2019: The health policy year in 12 charts

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January: new long-term plan for the NHS

2019 began with a bang (in health policy terms at least) with the publication of the NHS long-term plan. ‘Long in every sense of the word’; at more than 120 pages, it covered everything from reducing the NHS’s contribution to air pollution to the role of competition regulators. But underneath the headlines, the long-term plan offers evolution rather than revolution and builds on the vision of more integrated care contained in its predecessor: the NHS five year forward view

And for health policy Kremlin-watchers, January also saw the first meeting of the new ‘NHS executive group’, which brings together national directors with the seven regional directors of NHS England and NHS Improvement. This provided further proof of the Nigel Edwards’ maxim on the staying power of NHS regional offices, even if the actual number of regional offices continues to wax and wane (see figure below). 

And finally, in January hope was rekindled that a Green Paper on social care funding reform would appear, when the Secretary of State for Health and Social Care, Matt Hancock, announced the document would be published by April. These hopes would be dashed by the end of the year. 

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February: primary care networks emerge

February brought two new acronyms and the ‘biggest reform to GP services in fifteen years’. The month began with Matt Hancock announcing the creation of NHSX (the X stands for ‘user experience’…) – a new unit that brings together teams from different national bodies to drive digital transformation. And a review from US digital guru Eric Topol recommended changes to the digital training of health care staff.

Sticking with the theme of bringing things together, in late January and early February more details were announced about a new contractual framework to establish 1,300 primary care networks (PCNs). It is hoped that PCNs will be a game changer for health services, by encouraging different primary care professionals and general practices to work more closely together to deliver better care for patients.

And finally, February brought two regular features of the health policy year. The annual ‘supplementary estimates’ process saw the Department of Health and Social Care 2018/19 budget topped up by £600 million to cover ‘unforeseen one-off in-year pressures’ (a topic we will return to later in the year). And the results of the latest NHS Staff Survey brought more evidence of both the pressures NHS staff were experiencing and their extraordinary sense of vocation (see figure below).

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March: change at the top of the NHS

Even before the ides of March there was dramatic change at the top of NHS national bodies. Ian Dalton stepped down as Chief Executive of NHS Improvement. And he was followed two months later by Matthew Swindells, the Deputy Chief Executive of NHS England. So, by the end of summer the people who had been placed third and fourth in 2018’s HSJ’s ‘Top 100 NHS leaders’ list had left their posts, with NHS England Chief Executive Simon Stevens assuming control of both organisations.

This started a trend of joint leadership throughout the NHS at the national level (with joint appointments across national bodies including Health Education England and NHS England and NHS Improvement before the year was out), and at the local level (as a new round of clinical commissioning group (CCG) mergers commenced, and provider trusts – particularly in London – shared a single chairperson).

March also brought preparations for a no-deal Brexit deadline at the end of the month, indications of declining satisfaction with the NHS from the British Social Attitudes survey, and the interim report from the national review of NHS waiting time targets. Given the scale of performance challenges facing services, there was a lot of ground for this review to cover (and a lot of ground to make up, see figure below).

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April: precision surgery on the NHS statute book

The start of the new financial year (and new NHS five-year funding deal) saw NHS England and NHS Improvement finish their consultation on proposed legislative changes that would help implement the NHS long-term plan. These changes were described by Simon Stevens as ‘precision surgery’ to allow for closer working across NHS England and NHS Improvement and changes to NHS competition and procurement law.

In other long-term plan-related news, the NHS Assembly held its first meeting in April. Chaired by Sir Chris Ham and Clare Gerada, the assembly brings together patient champions, NHS clinical and managerial leaders, charity bosses, trade associations and local authority leaders (see figure below) to provide advice and guidance to national NHS leaders on how to deliver the improvements envisaged by the long-term plan.

And in unfortunate, but not unexpected, news the hoped-for publication of the social care Green Paper was delayed (again) from April to ‘the earliest opportunity’.

Hover over or tap on the boxes below to find out more about the members of the NHS assembly.

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May: a (very late) mandate

A relatively quiet May saw the publication of the NHS Mandate, which sets out the government’s high-level objectives for the health service each year, and a short delay to the anticipated NHS Workforce Implementation Plan (later to become the NHS People Plan).

And while the social care Green Paper remained on pause, pressure continued to mount within the sector. May saw the holding companies behind Four Seasons – one of England’s largest care home providers with about 17,000 residents and 20,000 staff – start a sale process after falling into administration in late April. The pressure in social care services was echoed later in the year by the latest data from the 2019 survey of council directors of adult social services (see figure below).

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June: workforce, workforce, workforce

June brought a clear workforce focus to health policy. First, the Interim NHS People Plan outlined initial plans to address the NHS workforce crisis, with a fuller People Plan expected to follow the 2019 Spending Review later in the year (the end of the year would find the NHS still waiting for this). Given the precipitous drop in nursing recruitment from Europe (see figure below), the full People Plan can’t come soon enough.

In June the Migration Advisory Committee recommended that the government add all medical specialties to the shortage occupation list – an acknowledgement of both current workforce shortages and the reliance of the NHS on international recruits. And finally, the impact of changes to pensions tax allowances hit the headlines again as reports grew of clinicians turning down work to avoid punitive tax charges. The Department of Health and Social Care announced a consultation on how the current rules could be amended, even as the British Medical Association warned the proposed changes did not go far enough and there was further pain to come.

