but I don’t know a better phrase. We do a lot of work to try and highlight the pressures in A&E Departments and other parts of the health and care service. You see it in the paper. You will see your work appearing or talked about on the radio, but you sometimes wonder if it has ever cut-through. You know, a lot of people I know who work in the King’s Fund, who work in other bits outside of policy, came up and said, “I saw that programme and it was awful.” I’ve got text messages from people I haven’t spoken to in months who have said, “I just wanted you to know that I saw that programme and it was awful.” So, I think there is something about, you look at the numbers in performance, you look at things like no A&E Department meeting the target for 95% of us to wait four hours in an A&E Department, and you sort of know that is bad. But until you see people screaming out in pain and not being heard. Until you hear the panic And this is the thing that really stuck with me from the clips, there is one point where the undercover reporter who is working as a member of staff in that A&E Department just realises that he has been asked to do a task that he is not qualified to do.
You can absolutely hear the panic, the franticness in his voice, and I have felt like that in previous jobs where the stakes are low, but I am sat there thinking, “I don’t know how to do this,” and he has got people’s lives in his hands. So, I would say if you really want to understand the pressures in A&E Departments, watch Despatches. And bringing it back to politics in a kind of cackhanded way, both main parties, the Conservative Party and the Labour Party have said they are going to return A&E performance standards to where they should be by the end of the next parliament, and the King’s Fund have said, “This is a huge ambition.” Watching that Despatches programme, it made me feel really conflicted, because on the one hand it is absolutely a good ambition to try and improve performance in these departments. I am glad that both parties are focusing on it. But at the same time, it is such a reality check watching that programme and just how poor standards of care have become. It just shows what a deep hole they are in and what a big hill they are going to have to climb.
SM: You are absolutely right. We at the Fund kind of every week, every month, respond to the super stats in the NHS, and you have just got to a point where month after month the stories are really big numbers. Month after month they are staying big, and you can lose that sense that these are people, they are people in a lot of pain with a lot of anxiety. These are people with friends and family around them as well. So, I think it is why something like Despatches is really so powerful at bringing home the reality of what it is like for a lot of patients. And Dan, you are one of our experts on patient involvement, patient experience. When you watched Despatches, what was the kind of main thing that struck you about what it says about patients and their relationship with the NHS at the moment?
DW: It was a really difficult watch, wasn’t it? It was a really hard watch. The thing that struck you most was it just isn’t that surprising. I think you can be shocked by it, but perhaps not surprised at the same time. It is really important, you know we do get lost in the stats, we do get lost in the figures, and behind every single one of those numbers is someone’s story. I think what really struck me about that, it is not just waiting times or hours waited, it is how you wait, it is dignity and respect. And particularly from the staff, you just felt that this is a level of care they don’t want to be providing. It is the challenge that they are facing. I did look at the staff survey, which is a really largescale piece of work which hears from hundreds of thousands of NHS staff, and there are some really key questions in that survey which is, ‘Are you happy with the standard of care provided by your organisation?’ and that organisation in particular, less than 50% of staff said they would be. So, it is really listening to those stories, and it is a long way back.
We look after something called the British Social Attitude Survey at the King’s Fund with our colleagues over at the Nuffield Trust. It measures overall satisfaction, public satisfaction with the NHS, and this year we recorded the lowest figure we have ever seen since 1983. Just to put that into context, so it’s 24% of the public said they are satisfied with how the NHS runs nowadays. As recently as 2010 that figure was 70%. So, the last few years have seen a real precipitous drop in that satisfaction. So, again coming back to the election, it is really not surprising that the NHS is as prominent in the manifestos, but particularly in the public consciousness, in terms of the importance of this. There are so many people on waiting lists who have friends and family who are anxious on their behalf, and it’s always exactly as Siva said, the reason why those types of pieces are so important and why patient’s stories are really important is because there is human stories behind all those numbers.
The other thing that struck me I think is that you often hear people talking about a rise in patient expectations for the NHS, and I have always just sort of seen that with a bit of scepticism and just thought, “You know what, I don’t think our expectations are rising.” And one of the things that was said in that programme is unfortunately this is the level of care that some people have come to expect from the NHS. That is what really struck me, was people waiting for 24/48 hours, often in extreme pain. But people aren’t blaming the staff. They recognise this is the state of the NHS. So, it was shocking, harrowing, and as I said probably not that surprising, I’m afraid.
