The NHS looks set to emerge from the covid-19 pandemic with its status enhanced. The public have “clapped for carers,” displayed NHS rainbows in their windows, and every adult will personally experience the service this year through the vaccination programme. Politicians have praised staff and the NHS has had central status in appeals to the public, such as through the “Stay Home, Protect the NHS, Save Lives” message.

As the backlash against the recommendation of a 1% pay rise for NHS staff demonstrates, this high degree of public and media support will have consequences, now and in coming years. NHS staff and the public will expect government to translate its rhetoric into investment and practical support for a public service that despite its many successes, now faces immense challenges that have been exposed and exacerbated by the pandemic.   

The scale of these challenges is perhaps not yet fully visible. The NHS went into the pandemic with shortfalls in funding, growing workforce shortages, rising waiting lists, and with the pressures arising from an underfunded and unreformed social care system. By the end of January 2021, the number of patients waiting to start treatment was 4.6 million, with 300,000 people waiting longer than a year for hospital treatment, compared to fewer than 2,000 a year before. These figures mask additional “hidden” demand, with 4.7 million fewer patients in England referred for consultant-led, routine care in the first eight months of 2020 compared to 2019, indicating significant pent-up need for care. With ONS survey data reporting anxiety levels in the population higher than at any point in the past decade, demand for mental health services is also expected to rise as the direct and indirect impacts of the pandemic fully materialise.

But despite the Chancellor’s commitment to give the NHS whatever it needs, this year’s budget left the NHS with significant uncertainty about how the ongoing costs of the pandemic will be met. A more sustainable funding settlement will need to be informed by the scale of the backlog of care needs, the direct costs of covid-19 care and the vaccination programme, and the impact on day-to-day operational productivity of continued infection control and social distancing measures. 

Meeting the high level of demand will also require the NHS to innovate rapidly in how it delivers care, building on the many examples of staff ingenuity and service change demonstrated during the pandemic. Work is underway nationally to identify and spread beneficial changes that staff have led in the past year, and a similar or greater pace of innovation will be required to meet the challenges ahead. Policymakers and practitioners will also need support from the research community to understand the impact of these changes before automatically locking them in. For example, survey data shows that while a significant majority of patients and staff who increased their use of technology during the pandemic reported positive experiences, 42% of these patients and 33% of these staff thought that the quality of care was worse than traditional methods. Faster methods of robust evaluation of the impact of these changes will be needed so they can be adapted to ensure they meet quality goals, and work for all.  

But a significant determinant of service recovery will be staff recovery. Results from the NHS Staff Survey 2020 show that 44% of staff reported feeling unwell as a result of work-related stress, the highest result over the past five years. A study conducted after the first wave of covid-19 in summer 2020 found almost half of critical care staff met thresholds for Post Traumatic Stress Disorder, depression, anxiety, or problem drinking. Some staff are likely to have experienced moral injury, the distress arising from being unable to act in line with their personal ethical codes.

Supporting staff to recover and prepare to address the coming challenges will require a blend of local and national action. Within organisations, good management practice could include supportive line management that recognises the variation in individual experience and responses, providing structured forums for processing and reflection such as Schwartz rounds, and access to professional mental health support.  Innovative organisations such as Northumbria Healthcare NHS Foundation Trust, which regularly performs strongly on staff survey metrics, complement the annual national survey with more frequent measurement of staff experience, informing tailored local responses. 

But local action can only go so far. Developing a system able to meet demand and that is more resilient to future health challenges will require significant investment in supporting productivity-enhancing innovations, and in the NHS and social care workforce, with an additional 1 million new staff required by 2033/34. Without a funded and credible workforce strategy that addresses these shortages and improves recruitment and retention, both service quality and staff satisfaction will remain precarious, and vulnerable to any future large-scale system shocks. And in the short term, a more generous pay offer would send an important signal that NHS staff are as valued as the political rhetoric would suggest.

Will Warburton, Director of Improvement, The Health Foundation.

Competing interests: none declared.