2020 started with policy fireworks, as plans for new primary care networks (PCNs) nearly went up in smoke. The furore was sparked by mounting criticism from GPs since Christmas over the ‘totally unrealistic’ expectations of what could be delivered under the new GP contract specifications. But after this bumpy start, the PCN show was back on the road by early February thanks to concessions and more funding from NHS England and NHS Improvement.
This month was also dominated by the continuing spread of a novel coronavirus in East Asia and the UK leaving the European Union nearly four years after the Brexit referendum (two themes that would bookend the year). By the end of the month the NHS had entered the first phase of preparation and response to Covid-19 when it declared a level-four incident to allow NHS England and NHS Improvement to take national control and co-ordination of the response to the pandemic.
January saw the publication of the 2020/21 NHS planning guidance, which asked NHS organisations to take a ‘system by default’ approach to planning and delivering health services in the coming year. The NHS Funding Act 2020 enshrined the five-year NHS funding deal in legislation, which met the government’s manifesto commitment but had little more than a symbolic impact on the NHS. And former Secretary of State for Health and Social Care Jeremy Hunt became chair of parliament’s Health and Social Care Select Committee.
A mild 2020 winter and low levels of flu saw (pre-Covid-19) mortality in the UK remain at the lower levels seen in 2019 and news emerged on a potential merger between the Royal Brompton and Harefield NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust that would potentially create the UK’s first £2 billion provider.
And finally, the newly knighted Sir Simon Stevens created waves with his less-than-complimentary review of Gwyneth Paltrow’s new Netflix show The Goop Lab, noting that misleading information could contribute to a rise in vaccine-preventable diseases such as mumps, and unwind some of the incredible progress of recent decades (see Figure 1).
This month saw an unplanned Cabinet reshuffle that ended with a new Chancellor in post just three weeks before the spring Budget. This was accompanied by reports of a potential Number 10 ‘power grab’ that would use additional legislation to rein in NHS England and NHS Improvement’s autonomy (and which brought to mind comments from one Number 10 adviser in the early days of NHS England: ‘They are meant to be independent, but not that bloody independent.’)
And ten years on from his original review, a report by Professor Sir Michael Marmot revealed people can expect to live more of their lives in poor health than they did 10 years ago and the gap in health status between people who live in wealthy and deprived areas is growing. And the 2019 NHS Staff Survey and Workforce Race Equality Standard report highlighted why a new national NHS People Plan was so badly needed, as staff from ethnic minority groups were more likely to be bullied, less likely to be appointed from shortlisting, more likely to enter the formal disciplinary process, and less likely to be members of NHS boards than white staff (see Figure 2).
Three months after the first worrying reports of a new flu strain emerged from the Chinese city of Wuhan, it became clear that coronavirus (Covid-19) would be the issue dominating 2020 – an issue that national leaders said ‘presents the NHS with arguably the greatest challenge it has faced since its creation’.
Covid-19 certainly overshadowed the spring Budget 2020, as the Chancellor promised to give the NHS ‘whatever it needs, whatever it costs’, including part of a new £5 billion emergency response fund for public services, and £6 billion of extra funding for the NHS to support the government’s manifesto commitments for more nurses, hospitals and primary care appointments.
And as the month marched on, the impact of Covid-19 became more widely and deeply felt in every area of life. People lost loved ones before their time. Health and care staff were put under increasing pressure. Staff who were in training or retired (including the Irish Taoiseach) joined the front line. Planned operations were deferred; activity at A&E departments plummeted; and patients were rapidly discharged from hospitals. Formula 1 car-makers and other manufacturers were asked to help produce ventilators. Conference centres were repurposed as emergency Nightingale hospitals. And every Thursday night, people stood on their doorsteps to applaud health and care staff and other frontline workers.
Turning back to health and care policy, several planned announcements and regular features of the health policy year were postponed or cancelled outright because of Covid-19. The publication of the NHS People Plan and the Clinically-led review of access standards was pushed back from March to the end of 2020. And the national payment system (the ‘tariff’) was paused to reduce administrative burden.