SW: Thanks Dan. We will come back later in the podcast to that question about people’s attitudes towards the NHS and what they want to see. So Dan, Siva, thank you so much for those reflections on the Despatches story we saw at the start of the week. It is fair to say that this is not going to be the only event that puts health and care in the headlines in the campaign this week as well, because we are recording on Thursday morning, and just a couple of hours ago the junior doctors went out on strike again and they will be striking until the beginning of next week. So Siva, can you just talk to us a bit about what the impact of junior doctors striking will be to patients and the public.
SA: I suppose the first thing is obviously it has an impact, and health services fortunately are pretty well practiced now in how to deal with this, so there is an awful lot of mitigation that goes in place to try and minimise the impact on patient services. So, things like you send out early cancellation notices so you’re only delivering necessary care. You try and agree that, as some Trusts have done that were particularly hit by cyberattacks, that you can still get staff to come in who should otherwise be on strike, so you can support cancer services. And so you are trying to mitigate the impact, but there is still a massive impact. The most obvious one is delayed care. So, outpatient appointments are increasingly being rescheduled. We have already had over a million of those rescheduled over different waves of industrial action. And if you break down the impact, there is an impact on patients, there is an impact on staff as well, both the staff who go out on strike who are losing pay and dealing with the moral injury of going on strike from something that is a vocation.
There is an impact on the staff who aren’t on strike who are also potentially picking up extra shifts. And there is a financial impact. You know, you have to pay the cost of additional staff who are going to provide cover. There is a loss of income because you are doing less work. So financially, staff, human costs, patient care, all of these are having an impact. I am still amazed at how normalised this is all becoming. We have got junior doctors out on strike during a general election. I mean, this would just be unthinkable even five years ago, and we are just getting so used to this and it is becoming something you have to handle and something you have to work through. I just don’t see how that is tenable going forwards, and I say that because again both parties have made massive commitments on how they are going to improve NHS performance. There is just no chance you can do that unless you resolve industrial action for junior doctors and other staff groups who might go out on strike.
The parties haven’t been really concrete so far in exactly how they are going to resolve industrial action, and to be honest I am not sure how much we could expect them to be concrete, particularly parties not in government, because they haven’t got access to all the information they need to. But I think the one thing I would say is, whatever your level of ambition is to improve health and care services, the path through it can’t go around resolving industrial action. It has to resolve industrial action before you can do anything else.
SW: So, it definitely feels like top of the intro for day one of a new government next Friday will be how to take the first steps in resolving that. So, thank you very much. I think that was a really comprehensive look at the events that have been dominating health and care in the election this week. Let’s move onto the next question then. So, what hasn’t been a main story, but really should have been? So, again when I think about the campaign, almost every day we have been hearing stories about polling, about projections of seats, about MRPs, and confidence intervals, and who is up, and who is down, and are the polls narrowing or not? But they have all been about politics and projection of seats. What I think we have heard much less of is polling about, what is it that the public want from a new government? And particularly I suppose for us at the King’s Fund, what is it the public want about health and care, and to what extent is what they are hearing from the political parties matching their ambitions? Dan, you know an awful lot about what the public think and how they are responding to what they are hearing, so how is the campaign going so far in terms of understanding what people want and whether they are seeing stuff that stands up to that?
DW: It really depends how you ask people. I think that is a really important thing for us to bear in mind because as they said in the West Wing, and you will remember Joey Lucas who is the pollster in the West Wing, ‘Polling tells you where people are, not where they could be.’ I mean, I have spent most of my career doing this Sally, so I am now going to criticise a little bit of what I have been doing for the past 20 years, which is that polling can tell you what people want right now. Actually, those conversations with people are going to be really important about what could be happening as well. But you can see from the manifestos, you can see from what the political parties have been promising, that they are entirely in line with what the public say they want in largescale service. It is like the British Social Attitudes Survey that we run. Going back to the Despatches programme, there are very long waiting lists, so any promises to target waiting lists, to target access to primary care. Primary care has become such an issue. It is the issue when you speak to people like Healthwatch England that are constantly hearing from the public. They will say it is almost the number one issue they are hearing time and time again each month. And the manifestos really reflect that in terms of the priorities.
It is also worth looking at the polling in terms of all of the pledges that the Lib Dems, Labour and the Tories have made, the health pledges are the most popular pledges in all of the manifestos. Which just speaks to the importance of the NHS in the public’s consciousness and the fact that it is clearly not working for large proportions of the population. I always remember doing a piece of work a long time ago, and you know there is lots of talk about how the NHS is the closest thing we have to religion, but someone put it as well as I have ever heard it expressed in some work I did many years ago, which is someone said the NHS is in the marrow of our bones. It is as important to us as that, you know the cradle to death, everything that is around it. It is why it is as essential as it is. I would just say though Sally the one thing that is really interesting that isn’t being discussed is tax. Tax is being discussed in a sort of race to who isn’t going to put up taxes. What is really interesting is that isn’t in line with what we are hearing from lots of different pieces of work from the public.
