Writing in the BMJ before the Queen’s Speech, Chris Ham, chief executive of The King’s Fund, said that NHS England will ‘continue to promote evolutionary changes to the organisation of the NHS, including collaboration and in some cases mergers’. Niall Dickson, chief executive of NHS Confederation, suggested that ‘political uncertainty’ may impede service change.
The Queen’s Speech underlined the fact that Brexit will dominate the agenda for the next two years, which will have ramifications for the NHS and social care as around 150,000 EU nationals work in the sectors. On health policy, the government will bring forward a consultation document on social care reform, but did not commit to changing the funding model. Mental health legislation will be reformed and a Green Paper published on children and young people’s mental health. Reforms to ease the implementation of the NHS five year forward view, hinted at in the Conservative manifesto, are off the agenda until 2019 at the earliest. Looking across these plans and reflecting on the general election debate, it’s clear that several pressing issues in health and social care are not going away.
First, the election seems to have left the social care debate in disarray. The Tories’ manifesto headed in an unexpected direction when they scrapped the Dilnot cap, rapidly reversing that decision following widespread criticism. The other parties’ offers were different, but, as Richard Humphries wrote, none went far enough. As Nick Timmins alluded to in his blog, part of the problem seems to be that there is agreement that something must be done but no consensus on what that should be. It remains to be seen whether the government’s consultation paper will attempt far-reaching reforms that could command cross-party support or opts to tinker at the margins. The Tory–DUP agreement to maintain the pensions triple lock and universal winter fuel payments would suggest that funding reform is less likely.
Second, the complex and fragmented NHS landscape created by the Health and Social Care Act remains an issue. While Jim Mackey, NHS Improvement chief executive, used his speech at NHS Confederation’s conference to say that much of the proposed integration can be delivered within the existing law, others have raised concerns. In particular, it’s been suggested that the lack of statutory backing for sustainability and transformation partnerships may slow collaboration between organisations and leave the door open to challenges via judicial review. Ultimately STPs are a workaround – and that’s unlikely to be sustainable long term.
Third, workforce is increasingly front and centre of service leaders’ minds. With inflation approaching 3 per cent last month, many voices are calling for an end to the 1 per cent public sector pay cap. The Royal College of Nursing has launched a national campaign – or Summer of Protest – and raised the prospect of industrial action if the policy isn’t changed. The Labour Party added to the pressure by forcing a Commons vote on the issue. Although Jeremy Hunt has hinted he’s lobbying in private for a change and there have been rumours that the policy is under review, it’s still not clear that the chancellor will loosen the purse strings.
Last but not least, the funding question remains. It seems that the NHS delivered financial balance in 2016/17 – ‘achieved the impossible’ as Jim Mackey put it – with commissioners’ £900 million underspend cancelling out provider deficits of around £790 million. But the new financial year doesn’t offer much relief: Mackey recently conceded that trusts are likely to overspend by £500 million in 2017/18. The government’s pledge of an £8 billion real-terms increase for the NHS over the parliament falls well short of what’s needed. And the wider point, perhaps, is that the election campaign does not seem to have shifted the debate nearer to a long-term funding settlement for health and social care. All the parties pledged more money, but as Chris Ham, Jennifer Dixon of the Health Foundation and Nigel Edwards at the Nuffield Trust wrote in a joint letter to the Times, none offered a sustainable solution.