Roderick Crawford edited Parliamentary Brief 1992-2012 and currently works in conflict resolution.
The NHS is about to go into the worst crisis in recent history – perhaps in its history. It will be stretched beyond capacity for bed and staff and equipment.
Solving its capacity deficit in short time is going to be the key to ensuring it can play the fullest part in saving lives during the course of this pandemic. Just as importantly will be making sure that how we respond now adds to our ability to address future phases of this pandemic and future pandemics.
I wrote last week about how the NHS might find a source of tens of thousands of beds by taking over hotels as either stand alone medical units or as extensions of hospital wings. But what about the additional staff that will be needed? How can they be found at short notice and integrated into the system?
The UK has another service that is stretched by emergencies and has had to upscale quickly: the Army. Our standing Army has always been small in peacetime and relies on utilising Reservists and Territorials to meet its war needs.
During the Cold War, its ability to defend West Germany was based on rapid mobilisation and deployment of those additional reserve forces (albeit cut back by the controversial policy put in place by the 1966 Reserve Forces Act).
Without these reserve forces the Army could not possibly have met the demands placed on it had an East-West conflict broken out in Europe, nor would it have had the credibility of meeting those potential demands. This has been true of all the major operations since the end of the Cold War too.
Reliance on reserves has long roots, going back to militias in centuries past. When Robert Peel faced a renewed French threat in 1844-45, it was to the militia that he turned as a practical solution to a threat that had suddenly emerged and which might as quickly recede.
In the economic circumstances of the time it was the right response; the militia complemented the policy of strengthening key points of vulnerability on the coast and bought time for the naval rearmament programme to bear fruit. The policy had the full backing of his chief colleague, Wellington.
It was Richard Haldane, Secretary of State for War 1906-12, who gave new institutional framework to the militia and yeomanry.
The new Reserve and Territorial forces were specifically designed to provide for an enlarged expeditionary force capable of fighting the kind of European war that the Army was now facing for the first time in a century.
It was what enabled the British Army to play its part in supporting the defeat of the German offensive in 1914 and preventing, therefore, its victory.
The structure the Army established around the reserves was the basis for building up new battalions and thus up-scaling the Army to its full war-time size. Haldane’s reforms made a vital contribution to the final defeat of Imperial Germany. He was, in the words of Field Marshall Douglas Haig, the greatest Secretary of State of War in history.
These policies present examples that the Government could follow to give the NHS the additional capacity it needs now and in the future – a capacity that it cannot build into its normal full-time staffing levels as it cannot predict what level of staffing would be needed for addressing the additional demands on the health system arising from unknown pandemics in the future.
The Army has two types of reservists – those from other walks of life who volunteer as part-time soldiers, and those who, on retirement from their service in the Army join the reserve.
Both undergo 19-27 training days a year and are paid on the same basis as their full-time equivalents in the service, as well as receiving a tax-free bonus on completing the required training days. Something not dissimilar could form a model for the NHS.
Much of the basic care needed by people who become very ill from Covid-19 could be managed by volunteers trained up as auxiliary nursing staff to support regular nursing staff in day-to-day care for these patients, freeing full-time staff to work alongside them addressing complications, additional care for underlying conditions and of course enabling full-time staff to man expanded ICU beds.
As in the Army, reserve staff could work alongside full-time staff as part of care teams, or in teams of reserve staff that combine ex-nurses and doctors with trained volunteers. Depending on the level and speed of increased demand, both models might be needed.
Nursing has seen a significant outflow of staff, pre-retirement, over many years. The number of doctors leaving the NHS has been so high it is now labelled Drexit (Doctor-Exit); though most are moving abroad to work, many have left the profession or are working part time only.
Between them, we have a large pool of already trained and qualified staff to draw on. What has been a problem can now be turned to advantage to meet this present challenge faced by the NHS workforce.
What is essential, is that this potential workforce reserve is invited back into the workforce in a way that is structured to provide not only a legal basis for their employment now but also structured into new workforce models that can meet the demand for staffing in this and in future national crises.
The need to build medium-term capacity — not just for this coming winter and 2021, but for the foreseeable future — calls for the instituting of an official reserve staff structure of ex-professionals as well as suitable volunteers.
It will need to be put in place by the Department of Health, with the support of Health Education England and the local education and training boards to ensure that the right training is provided, as well as by their Scottish, Welsh and Northern Irish equivalents.
This is not about an NHS on the cheap. It is about how to create the resources needed to confront a sudden increase in demand for healthcare not seen in our lifetime, and one that may reappear just as suddenly – not only as a repeat occurrence of this particular virus but of others both less and more virulent.
Establishing a fixed level of appropriate nurse numbers is not possible in the face of such potential shifts over and above usual changes in seasonal demand and demographic change.
The Government’s plans for more new nurses and higher retention, when delivered, will not provide the capacity needed to address this kind of spike in demand, helpful as it will be in building stability in our everyday workforce and in meeting rising demand of around four per cent per year.
Ensuring that the NHS has in place the resources to meet these now expected sudden increases in demand is essential. That these resources must be provided for in an economically and socially sustainable manner is also evident.
With the economic hit the UK is taking and the state of the global economy that we will be re-entering post crisis, as well as the difficulties of recruitment and retention of NHS staff (including the problems of overseas recruitment both practically and morally in this new environment), reserve workforces are the only realisable and sustainable policy response.
Sir Robert Peel’s example is one that should guide Boris Johnson and Matt Hancock would do well to learn from the work of Richard Haldane. They got it right.