So, again with the British Social Attitudes Survey we saw almost one in two people said they would support a raise in taxes, and that is particularly people who are better off and older people. The same was found in the work that the Health Foundation did with Ipsos where they really explored this in detail. So, politicians are often sceptical about polling that says that people want to put up taxes, which may say more about them than it does about the public, because actually when you speak to the public, there looks like there is more appetite to pay more for the NHS. So, that is the thing I think I have noted Sally that isn’t really being talked about. That the public is possibly in a very different place to politicians on tax.
SW: Thanks Dan. And you get bonus podcast points for putting in a West Wing quote in that. That is always good to see. I think that is a really helpful reflection, that health and care is a really important issue for the public. They are seeing and liking what they are seeing in the manifestos in terms of individual commitments and pledges, and that is resonating with them. But almost that they then have more ambition and that they would like to see more investment, and they are happy if that investment does … well, happy might be too much of a stretch, but they understand that higher taxes might be needed for that, and even when it comes to that might mean they are having to pay more taxes, they think that our health and care system needs that.
Regular listeners will know we every week ask ourselves a question about social care, which means this week I’m going to ask myself the question first off and I’m then going to bring Dan in. So, our regular question is, are we hearing anything of substance from the two main parties on adult social care? If I just do a quick response on this. I think what we have seen in the last week is pretty much the same pattern we have seen the entire campaign which is that the Lib Dems are absolutely wanting to talk about health and care, and they are putting it front and centre, and this week there was a great interview from Sir Ed Davey and his wife reflecting on their lives as carers. So, I think we have seen a strong sense of that. But really nothing of substance from the main political parties. I wonder Dan, again just thinking from what we know about what the public think about social care, can you help us understand why is it that the politicians just are trying to steer clear of talking about social care at this campaign?
DW: The simple answer I suppose is it is just not very well understood. People don’t understand how it is currently funded often, they don’t really understand who provides different elements of social care. So, you definitely see the politicians who do work with the public kind of almost come to this realisation that in order for them to discuss it, they are going to have to really tell people the current situation. That being said it is really interesting, and the Lib Dems who have been talking about social care, that is one of the most popular pledges in their manifesto. As more and more people in society struggle to get care for working age adults, for older people, we are starting to see it come up the agenda. We know the connection between NHS and social care, and we know they are very different things, but I think people are starting to understand that connection, that actually the NHS can’t survive without a functioning social care system. So, I think they are trying to avoid it for those reasons, that it not the salient issue, it is not the number one thing. That is always going to be the NHS. But I think it is coming up in the public’s consciousness.
SW: Fingers crossed that although it might not have featured much in the campaign, it does need to feature in a government’s ambitious plans for reform and improvement across health and care. So, let’s see if that happens.
So, it’s now time to move to our listener question, and our question this week comes from Steven Joseph. Thank you for your question Steven, it is a great one. His question is that Labour have spoken about rolling out plans for extra evening and weekend work that have already been set up at Trusts like Guy’s and St. Thomas’s here in London. It feels like we hear about similar plans all the time and they are always coming from big teaching hospitals that have advantages in terms of funding and staff. How realistic is it to expand these programmes to smaller district generals to clear the backlog, and do you think politicians truly understand these challenges? I think Siva, I will come to you first on this one, because I think if we are kind of going beyond the detail of the specific intuitive here, but actually this to me encapsulated that there is a real dilemma about how do you deliver commitments in the NHS, in social care, in a system that is so large and so disparate? So, what are some of the approaches and choices that a government will need to make about how you deliver improvement, how you meet your commitments?
SA: Great question from Steven. I am going to go down a little bit of a technocratic rabbit hole.
SW: We’d be disappointed if you didn’t Siva.
SA: Well, I mean if Dan is giving quotes from the West Wing, I think I have found my tribe. I really like this question for a number of different reasons. The first is that it illustrates that hospitals are different. You know, there are some hospitals in this country that have 3,000 beds, some that have 300. You know, the Renal Centre of Europe do loads of research and development, have people flying over from … you know, I was talking to someone who had flown over from South America because he said, “I wanted to come and train in this hospital. It is world renowned.” And others that are basically rural hospitals and have been in the same place doing broadly the same thing for a long, long time and providing essential local services. So, you have got a big mix of different types of hospital. The second thing I would say is I have seen good things going in both directions, so sometimes it is definitely the case that something is invented in a big teaching hospital and then is spread to other district general hospitals.
