The NHS is back in the headlines as hospital admissions of patients with covid-19 increase again and work to restore services for patients with other conditions gathers momentum. Underlying the presenting problems that have featured prominently in news reports, including lengthening waiting times for diagnosis and treatment, are fundamental weaknesses that have been thrown into sharp relief by the pandemic. Foremost among these weaknesses are shortages of capacity that have tested the NHS to the limits.

Capacity constraints are evident in staff shortages in many areas of care, limited critical care facilities, and insufficient hospital beds—to name but three. All services are running hot with the pressures most visible in hospitals where growing volumes of patients mean that summer feels like winter as staff respond to high demand for care. Staff absences as a direct result of covid, and because of the impact of the pandemic on staff health and wellbeing, mean these pressures are now “acute on chronic” with little immediate prospect of respite.

The reasons why capacity is constrained can be found in the underfunding of the NHS by successive governments together with failures of workforce planning. A partial exception was in the noughties when the Labour government made a commitment to sustained funding increases above the long-term average. These increases resulted in measurable improvements in care, most notably substantial reductions in the time patients waited for diagnosis and treatment, investment in priority services such as cardiac and cancer care, and increases in staffing.

The decade of austerity that followed saw performance on some indicators decline steadily, exacerbated by the pandemic to the point where waiting times are now at record levels. In truth, capacity constraints can be traced back much further with the Treasury’s control of the purse strings acting as the rate limiting factor in the ability of the NHS to meet rising demand for care. Brian Abel Smith, historian of healthcare as well a government adviser, once famously commented that the NHS had morphed from being the envy of the world to become the envy of the world’s finance ministers because of its record in controlling costs.

One of the consequences of government inspired efficiency drives, going back at least until the 1980s, has been to require the NHS to do more with less. This is most evident in the long-term reduction in the number of hospital beds and substantial increases in the number of patients treated in these beds. Changes in methods of treating patients, including the expansion of day surgery and cuts in length of stay in hospitals, help explain this trend, but so do policies requiring the NHS to deliver sustained improvements in productivity. 

A perverse consequence is that the quest for efficiency results in inefficiency when patient care is postponed because essential capacity like beds and critical care is lacking. This is a routine occurrence in many hospitals during winter when planned care cannot proceed as scheduled in the face of rising emergency admissions. Surgical teams whose operating sessions are cancelled are left having to break the news to patients while also enduring the frustration of being unable to undertake the work for which they are employed. 

Many healthcare systems face similar challenges, but few experience sustained pressures on the scale of those in the NHS. A cursory examination of health data collected by the OECD suggests that this is because the number of doctors, nurses, and hospital beds is low in the United Kingdom compared with most other countries. Pre-pandemic this resulted in inconvenience for patients and frustration for staff, but during the pandemic it had serious consequences for patient care. Capacity constraints were particularly visible in critical care, where the United Kingdom is in the middle of the international range of provision, and only rapid action by clinical teams working with managers prevented the NHS from being overwhelmed when covid led demand to surge. 

It was Ernest Hemingway who was reported to have said that you go bankrupt “gradually then suddenly.” A similar observation might be applied to the NHS which appeared to cope with the growing gap between available resources and patient demand over many years until the pandemic resulted in a tipping point that put staff and patients at risk. The government responded by providing extra resources to weather the storm and now needs to work with leaders in the NHS to avoid a similar situation ever happening again. 

This means building the infrastructure required not only for business as usual, but also for other eventualities which have potentially dire consequences in the absence of adequate planning. The focus should be on staffing, critical care facilities, hospital beds, information technology and equipment. For its part, the Treasury must revise its thinking on NHS efficiency and recognise that spare capacity is not a sign of waste but rather an example of prudent preparation for an uncertain future. 

Investing in infrastructure is equally important to rebuild the public health system and to strengthen research and development, both of which have played a vital role in the covid response. This includes ensuring that capacity for vaccine production and testing are in place to bring innovations into use. In public health the priorities should be to restore cuts in government funding and to ensure the workforce exists to enable councils to build resilient teams able to provide an effective defence against future threats.

If any good can come from the tragic experiences of the past eighteen months, it will be the ability to avoid history repeating itself. Failure to learn the lessons will not be forgiven by a population that has made unheard of sacrifices and is now looking to its leaders to take the longer view in protecting the health of the nation. Responding to covid and restoring other services may be the immediate priorities, but investing in additional capacity and creating the headroom to deal with future shocks are equally important.

Chris Ham is chair of the Coventry and Warwickshire Integrated Care System, non-executive director of the Royal Free London Hospitals NHS Foundation Trust, and co-chair of the NHS Assembly. He writes here in a personal capacity.

Competing interests: none declared.