The new government’s in tray is unusually full of pressing challenges, but what should it do on health and social care in England in this parliament?
No surprise that health didn’t feature prominently in today’s Queen Speech. Commitments were made to reform mental health legislation, as well as a framework to help improve patient safety. And the government is to press ahead with at least a consultation on improving social care.
Clearly preparations for Brexit and the cooling economic situation are rightly major preoccupations, and the legislative schedule will be pretty jammed with the former. In the meantime, the NHS has a Five Year Forward View and needs to get on with it without new priorities or distracting political interventions.
On the other hand, there may be trouble ahead which needs to be headed off quickly. The fact that the NHS regularly topped the list of public concerns during this election, and the protest against austerity seen in part by the unexpected success of Labour’s pro-public spending policies, isn’t lost on politicians. Nor is the number of seats with slim majorities, nor still results like Canterbury where concerns about local NHS services may have played a significant part in the rejection of the sitting MP. Even in Jeremy Hunt’s very safe Conservative seat of South West Surrey, there was an 11.5% swing to a National Health Action candidate GP Louise Irvine, who came second. In 2013, Irvine led a campaign to save Lewisham hospital from closure, and won. This (and the possibility of another general election in the foreseeable future) will be concentrating minds in Westminster.
Smooth sailing for the NHS ship in the meantime would help. But big rocks loom under the waterline in terms of:
- noisy public opposition to reconfiguration plans by STPs with the possibility of legal challenge, and/or ‘rationing’ in areas of ‘capped expenditure’;
- winter pressures made worse by staff shortages of GPs, social care workers and in particular nurses (exacerbated by Brexit);
- rising discontent with NHS pay restraint.
On reconfiguration, Next steps on the NHS Five Year Forward View already outlines five key principles for public engagement, and four tests where significant hospital bed closures are on the table. These appropriately require a lot of shoe leather diplomacy – communication, communication, communication – a task which because of the election results in some areas just got a whole lot harder. A local task, yes, but the government could review how this activity can be boosted to get the best friction-free results for the population. Isn’t politics after all the art of the possible? Is the process we already have to make sure a robust set of proposals are properly developed and consulted on adequately? And the methods to adjudicate the merits of awkward cases? Interestingly there is little mention of these issues in the 2017/18 NHS Mandate. Without more action, surely the result will be an avoidable and drawn out challenge, and the government having to back off some needed change.
On staffing, the immediate task must be to guarantee the rights of the 7% of NHS staff who are EU citizens, not least given the current staff shortages, the spectacular drop off of new registrants to the UK nursing register and evidence of exodus.
Despite the toxicity of the proposed so-called ‘dementia tax’, the government should press ahead and try to get a better solution on social care funding, by developing a green paper as planned. They could make a virtue of doing this in an unusually open, inclusive, evidence based way – surely a model for how other complex issues are best tackled, as the public would expect. In the short term, and especially to help head off winter problems in the NHS, it is hard to imagine that more funding for social care will not be forthcoming.
Ditto to relieve obvious pressures on the NHS. Not least to make up for the planned reduction in spending per person in 2018/19 and 2019/20 (an extra £230m and £450m respectively would be needed) – or instead for increases in funding to match GDP growth, which would mean an extra £1.4bn and £2.9bn respectively. (Read more in our recent election briefings.) You could say the NHS has earned it, not least with a reduction in agency spend and the overall trust deficits falling to circa £800m in 2016/17 from £2.5bn the year before, as well as access and quality of care largely holding up. An impressive result by all concerned. But while there have been rumours (or wishful thinking) of a summer budget, an autumn spending review is more likely. The government will want as much time as possible to ponder its options given other pressing considerations.
All the above are relatively short term issues, but each have longer term roots that are complex and need facing. Surely the election result was a call to do things differently – to widen the political telescope from the tactical short term and to be more sophisticated (er modern) in finding solutions. What should be on the agenda?
First, a recognition that health and wellbeing are crucial assets – the basis for a flourishing society. In other words, investment in services which promote health are a human capital investment like education, decent housing and employment, not a drain which slows down debt reduction or a drag on the economy. A start would be a serious ‘health in all policies’ approach, not unlike that taken in Wales with the Wellbeing of Future Generations Act. Deny the value, skimp on these and you can kiss goodbye to prosperity akin to our European neighbours in the future.
Second, productivity. In the wider economy, levels are the limpest in Europe – the UK currently ties bottom with Italy. NHS productivity growth in recent years has exceeded that in the wider economy, which is good, but anyone working in or using NHS care can see that a lot of progress can be made. This needs serious attention. Yet in the meantime, the productivity growth of the largest ‘industry’ in Europe – the NHS – does not feature in the Government’s green paper on industrial strategy. To those who have been calling for a Royal Commission on funding the NHS, I say higher priorities would be a commission on health and wellbeing, and then on productivity in the NHS.
Third, infrastructure and not just buildings, technology and other kit (which governments get excited about) but human capital (which they don’t) need to be seen as part of the solution. This will need planning and investment. The calls for an integrated national workforce strategy for the NHS are well made. Part of this strategy must be a serious effort to develop a continuous learning culture within the NHS based on continuous quality improvement along the lines of Developing People – Improving Care. Don’t put all your bets on new technology. Without the right numbers and skill of staff, bottom-up change just won’t accelerate, and productivity will remain suboptimal.
What should the government do, then? In short, more thinking, more dialogue, more analysis, with more and different people around the table, with humility, and with the longer term in mind. Especially in the current climate, no government can do it on its own – they will need help from all of us. Get active.
Dr Jennifer Dixon is the Chief Executive of the Health Foundation
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