I have also seen district general hospitals come up with some real innovations over patient care that can then be rolled into larger teaching hospitals. I remember a Medical Director saying, “I used to work in this big tertiary centre with thousands of clinicians. I actually really like working somewhere where there are about 80 consultants in my speciality. I can wrap my arms around them and if we decide we want to change something we can change it that week.” So, good things can spread both ways. The other reason I really like this question is it shows how politics is going to have to get real, because there are some choices in health policy that have been ducked. So, for example ten years ago I would have looked at national policy documents and said, “The trend is towards what we were calling surgical factories.” Basically, you pull out lots of work from local hospitals and create these huge centres where you just do knees and hips. That is all you do, and you push as many knee and hip operations through there as possible and they specialise in that, and the local hospitals pick up everything else of what is left, like A&E and maternity services.
Fast-forward about five years and things have changed in the other direction. It was, “No, let’s keep things broadly where they are, and instead we will take specialist expertise from hospitals and link them with rural hospitals through better use of technology.” So, that is just one illustration of what is your model for change in the NHS? Is it sucking things in and doing it in bigger centres, or is it pushing skills out and keeping local services? Politicians are going to have to make that choice. Of course, promising more appointments and surgeries is going to be a popular manifesto pledge. Now, when you inherit a health and care service, whatever or who the government is, it is going to have to work through that policy detail. It is going to have to understand how you spread innovation. That is why I think all of this stuff is about to get real. I can just imagine how irritating it is for politicians to be told by thinktanks and everyone else that it is going to be a bit more complicated, but it is going to be a bit more complicated and you have to work through that complexity, otherwise you are just going to spend five to ten years being really frustrated over, “Why is the thing I wanted to do not happening.”
SW: Thanks Siva. Dan, some of these questions about how you do implementation, to what extent do you have one model that you roll out nationally and it should be the same everywhere else? You have done a lot of work about how systems can work at much more hyper local level, working with communities. What is your reflection on some of the choices and dilemmas about how you can best implement things which are really going to work for people.
DW: I think I will just take us out of Siva’s rabbit hole for a second and probably go down another one, if that is okay Sally, because this is a classic pledge which is we just say more of the same. You know, you see that from the polling, you end up with a status quo bias which is, “We will just have more hospitals, more GPs, that is the answer.” Actually, say you take people with musculoskeletal problems on waiting lists, they don’t just have musculoskeletal problems, it is about working with all of the multi-mobility that they have, and actually it is recognising that actually many of the solutions might not lie in hospitals. This is about innovation, and it is exactly as you say Sally, it is working with people and having maybe slightly different conversations. So, I would flag an initiative that took place in Sussex where they took 500 people from the waiting list, and they had very different what they call strength-based conversations. It is just, “Tell me about yourself. Tell me about your life. Tell me about what is going to make a difference.” And recognise that actually some of the solutions weren’t going to be care in a hospital. For some people it was in the community, it was within community groups, it was how to find opportunities for exercise with others.
And that initiative took, I think it reduced the waiting list for those people by about a third. So, I think one of the challenges coming back to the polling data is, if you just work on polling data you end up with the status quo. That is where I think there is a real challenge, just to circle back to the West Wing, is polling tells you where people are, not where they could be. I think there is a really important role for politicians to lead and to show that there are different solutions to some of the problems that we have. Some of that is moving care, as we have advocated, and as the public are clearly stating when you have those conversations, is moving care out of hospitals. It is moving care into the community, it is moving care closer to home, and it is having different conversations with people which aren’t about single conditions. That is where we are seeing the real innovation out there. So, that is a real challenge. Different from the polling numbers, but it is about where I think thinktanks and the public are probably a bit clear about what needs to happen.
SW: Thanks Dan. I think I am going to take your West Wing quote and raise you a Hamilton quote. So, I think this conversation about the complexity in delivering makes me think of the quote, which is, ‘Winning is easy, governing is harder.’ And I think there is a real risk in election campaigns that winning is, “Let’s have catchy soundbites about specific pledges and commitments,” but actually governing is much harder in terms of there is trade-offs, there is complexity, there is contradictions in some of those. So, it will start to become a much, much harder task to actually turn those pledges into something that the patients and public will start to feel. I am afraid this though is all we have got time for today. So, thank you Dan and Siva for joining me today, it has been a great conversation.
DW: Thank you, Sally.
SA: Thanks Sally.
SW: We won’t be publishing an episode next week on polling day, but you can look out for our final episode in our Election Series which will be publishing the following week. In the meantime, please do catch up with all of our general election content on our website. The producer for this episode has been Natalie Cleverly, and it has been edited by Bespoken Media. Thank you so much for listening, and we really hope you can join us next time for our final special episode.
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