NHS England started this process at its recent board meeting. A background paper for the meeting stated that ‘with its 2018/19 budget the NHS will likely not be able to do everything being expected of it’. The paper went on to note that clinical commissioning group deficits would need to be covered by the funding available next year and argued that protected planned investment in mental health, cancer and primary care should go ahead.
Crucially, the paper added that there was a need to be realistic about what can be expected from the remaining available funds. As an example, it stated that new advisory National Institute for Health and Care Excellence guidelines would only be implemented ‘if in future they are accompanied by a clear and agreed affordability and workforce assessment at the time they are drawn up’. Another example – of greater significance to the public – was expectations around waiting times for non-urgent care where NHS England forecasts that ‘NHS constitution waiting time standards… will not be fully funded and met next year’. Speaking at the Fund’s annual conference, Jeremy Hunt, Secretary of State for Health, rejected this possibility saying that the government is ‘absolutely committed’ to meeting waiting times targets.
While press reports have suggested that NHS England’s stance has set it on a collision course with the government, the reality is more nuanced. Like any self-respecting leader of a government spending department, Jeremy Hunt has played his part in seeking more funding and clearly recognises the challenges faced by the NHS. The fault line is therefore between the Department of Health and NHS England on the one hand and the Treasury and No.10 on the other, at a time when those at the heart of government are preoccupied with Brexit and convinced that more can be done to increase NHS efficiency.
There is no doubt that efficiency can be improved by taking forward the programme of work initiated by Lord Carter and particularly by reducing waste and variations in clinical care. There is also considerable scope to reduce management and transaction costs in the complex and fragmented organisational arrangements that are the legacy of Andrew Lansley’s Health and Social Care Act 2012. Yet even if these and other opportunities are pursued with renewed vigour, they will not be sufficient to bridge the funding gap we and others have identified.
Equally important is to give priority to reforms that are beginning to deliver the kinds of changes needed to enable the NHS to manage demand for care more effectively. The work of the new care models established under the NHS five year forward view shows that it is possible to bend the demand curve and deliver care differently. The accountable care systems announced in March have the potential to take forward these reforms at scale and deliver on NHS England’s commitment to make the biggest move to integrated care of any western country.
Debate about what the NHS can deliver with available funding will come to a head in negotiations between NHS England and the Department of Health to update the NHS Mandate early in 2018. Now is therefore the time to have an informed discussion about the choices to be made and what is needed to place the NHS and social care on a sustainable financial footing in the longer term. For this to happen, NHS England and the Department of Health need to come together and be honest with the public about current realities and the consequences of continuing austerity.
Coming together does not mean masking genuine differences about what should be done where they exist. The onus on national leaders is to fashion a constructive argument about what the NHS can deliver and in so doing avoid a descent into adversarial disputes which will undermine public confidence in their stewardship of the NHS. Resisting the temptation to apportion blame for the challenges facing the NHS would be a good starting point.