Capacity pressures in health and social care in England

This article is part of the series Research in brief: Quick reads for the 2024 Parliament, produced for new Members of Parliament after the 2024 general election.

Record demand, an ageing population and inflation are all squeezing health and social care services, and both face significant capacity issues. In England, waiting lists for hospital treatment peaked at 7.8 million people in 2023 and delays in discharge are affecting one in eight general and acute hospital beds.

Sources of pressure in the system

Health and social care services are under pressure, with high demand and inflation all leading to a squeeze on NHS finances and a reduction in timely access to services.

Key waiting times standards are not being met. In England, the 18-week treatment target has not been met since 2016, and the waiting list for hospital treatment rose to a record of nearly 7.8 million in September 2023 (although it has fallen since then, to 7.6 million in April 2024), as shown in chart 1.

There also delays in accessing mental health services, and GP and dentist appointments, pointing to capacity issues across the healthcare system.

In the social care sector, the Association of Directors of Adult Social Services estimated that in England around 250,000 people were waiting for a care assessment in August 2023.

Health and care services are largely devolved across the UK but there are similar pressures on health and social care services in Scotland and Wales, and particularly severe challenges in Northern Ireland.

A productivity challenge

While it is difficult to measure productivity in healthcare, NHS England has acknowledged that despite staff increases, NHS hospital productivity in 2023/24 was more than 10% lower than it was before the covid-19 pandemic (or around 8% lower if adjusted for the impact of industrial action).

It attributed the decline in productivity to reductions in capital investment, a lack of spare capacity leading into the pandemic, patient flow challenges and the related issues of staff burnout and high turnover.

Demand for capital investment

There are broad agreement that the NHS needs more investment in modern IT, medical equipment and buildings to increase capacity and efficiency. There is also a growing maintenance backlog, including the need to replace reinforced autoclaved aerated concrete (RAAC) in hospitals. Despite this, NHS capital budgets have often been reallocated to cover shortages in funding for day-to-day running costs.

The March 2024 Budget announced £3.4 billion investment in digital technology and equipment to make productivity gains in the NHS.

Higher rates of bed occupation

Reductions in average length of hospital stay, an increased use of day surgery and a policy to move more care of patients from hospital to the community have allowed the NHS to reduce the number of beds it has. But bed occupancy rates have also increased, from around 85% in 2010 to over 90% in recent years, according to NHS England data.

Higher bed occupancy is associated with poorer quality of care and outcomes, with people experiencing lengthy waits to be admitted, and ambulances facing difficulties handing over patients to emergency departments.

Moving some care out of hospitals

The Nuffield Trust and King’s Fund have highlighted that despite political and public support for moving more care away from hospitals, successive governments have overseen substantially higher funding increases for hospitals than for community and primary care services.

Reform of mental health legislation also aims to divert more people away from detention in hospital. There are further ambitions to move care of autistic people and people with learning disabilities away from long-term inpatient settings. The success of these reforms depends on capacity in community teams.

Plans to increase capacity

NHS England has announced several measures to address capacity issues, such as its plan for tackling the covid-19 backlog of elective care and its plan for recovering urgent and emergency care services.

The government’s 2022 Our plan for patients referenced the need to expand hospital capacity. It also set out aims to prevent hospitalisations, and to treat more people at home or in the community.

Long=-term workforce planning

The June 2023 NHS Long Term Workforce Plan for England set out measures to address workforce shortages. According to the plan, to reach the capacity needed to meet the increasing healthcare demands of an ageing population, the permanent NHS workforce would need to increase from 1.4 million in 2021/22 to between 2.2 and 2.3 million in 2036/37.

This assessment was based on several ‘modelling assumptions’. These include ambitions to deliver more care in the community rather than in hospitals, anticipated growth in labour productivity and alternative, less expensive, delivery models like virtual wards.

The Library’s briefing on NHS statistics for England has more on waiting lists and workforce numbers.

Delayed hospital discharges and health and social care integration

Delayed discharge is when patients with ongoing care needs cannot leave hospital despite being medically fit enough to do so. This can happen because of delays in hospital discharge processes or when other care arrangements are not available to move to.

According to NHS England data, in February 2024 there were between 13,200 and 14,200 patients remaining in hospital each day who did not meet the criteria to stay. This represents over one in eight general and acute beds in England.

While there are variations, the overall numbers of patients facing delays in discharge have not significantly changed over the last two years, as shown in chart 2. However, there are concerns that the number of people delayed in hospital for more than three weeks has increased.

See our Insight on delayed hospital discharges and adult social care for more.

The impact of delayed discharges on hospital performance

As well as contributing to high bed occupancy rates, staying in hospital longer than is necessary can lead to poorer patient outcomes and contribute to a loss of independence. NHS England also refers to evidence for the negative impact of unnecessary hospital stays for patients with dementia.

Current plans to address the causes of delayed discharge

In its January 2023 delivery plan for recovering urgent and emergency care, NHS England said increased capacity in social care and in intermediate care (where the NHS funds temporary support like physiotherapy) was needed to improve discharge. It said this “requires sustained long-term investment, in particular in the social care workforce given the scale of vacancies”.

A ‘discharge to assess’ model has been introduced by the NHS in England, where a limited needs assessment is carried out in hospital and patients are then discharged home or to intermediate care, where a more detailed assessment of their long-term needs takes place.

Although this was rolled out nationally during the pandemic, it was separate to the decisions, made during the early stages of the pandemic, to free up capacity in hospitals by discharging patients into care homes. The UK’s Covid-19 inquiry will consider this in 2024 and 2025.

Improving how hospitals and social care providers work together

While healthcare in the UK is provided by the NHS, social care is the responsibility of local authorities. All areas of the UK have sought to improve joint working between health and social care services. In England, the Better Care Fund was established in 2015 to encourage this by requiring the NHS and local authorities to agree joint spending plans for integrated health and social care.

In June 2022, 42 “integrated care systems” were formally established in England, bringing together health and social care services. NHS England’s 2023 delivery plan for recovering urgent and emergency care services included commitments to improve discharge processes between hospitals and other care providers.

The government’s 2023 social care reform policy paper, Next steps to put people at the heart of care, highlighted plans to increase the use of digital care records, which, it suggested, could improve the transition of patients from NHS hospitals to social care settings.

In February 2023, the Health Service Journal reported that efforts to improve integration of health and social care had not so far delivered any overall reduction in delayed discharges. The government reported some evidence that a fall in delayed discharges was associated with additional funding distributed through the Better Care Fund over December 2022 and January 2023. However, the review of the impact of this funding noted challenges in evaluation and data quality that might have affected these findings.

Further reading

• The structure of the NHS in England – House of Commons Library
• Funding for adult social care in England – House of Commons Library
• NHS key statistics: England
• The NHS workforce in England
• Delayed hospital discharges and adult social care

Authors: Thomas Powell, Carl Baker and David Foster

Photo credit: (© By toodtuphoto– stock.adobe.com).