The changing NHS: but change is not coming fast enough to ease the workforce crisisWhat could sink NHS Titanic? It is the world's largest, oldest publicly funded 'cradle to grave' health service - and the best. But it is seventy years old and feeling its age. It is vulnerable.
Some will say it is the obesity/diabetes time bomb or the mental health time bomb or the longevity time bomb, that will be the iceberg that sinks the NHS. Others say it will be political ideology (as in privatisation) or the threat of an American-style health service that could follow a post-Brexit trade deal with 'America First'.
Having reported on the NHS in Wiltshire for some years now, I am certain that the iceberg will be the staffing crisis. But - to make an eye-popping change of metaphors - it also continues to be the elephant in the waiting room.
In March a member of the King's Fund think tank wrote: "It is astonishing that politicians have watched the NHS staff crisis develop to this point without taking action." He cited "...more than 100,000 NHS staff vacancies - that's one in eleven of all NHS posts."
The blame for much of this can be laid at the government's door. Taking away bursaries for trainee nurses and substituting them with the need to take on debt, was short-sighted. The earlier cutting of the numbers of doctors in training was just stupid.
For years they kept NHS's annual funding just high enough so they could claim it was being increased. For years they kept pay levels flat or with miniscule rises - hardly a good recruiting position.
In 2012 Health Education England (HEE) was set-up - with no legacy expertise. Almost immediately it suffered a nine per cent budget cut.
Their website describes HEE's aims: "[HEE] exists for one reason only: to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place." Not yet, then.
We could run through an endless list of dispiriting statistics about the workforce crisis. Let's just stick with the 100,000 vacancies.
One problem is that the staff shortages become part of a vicious cycle that saps morale and leads to high levels of departures from the NHS reduces staffing levels which makes the crisis worse. It will also impact on patient safety.
The pressure from the staffing shortage is part of the reason why days lost to stress among all NHS staff have increased by over 30 per cent between 2013 and 2018. And days lost to stress among those working in acute medicine increased by well over 35 per cent.
Even before the referendum, the government made recruitment of doctors and nurses from the EU more and more difficult and costly for hospitals. In a Daily Mail reaction, they brought in a language test that was much more than a language test and was even failed by some managers who took it.
About (at the last count) 60,000 of the NHS's total staff are from EU nations (not to mention the 104,000 who work in adult care). This graph [below] shows that following a period of determined recruiting from EU nations to fill the great gap in the number of nurses working in the NHS, the impact of the Brexit referendum was immediate.
And that only showed incoming recruits. It does not show the numbers of EU staff who have returned home - fed-up with patients telling them they are not wanted in this country. Another difficulty for recruiters to overcome - in addition to the everyday racism many NHS staff face.
How does this affect Wiltshire's health services? We know in Marlborough that for a long period the practice was short of GPs - and this was one reason for the merger of the Pewsey and Marlborough practices to form the Kennet and Avon Medical Partnership.
Great Western Hospital has a modest vacancy rate of 8.29 per cent. But it struggles to find applicants for some of its key consultant and specialist clinical roles. It has recently appointed a Workforce Transformation Lead whose job will be to boost recruitment - and retention - of staff across all the GWH Trust's services.
The real pinch in our area is being felt by the Avon and Wiltshire Partnership (AWP) which is responsible for mental health services. In December their vacancy level was at 21 per cent - and the two previous months were at 20 per cent.
What is more AWP finds it especially hard to fill vacancies in Wiltshire - applicants seem to prefer working in Bristol or Bath. In April they were advertising for a Consultant Psychiatrist in Learning Disabilities to be based at Savernake Hospital. A full-time post with an annual salary of £70k-£100k - one of twelve Consultant Psychiatrist posts AWP is advertising.
What plans are there to defuse this staffing crisis? The NHS has proposed a strategy that means in essence: "You are welcome to come to England, earn more than you ever will, learn from us, but then leave after three years."
The ethics of this strategy have been challenged. One consultant writing in the Health Service Journal called it a signal of desperation by NHS leaders. He would prefer that "...people came, stayed and contributed". But he acknowledged his view ran counter to the 'current Brexit narrative.'
The Labour Party have responded with a policy to 'green-light' visas for all NHS staff coming to England.
The government has not moved on from its 'hostile environment' policy towards immigration - including towards overseas students. It is now proposing that from 2020 students coming from the EU will face full international student fees.
This led one research scientist to list the ground-breaking advances - especially in cancer care - his recent PhD students from EU nations had made while studying in Britain.
As policies stand, in the near future research will suffer. Programmes like the Primary Care Networks and the government's repeatedly declared intention to improve mental health services will - without sufficient staff - struggle to succeed. And the on-going crisis in acute hospitals will just continue...
Last week Dame Donna Kinnair of the Royal College of Nursing gave evidence to the House Commons' Health and Social Care Committee: "We cannot deliver the [NHS] Long Term Plan without the workforce on the ground. We are talking about accountability to Parliament for the workforce of our biggest treasure - the NHS."
This is the fifth in our series of articles on the new shape of the local NHS - following our introductory report of 28 March 2019. Next: Is Wiltshire Council playing its part?