Every year since I can remember there have been apocalyptic headlines declaring that the NHS is at breaking point or close to it. The current dispute with hospital doctors has added pressure to the struggling hospital system, which is trying to recover from the large backlog to referrals and subsequent treatments caused by the COVID-19 pandemic. In England, there are 7.7 million patients waiting to start treatment as of the end of October 2023 (NHS England, 2023), with some patients on multiple pathways. This indicates there are about 6.5 million patients on waiting lists, with a median waiting time of 14.6 weeks, although this may disguise the grim statistic that only 58.2% of patients are treated within 18 weeks (NHS England, 2023). However, waiting for hospital treatment is not a new phenomenon and reducing waiting times has been a challenge for successive governments (Marszalek et al, 2023). Waiting times have been a feature of innumerable general election campaigns, with Tony Blair caught up in a debate about access to tonsillectomies (which in those days were a common surgeries for children despite being a relatively limited treatment in other Western countries, as it is in the UK today [ENTUK, 2021]).
One of the foundations, and a critical component, of the NHS is primary care with its role in ‘sifting’ patient needs and, either managing treatment and care outside secondary care, or referring onto secondary care for diagnosis, treatment and care. Therefore, issues in primary care have a significant impact upon the patient experience. Accessibility to general practitioners is crucial to patients but there is increasing evidence of an 8 am phone call lottery for appointments, many of which may be for virtual or phone consultations (despite patient preference for in-person consultation), and reduced continuity of carer as a consequence of a part-time general practice workforce. Healthwatch (2023a) gathered evidence of peoples' experiences of using the primary and community care services of the NHS and noted that, while in some areas things are working well, there were six barriers to access which needed addressing. These were: lack of appointment availability; both primary and community services can be hard to contact both by phone and online; the hours of operation of services have limited accessibility; people are increasingly offered services remotely despite many finding this neither accessible nor desirable; access costs due to transport costs; and the cost of making repeated calls or waiting on the phone for a significant time to get a response. The NHS England GP Patient Survey has reported a consistent decrease in accessibility to information and services between 2018–2023 and, although more GP appointments are taking place compared to 2019, a lower proportion are being offered within a week (Nuffield Trust, 2023).
Additionally, interfaces between the components of integrated care and secondary care are not always frictionless and efficient. The Academy of Medical Royal Colleges (2020) lamented the cultural barriers impeding communication between secondary and primary care colleagues and outlined 10 principles to promote good relationships between colleagues. More recently, the Academy of Medical Royal Colleges (2023) has published a range of examples including initiatives across older age, acute medicine and psychiatry, which have benefitted both the patients and healthcare professionals. However, the report acknowledged that the success of initiatives may be dependent upon their local environment including strength of local leadership, local cultures, customs and practices and even the personalities, including the enthusiasm of local managers and clinicians. Nonetheless, the range of potential initiatives provides ground for optimism if practitioners have the courage to think and do things differently to deliver ‘local-solutions-for-local-challenges’ as part of integrated care provision. The report notes that there is potential for cost savings, as well as reductions in clinical workloads and improvements in patient safety and care quality.
Optimal integrated care requires previously fragmented provision to transition to seamless integration with the same actors/professions required to work together, each bringing their identity and culture to yield the necessary cooperation and coordination so that a common culture of values enables mutual understanding, minimal conflict and maximum effectiveness (Haring et al, 2023). Haring et al (2022) have described sources of tensions within integrated care systems, namely: organisational tensions due to competing designs and processes, performing tensions when different professionals pursue divergent goals despite declared collaboration, learning tensions when using and perhaps destroying past practices to create new ones, belonging tensions arising from the competing identities of individual practitioners alongside cross-cutting tensions, which fall across two sources of tensions. Haring et al (2023) argued that it is imperative to deal with conflicts and their underlying causes so that there is effective management of tensions and their associated dynamics to promote virtuous cycles and avoid vicious cycles. They advocated reflective management to orchestrate tensions and use identified tensions as motivators for change, thus negating their potential destructive effects.
The Healthwatch (2023b) report illustrates the importance of effective collaborative working between the NHS and non-NHS partners as well as between healthcare professionals, departments and services across the NHS. In particular, while some services were joined up and communicated well with each other, patients had negative and difficult experiences in other settings. Patients valued a health and care system which understood their needs as a whole person, was responsive, enabled them to navigate the ‘system’, signposted them to local and community resources, and helped them to make efficient and cost-effective use of health and care resources. The plight of feeling unheard or ignored was evident among patients and carers, as were the challenges of navigating a complex system to seek help with poor or lack of communication being at the centre. Worryingly, as access to healthcare is becoming increasingly difficult, a two-tier system is emerging, with healthcare more accessible to those who can afford to pay, with 1:7 respondents reporting that they were advised to seek private healthcare by NHS staff (Healthwatch, 2023c). It was also evident that treatment delays impacted peoples' lives due to pain and disability, and in some cases, caused health deterioration and worse, long-term health outcomes.
Dental services were extremely disrupted by the COVID-19 pandemic and all the evidence indicates that universal NHS dentistry is in a perilous state, with Williams et al (2023) recommending radical action to preserve NHS dentistry. Garratt's (2023) research briefing for the House of Commons reported the British Dental Association 2022 survey data, which indicated that 3000 dentists had stopped providing NHS dental services since the start of the pandemic, a further 45% had reduced their NHS commitment since the onset of the pandemic and 75% are expected to reduce the NHS commitment during the next year. Healthwatch (2023c) described how people cannot access local NHS dentists despite being unable to eat, with others feeling ashamed of their teeth and some resorting to self-treatment including extracting troublesome teeth with pliers. Williams et al (2023) have enumerated the problems, which include access to dentistry, poor perceptions about access and costs, especially dental charges above the rate of inflation, wide variations in provision across regions, persistent inequalities regarding access and outcomes, workforce challenges including geographical shortfalls and an ‘unfit’ NHS dental contract from 2006. While not denying the importance of dentistry to children's health, access to dentistry for older people is hugely important because poor oral health impacts general health through impaired chewing and reduced eating abilities, which affects nutritional intake and may also increase the risk of choking. Hopefully, there will be an urgent review to ensure access to a basic core service for children, older people and those unable to pay for private dentistry.
Equally important to older people is access to high-quality optometry, audiology and podiatry if independent living is to be sustained. Interestingly, evidence relating to their accessibility and other service aspects is very sparse, although the Care Quality Commission inspects individual optometry and podiatry services but Care Quality Commission registration is not currently compulsory for hearing services. In light of this, it is difficult to assess the extent to which the needs of older people and their carers are currently being met by optometry, audiology and podiatry services or their individual providers.
Community pharmacies play an increasing role within the health system as part of the NHS Long-Term Plan and receive funding through a range of income streams. Views of pharmacies are overwhelmingly positive and this extends to the new services being offered by pharmacies (Ipsos, 2022), which perhaps confirms that pharmacies are meeting health needs that hitherto would have been met by other services.
In summary, while some of the population appears to be well served, there is evidence that there is room for improvement across health and care provision and this is without examining the extent to which meaningful health promotion and public health form part of the NHS.