The NHS in England faces an extremely challenging winter and the prospect of very low growth in its budget thereafter. The Chancellor’s autumn statement gave priority to cutting some taxes, albeit with the overall tax burden set to reach record levels. It also outlined public spending plans so tight they were described by one think tank as “implausible.”1
The government has rejected a request from NHS England for additional funds in the current financial year to cover the costs of industrial action. It has also been adamant that the NHS—and other public services—should redouble efforts to increase productivity. In response, NHS England has reiterated the importance of the NHS achieving financial balance this year and reprioritized national budgets to release some funds to help deliver this. It has also acknowledged the need to work towards a limited number of targets and accept that progress in reducing waiting times, one of the prime minister’s priorities, will slip.2
The effect of these decisions will be to focus the minds of NHS leaders on immediate financial and operational issues, for example ensuring that urgent and emergency care is able to cope with winter pressures. While understandable, the risk is that short term imperatives will crowd out time and energy to deliver long term ambitions to transform health and care in line with the aims of the Health and Care Act 2022. Integrated care systems established under the act are developing plans to improve the health of their populations and care delivery and these plans may now be put on the back burner.
There is a precedent in what happened in 2015/16 following the announcement of additional resources for the NHS known as the Sustainability and Transformation Fund. Financial pressures meant that the sustainability of services took precedence over plans for transforming care, and resources intended for capital investment were diverted to fill gaps in day-to-day spending.3 This made it difficult to fund innovations in care which held out the prospect of improving the working lives of staff and the experiences of patients. The opportunity costs of transferring capital to revenue this time around are arguably much greater in view of the potential offered by digital technologies, artificial intelligence, predictive data analytics, novel therapies, and other advances in care.4
Equally difficult is how to ensure plans to improve population health can be delivered when recent governments have been reluctant to act for fear of being seen as a “nanny state” and public health funding has been cut. To be sure, there is scope for local leadership on prevention in the partnerships developing between the NHS, local authorities, and others, but this has to compete for time and attention with reducing NHS deficits and improving productivity. With the exception of welcome proposals to restrict smoking, the government appears to have little interest in using legislation and taxation to support local leaders in improving health outcomes.
The pandemic served as a reminder of the role of citizens in preventing illness and there is an opportunity to build on this by recognising the power of people and communities. Governments and public bodies may make more progress by going down this route than expanding treatment services, as illustrated by experience in areas of the country that have done so.5 By using all available assets to improve population health, it may be possible to reduce the burden of disease over time. Pressures on local government spending and the likelihood that more councils will declare bankruptcy reinforce the importance of using resources in different sectors.
The outcome of the forthcoming upcoming general election will shape how these issues are resolved. The next government will face difficult choices in view of the implausible spending plans outlined in the autumn statement and the dire state of the public finances. With taxes on an upward trajectory and government debt at historically high levels, room for manoeuvre is limited. The Labour Party has made clear that it will not increase public spending substantially were it to form the next government, and this again turns the spotlight on ways of increasing productivity and working differently with citizens.
Productivity improvements in a labour intensive service like the NHS depend on staff playing their part in reducing unwarranted variations in care and embracing worthwhile innovations. The discretionary effort on which the NHS relies has been eroded by the pandemic, staff sickness, and chronic staff shortages. Political leaders must show they value staff, find a way of resolving ongoing industrial disputes, and reduce bureaucratic oversight. It is encouraging that the new Health and Social Care Secretary, Victoria Atkins, appears to understand this more clearly than her predecessor.6
Investment in new buildings and technologies must also be prioritized to support the adoption of innovations in care. This means not raiding capital budgets to cover gaps in running costs and recognising the potential of digital technologies, personalized medicine, and supporting people to stay well and use services wisely. The effects of endemic short termism by successive governments are now in plain sight, making it even more important to create time and space for addressing long term ambitions of the kind the integrated care systems are now working on.7
An early resolution for 2024 would be to start work on a compact with the public setting out rights and responsibilities and the role that everyone can play in securing the future of the NHS. Initiatives around the country are showing what shared responsibility means in practice and illustrate what is possible.8 While public satisfaction with the NHS is at a low ebb, surveys show that there is little appetite for an alternative model.9 Now is the time to draw on the deep well of public support for the NHS in pursuit of sustainability and transformation.
As its founder, Nye Bevan, once said, the NHS will survive “as long as there are folk left with the faith to fight for it.”
Footnotes
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Competing interests: Chris Ham is emeritus professor of health policy and management at the University of Birmingham and Co-Chair of the NHS Assembly. He writes here in a personal capacity.
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Provenance and peer review: not commissioned, not externally peer reviewed.