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Within the space of 5 weeks, both Sir Simon Stevens and Matt Hancock will have left their posts. Their successors face huge challenges: recovering from the pandemic and charting a course for the NHS over the next few years, at a time of great economic, fiscal and societal uncertainty.

Understanding the impact of the pandemic on health – and what we can learn from other countries – is critical. In June, ahead of the G7 summit, we worked with the BBC to look at how the G7 nations compared. This showed that, looking at excess deaths compared to usual deaths, the UK was second only to the US. The other G7 countries – Italy, France, Canada, Germany and Japan – had fewer excess deaths, with the latter three having significantly fewer. For the period March 2020 to February 2021, the UK had 20% more deaths than expected.

COVID-19 was the cause of the vast majority of the UK’s excess deaths. But the reductions in treatment that occurred during the pandemic – partly as a result of having to free up capacity for COVID-19 patients – may have led to some additional deaths, and will certainly have affected quality of life. Thankfully, the success of the vaccine rollout has weakened the link between the virus and hospitalisations and deaths, despite cases having risen again more recently. But the disruptions to health services will cast a long shadow, both for individuals and for the system as a whole.

Tackling the waiting list backlog

Waiting times are one manifestation of this disruption. Those on the elective care waiting list in May have been waiting a median of 10.8 weeks compared to around 8 weeks immediately before the pandemic, and the number of people waiting for more than 18 weeks has more than doubled. And – most worryingly – the number of people being referred for treatment in 2020 was 6 million fewer than we would have expected. These unmet health needs won’t have gone away and it’s likely that many of these ‘missing patients’ will appear on the waiting list over the next few months, causing waiting times to grow even further. Dealing with these missing patients and recovering waiting times back to the standard is a major challenge for the NHS.

While there has been a lot of focus on hospital waiting times, there are also backlogs in primary care. We have been following GP activity throughout the pandemic period, and our latest analysis (in May) showed that there were 23 million fewer primary care consultations in 2020 than in 2019 – a reduction of around 10%. The smallest percentage reductions of 6% and 2% were for patients with one or multiple pre-existing conditions respectively, suggesting that these patients were still accessing primary care. However, the proportion of consultations conducted remotely rose from under 20% to between 50% and 70%. Although 2-week referrals for suspected cancer had recovered by autumn 2020, total referrals were down by 250,000 by the end of January 2021.

A new NHS payment system to support recovery

The NHS payment system (ie how health care providers receive their funding) can play a role in addressing the elective care backlog, by incentivising providers to do more and become more efficient. This is the subject of a new REAL Centre report, written with Frontier Economics. It argues that while it might be tempting to move back to an activity-based system, like Payment by Results (PbR), to deal with the care backlog, a system based on such payments alone will not help the NHS meet its wider objectives, including building capacity for the future and providing coordinated care. Instead, a blended payment system to replace the PbR tariff remains the right direction of travel.

Addressing long-term needs

Of course, waiting times are not the only challenge facing our health and health care system. Demand for health services is rising as a result of population ageing and the increase in chronic disease prevalence. The gains we were seeing in life expectancy have been slowing. And as our recent COVID-19 impact inquiry report shows, the pandemic has starkly exposed health inequalities and the consequences of our nation’s relatively poor health going into the crisis.

Although these are major challenges, requiring long-term thinking, history shows that tackling them is possible. Nick Timmins has written a wonderfully wise, insightful and entertaining report about the 2002 Wanless Review, based on interviews with key participants, including Ed Balls, Alan Milburn and Nick Macpherson. It’s a lovely blend of politics, history and health policy.

In his report, Nick reminds us that the UK entered the new millennium with long waiting times, poor health outcomes compared to European countries and open questioning of the funding model. The Wanless Review was set up by Gordon Brown to examine the trends affecting the health service and the funding required over the next 30 years to deliver high quality care. The secretariat was led by Anita Charlesworth, now director of the REAL Centre. Following the Wanless Review, the NHS received a significant funding boost and there was a concerted effort to improve outcomes and reduce waiting times.

In her foreword to the report, and in our recent podcast, our Chief Executive Jennifer Dixon asks whether it is time for another Wanless Review. The REAL Centre was launched with this question in mind and part of our role is to produce funding and workforce projections for various future scenarios.

Fixing social care

Recovery may be the immediate priority for the NHS, but for social care, recovery is not the right word. The system needs fundamental reform. It is underfunded and needs more money supported by policy changes – for example to address workforce issues.

Reform of the way in which we pay for care is also needed. Currently, people are exposed to huge and unpredictable costs. The costs for those with the greatest needs can run into hundreds of thousands of pounds. There is a solution on the statute books in the form of the Dilnot Commission proposals, but successive governments have failed to take action.

We explored some of the issues in a couple of recent articles. The first looked at alleged Treasury objections to reform – the cost and distributional impact – and whether they stack up. The second explored the impact of reform on those who are less wealthy, finding that the greatest beneficiaries could be those in former ‘red wall’ areas, who have the lowest levels of wealth and under the current system are most at risk of losing a large share of it.

What’s next from the REAL Centre?

In the next few months we will be producing our first full set of projections for NHS and social care funding needs to 2031, as evidence to inform the 2021 Spending Review. We’ll also be publishing analysis of the impact of the pandemic on health, and the effects of COVID-19 (and resulting reductions in the use of health services) on mortality and morbidity. We'll be sharing these findings, and more updates from our research, in our next REAL Centre email update. For those not already subscribed, you can sign up here.

Charles Tallack (@CharlesTTHF) is Assistant Director for the REAL Centre.

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