7 min read08 December

Amanda Pritchard is readying herself for a difficult winter.

The National Health Service saw its “busiest October ever” this year, with the highest number of hospital admissions compared to any previous October. According to Pritchard, this does not bode well for the next few months.

She tells The House there will be “unprecedented demand”, with spikes in flu, norovirus, respiratory syncytial virus (RSV) and Covid-19 infections, alongside ongoing hospital capacity problems, which are likely to make it “extremely challenging” for the NHS to cope.

Highlighting the importance of prevention, Pritchard has been telling MPs at roundtable events that “the more that we can do to encourage vaccination, the better”, in the hope that MPs will communicate this to their constituents.

It comes at a time when the NHS is trying to bring down the longest waiting times and waiting lists for urgent care. Pritchard suggests NHS England is now over the peak of the longest waiting times and that there is “unstoppable momentum” towards bringing them down further.

This year, waiting lists have been reduced. Now fewer than 3,000 patients are waiting for more than 78 weeks and fewer than 23,000 patients are waiting more than 65 weeks. This represents a 97 per cent reduction from the highest recorded number waiting 78 weeks – registered in September 2021 – and a 90 per cent reduction from the highest recorded number of patients waiting 65 weeks in June 2021.

On 5 December, Prime Minister Keir Starmer made a fresh commitment to reaching the target of 92 per cent of routine operations and appointments being carried out within 18 weeks. This has not been achieved in almost a decade.

Pritchard says this “next big step” will require “both a reduction in the total number of people waiting and taking more people off the waiting list and treating them”, alongside “innovation, reform and working differently”.

“This year, it’s really been about maturing and growing those services,” she says, pointing to the ramping up of vaccination programmes, expanding access to virtual wards, boosting urgent community response teams, and extending 24/7 mental health support so it can be accessed through NHS 111.

She is particularly keen to dispel the narrative that productivity in the NHS is falling.

“Productivity is rising,” she insists, adding that a “better” measure of productivity in the health service is needed to take community and primary care into account, rather than just acute hospitals.

The Covid pandemic dealt a huge blow to NHS productivity levels. However, there has been considerable growth in the number of patients treated by NHS hospitals in England in the past year, and NHS England is on track for a 1.8 per cent improvement in productivity by the end of 2024. Before the pandemic, the NHS was running at around 0.9 per cent productivity increase each year.

As well as using urgent community response virtual wards, Pritchard says hospitals are looking at improving “operational productivity” such as patient transport arriving earlier in the day and ensuring drugs are quickly prepared and ready to transport.

The thing that we haven’t been able to do is fix some of the underlying capacity challenges

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But NHS hospital productivity remains substantially below pre-pandemic levels. The number of treatments from the elective waiting list has been growing and has now reached pre-Covid levels, but still falls short of reaching the targets set out by the NHS elective recovery plans.

This is explicable, says Pritchard, “given the level of demand on our services, and given that there is still clearly an underlying level of fragility in the service because of some of those underlying things that just take longer to fix”.

“The thing that we haven’t been able to do is fix some of the underlying capacity challenges, particularly in relation to beds, tech, the state of the estate, the pressures on social care.”

In the autumn Budget, Chancellor Rachel Reeves announced a £22.6bn increase in the day-to-day health budget and a £3.1bn increase in the capital budget for this year and next – including £1.5bn for new surgical hubs and diagnostic scanners and £70m for new radiotherapy machines.

Pritchard says this investment was welcome as there is “still a gap” in productivity levels. “Proactive maintenance” and upgrades of the estate and technology would be absolutely crucial in closing it, she says.

The widespread presence of reinforced autoclaved aerated concrete (Raac) in hospitals across England was therefore “not a surprise” to her, given the crumbling state of many hospitals that were in need of investment for many years. While local hospital teams will assess the risks of Raac going into the winter, the NHS boss admits this “does not guarantee that there won’t be problems”.

“We have reasonably regular reports of things like bits of ceilings that will develop a crack, sewage pipes that will break, CT scanners that will break down, all the normal wear and tear of a building.”

In Pritchard’s view, it is “definitely not possible to talk about the NHS without talking about social care”, particularly on urgent emergency care. While productivity might be on the road to improvement, she is concerned about the longer length of patient stays in hospital, with pressures on social care meaning beds are taken up by those who should have been discharged.

She hopes that Health Secretary Wes Streeting’s 10-year plan for social care could go some way to address this. It is intended to run alongside the 10-year plan for the NHS.

Another key component of improving productivity will be reducing “expensive agency spend”, on which Pritchard claims progress. The NHS has delivered around £3.3bn worth of savings this year, and £1bn of savings on agencies over the last 18 months.

As the NHS approaches the winter, there is yet another issue for Pritchard to contend with: MPs voted for assisted dying legislation to pass to the next stage in Parliament, which would grant the right to an assisted death for terminally ill adults with less than six months to live.

Ministers have privately warned that this law change could heap further pressure on the NHS and “absorb a lot of time, energy and resources”, according to The Sunday Times.

Pritchard admits: “There will be a lot of work to do to properly work through what implementation would look like. We’ll wait for guidance from the Secretary of State on what the appropriate process would be.”

Another row across the NHS is the increasing use of physician associates (PAs) – healthcare professionals who work under the supervision of senior doctors to assess, diagnose, and treat patients.

They need around two years of postgraduate training, compared to between four and seven years for doctors at medical school. With plans to increase the number of PAs in the NHS from 4,000 to 10,000, doctors and trade unions have expressed concerns the lines between professions in the NHS are getting increasingly blurred and that PAs could be used to plug the gap when there is a shortage of doctors. The British Medical Association and Royal College of GPs have called for a halt in the recruitment and Streeting has announced a review, citing “legitimate concerns over transparency for patients, scope of practice and the substituting of doctors”.

Pritchard voices concern that PAs are “having a really hard time in lots of places at the moment”.

“There’s a lot of strong feeling about this, and some of the social media debate in particular has spilled over into, for some colleagues, their working environment being very difficult,” she says.

“I’m certainly aware of a number of places where they are having to provide quite a lot of mental health support, as well as professional support, for people in those roles.”

Pritchard says the NHS is “clear” that PAs are “not replacements for doctors” but that an “independent” review is “absolutely the right decision” as “good multi-disciplinary team working” is key to the NHS running smoothly.

It’s one challenge among many – but first, she’ll have to steer the NHS through what could be its most challenging winter for decades.

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