NHS at 70: A timeline of the National Health Service and its crisis

NHS not sustainable and Theresa May’s £20.5bn funding pledge won’t fix it, NAO warns

Auditors confirm ‘worst fears’ that NHS plan will fall flat without solution to staff and social care crisis

Alex Matthews-King
Health Correspondent
Friday 18 January 2019 01:05

The NHS is financially “unsustainable” and the government’s much-trumpeted 10-year plan is inadequate to rescue cancer, mental health and social care services, the National Audit Office (NAO) has warned.

Years of underinvestment have resulted in longer waiting times, critical staff shortages and “substantial deficits” that have been covered up by raiding funds for long-term reform, an NAO review found.

These factors “do not add up to a picture that we can describe as sustainable”, it said.

NHS England’s recently published 10-year plan sets out how it aims to spend the pledged £20.5bn increase in its budget by 2023 to break this cycle.

But the NAO warns its success is dependent on the government producing – and funding – a long-delayed plan to reform social care and an estimated £6bn repair bill to fix run-down buildings.

While NHS England expects to bring in thousands of staff from overseas to fill gaps, the report says ambitions to transform services will require significant additional growth.

“The NAO has laid bare just how difficult it will be to achieve the ambitions of the NHS long-term plan given where the NHS is starting from,” Richard Murray, chief executive of the King’s Fund think tank, said.

With health services finances “bedevilled by short-term fixes, fragile workarounds, and unrealistic expectations”, he said the NAO was right to make clear the government’s flagship investment is not an NHS panacea.

The NAO report concludes that NHS England had been “prudent” in its ambitions for the plan. However, key decisions about the future of waiting-time standards such as the four-hour treatment target in A&E departments have been deferred to a separate report.


Auditors warned more than £700m will be required just to bring the NHS surgical waiting list down from a 10-year high of more than 4.3 million, to March 2018 levels.

A workforce plan has also been delayed and the report says: “There is a risk that the NHS will be unable to use the extra funding optimally because of staff shortages.”

This is because scarce funds are currently being squandered on costly agency staff to plug more than 100,000 vacant posts, and there could be too few people in key roles – like cancer or community services – to deliver its goals.

“We see specialist cancer units closing because they cannot recruit enough cancer nurses, and mental health units struggling to meet demand,” Patricia Marquis, director of the Royal College of Nursing in England, said.

'We need to focus on prevention as much as we do on cure' Matt Hancock on the government's NHS long term plan

She added that the NAO report “confirms our greatest fear”, that the plan could be undone by a failure to address staff gaps, and the RCN is calling for an immediate £1bn investment in specialty nurse training.

Budgets for staff training, buildings and equipment, and preventative public health all fall outside the NHS plan and will need to be funded at the spending review.

“This will tell us whether there is enough to deal with the embedded problems from the last few years and move the health system forward,” the NAO adds. “Let’s hope there are not too many strings attached.”

But chancellor Philip Hammond has already said the NHS investment means little left for other sectors.

Councils budgets for prevention and social care have been ravaged by repeated cuts, and the Local Government Association warned the system “will buckle under the weight of demand” without urgent investment.

The government increased social care budgets by £650m in the 2018 budget, but the LGA estimates there will be an annual shortfall of £3.6bn by 2025.

Despite repeated calls to address this issue in 2018, the government has still not set a date for its green paper and scheduled another £100m in cuts for next year.

“A sustainable NHS is not possible without a sustainable social care sector and public health programme,” councillor Ian Hudspeth, chair of the LGA’s community wellbeing board, added.

Labour’s shadow health secretary Jonathan Ashworth said the government had spent nine years “running down” the health service.

John Kell, head of policy at the Patients Association, said: "As patients who need elective surgery can tell you, damaging a public service is easy, but fixing it again is hard. The NAO is right to highlight that short-term cash and logistical pressure risk undermining the delivery of the long-term plan."

“Waiting times continue to slip, cash injections haven’t improved the financial performance of trusts and even the government’s long-awaited vision for the NHS failed to address the workforce.”

A government spokesperson said: “We are pleased that the NAO recognises that ‘the NHS long-term plan sets out a prudent approach to achieving the priorities and tests set by government’.

“The long-term plan, backed by a significant funding increase of £20.5bn a year by 2023/24, rightly sets out that putting the NHS back onto a sustainable financial path is a key priority, and is essential to allowing the NHS to deliver further improvements in care.”

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