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July: declining health and satisfaction

The summer conference season brought its usual policy potpourri. In late June, NHS England boss Simon Stevens suggested the long-term trend to cut hospital beds should be reversed; the first stage of a review of primary care premises and estate was published; and a consultation was launched on digital-first primary care – following the entry of high-profile players like Babylon Health’s GP at Hand service. And away from the monthly cut and thrust of policy, two annual surveys from the Care Quality Commission showed patient satisfaction with accessing hospital and GP services declined as funding and workforce pressures over recent years took their toll.

Moving to July, the Department of Health and Social Care annual accounts for 2018/19 showed the department had managed to balance its books once more – but only with the help of the supplementary funding that had been provided in February. And the 11th hour publication of the prevention Green Paper by then-Prime Minister, Theresa May, received a mixed reception this month, as questions were raised over whether the warm words in the document would be matched with funding or action. Data published later in the year from the Health Survey for England 2018 demonstrated why more than warm words are needed (see figure below). But the survey also offered hope that change was possible, as the proportion of adults who currently smoke continued its steady decline from 27 per cent in 1993 to 17 per cent in 2018.

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And returning to the social care Green Paper, it was reported that proposals for a ‘clear course of action to address the crisis’ would now be published ‘in the autumn.’

August: a new Prime Minister starts to make his mark

What a month. 

In August the new national leaders (of the country, not the NHS) started to unpack their boxes and get to grips with their new jobs. The Conservative Party leadership contest produced a new Prime Minister as Boris Johnson succeeded Theresa May, and a new Chancellor, Home Secretary and Foreign Secretary after an extensive cabinet reshuffle. But after all this change England remained with the same Secretary of State for Health and Social Care, Matt Hancock – even if he has some way to go before he matches the staying power of his predecessor (see figure below).

The new Prime Minister wasted little time in putting the health and care service towards the top of his priority list throughout July and August. New capital investment was announced to help restore NHS buildings – though this sparked a furore over just how ‘new’ this funding was. A second consultation was launched to tackle the NHS pensions crisis (a crisis Boris Johnson had, while on the leadership campaign trail, promised to ‘fix’). And in his first speech on the steps of Number 10 in July, the Prime Minister promised even more: to ‘fix the crisis in social care once and for all’.

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September: party conference season

September is traditionally dominated by the stream of policy announcements from the party conferences. This year was no exception as the three main parties trailed their plans for everything from the state manufacturing of medicines to the introduction of more waiting time targets for mental health services to the abolition of (not insubstantial) car parking charges at hospital (see figure below).

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The impact of Brexit on long-term planning was also clear, as the multi-year government Spending Review was truncated into a one-year Spending Round to settle budgets for 2020/21. This did provide much needed investment to tide over the NHS, public health services and adult social care next year. But the need for longer-term investment in these wider budgets was highlighted by other data published in September, as the Office for National Statistics showed that the slowing down in life expectancy improvements in the UK since 2011 was continuing.

And as for the social care Green Paper (again, and finally) – the government announced that proposals would be brought forward – not ‘in April’, not ‘at the earliest available opportunity’, not ‘in autumn’, but ‘in due course.’

October: the month of capital

This month brought another Brexit deadline and another Brexit extension. It also brought more controversial capital funding announcements for the NHS with a new health infrastructure plan published in late September suggesting that 40 new hospitals would be built over the next decade. As scrutiny of the plan continued into October, it became clearer that the funding would allow six hospitals to be built or significantly refurbished over the next five years, with small amounts of seed funding available to develop plans for 34 more projects in future. Data on the deteriorating condition of the NHS estate was also published this month and revealed just how sorely additional capital investment is needed (see figure below).

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November: general election campaigns heat up

November saw campaigning in full swing ahead of the first December general election since 1923. Everything from free personal care to free car parking was on offer – all summarised in our handy policy grid.

But behind the national headlines were two important warnings about the state of health and care. The first was the quarterly finances of the NHS. These confirmed the new five-year funding deal is not a panacea for financial pressures in the service (see figure below). The second, and by far most troubling, issue were the leaked reports of care failings in the maternity service at Shrewsbury and Telford Hospital NHS Trust.

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December: a new government but familiar winter pressures

Just one day after the general election, new NHS performance statistics provided a stark reminder of the domestic pressures facing the new government. For the first time since modern records began, no NHS trust met A&E waiting time targets and the waiting list for planned hospital care swelled to 4.6 million people.

Moving back to politics, in the first major post-election speech by a member of the new cabinet, the Secretary of State for Health and Social Care added a fourth priority (infrastructure) to his initial list of technology, prevention and people. The process began for selecting a new chair of the Health and Social Care Committee to replace the outgoing – and highly respected – Sarah Wollaston. And a Queen’s Speech showed that 2020 would be a busy year to come politically, legislatively and operationally – with a new immigration policy and NHS visa on the cards. Any new system that is put in place in future will have to acknowledge the current reality that health and social care services are reliant on staff from Europe and the rest of the world.

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The year in review

Looking back, 2019 was a year of both new beginnings and hauntingly familiar problems. The year saw a new funding deal, a new long-term plan, a new government and everything from NHSX to PCNs added to the health policy lexicon. And it also saw financial performance and staffing pressures cling like limpets to the health and care sector. 

Each year brings surprises. In 2019, this included some expected events that failed to materialise – such as a full Spending Review, Brexit, a social care Green Paper and a full NHS People Plan. And it certainly included some things that materialised despite being deeply unexpected. So only a brave soul would try to predict in detail what will happen in 2020. In the end, the only constant in health policy is change. 

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