But it was not all stasis and postponement on the health policy front this month, as Health Education England announced that Navina Evans would become its new chief executive (see Figure 3). And, after making a manifesto commitment to begin cross-party talks on the future of social care within 100 days of the general election, Secretary of State for Health and Social Care Matt Hancock wrote a letter to colleagues in all parties. This one-and-a-half-page letter would remain one of the most substantial government statements on social care in 2020 .
In January, I thought the quote that would sum up the year would be ‘system by default’. But a Lenin quote does a better job and was often repeated this month: ‘There are decades where nothing happens; and there are weeks where decades happen.’
Figure 3 Recent leaders in the Department of Health and Social Care and a selection of its agencies and partner organisations, based on assumed sex and ethnic minority status
Notes: Data shown for the Department of Health and Social Care and a selection of its high-profile agencies and partner organisations. Information for NHS Improvement includes leaders of Monitor and the Trust Development Authority. Data on the ethnicity and gender has been assumed by the author based on personal knowledge and analysis of board reports.
As former HSBC chief executive John Flint said – ‘A crisis is not an event, it’s a series of episodes, much like waves crashing on a beach.’ The waves continued to crash in April as the number of people who died from Covid-19 – including more than 100 health and care staff – increased rapidly over the month. There were also stark reductions in the use of non-Covid-19 hospital services and wider changes to how people lived their lives (see Figure 4). This month the leaders of NHS England and NHS Improvement said the NHS was entering the second phase of its response to Covid-19 – which would mean the ‘surge capacity’ to deal with Covid-19 would be maintained, but some routine non-Covid NHS care would also slowly return.
And in a month where the Prime Minister was admitted to intensive care with Covid-19, the national health policy debate was dominated by three recurring themes. First, when staff would receive the personal protective equipment (PPE) they needed. Second, whether the government would meet its own target of testing 100,000 people a day for Covid-19 – with one NHS provider chief executive describing the lack of chemical reagents that Covid-19 tests require as ‘like having an espresso machine without the capsules’. And third, the rising death toll from Covid-19 in care homes and the community.
This month the government also announced £13.4 billion of NHS loans to the Department of Health and Social Care would be written off – something that might have led news cycles at any other time. The Secretary of State for Health and Social Care promoted a lapel badge for care staff. And while access to some traditional NHS services continued to plummet, use of digital health services understandably hit new heights – though while video-based GP and outpatient services grabbed many headlines, data suggested most of the ‘virtual consultations’ were based on a good old-fashioned phone call.
As the London Nightingale critical care hospital planned to close its doors, a new Seacole rehabilitation hospital (named after pioneering nurse Mary Seacole) prepared to open in Surrey – reflecting the growing focus on the long-term health consequences of Covid-19. Plans for more Seacole hospitals were later paused as national bodies suggested rehabilitation services could be delivered in existing services.
Polling data suggested public confidence in using NHS services was mixed, at best, because of Covid-19 – only 52 per cent of people were comfortable using their local hospital, with 78 per cent being comfortable using local GP services.
Continuing a tradition of executive chairs in senior NHS roles, Baroness Harding, chair of NHS Improvement, was appointed to lead the new Covid-19 test-and-trace programme (and would later wear a third hat as chair of the new National Institute for Health Protection). A new contact tracing app developed by NHSX would be launched on the Isle of Wight. And several NHS chief executives publicly criticised Dominic Cummings, the PM’s special adviser, after his trip to Durham during lockdown.
And moving only slightly away from Covid-19, four new integrated care systems were approved, and Sir Simon Stevens said the NHS had hit its financial targets for the 2019/20 financial year (though as 2020 comes to a close the 2019/20 accounts for the NHS remain unpublished). The Prime Minister belatedly scrapped the immigration health surcharge (a fee temporary migrants to the UK pay for accessing health care) for people eligible for a new health and care visa (including the many staff from overseas working in the NHS, see Figure 5), noting both that ‘I have been a personal beneficiary of carers who have come from abroad and frankly saved my life’ and that ‘on the other hand… those contributions (from the surcharge) help us to raise about £900 million’.
But the event that defined May was the murder of George Floyd in the United States, which sparked protests around the world. By the end of May a new NHS Race and Health Observatory had been set up, as health and care organisations created or accelerated their plans to support greater equality.
The killing of George Floyd in May continued to dominate headlines and brought what Sir Simon Stevens described as a 'stark and urgent’ focus to the problems people from Black, Asian and other minority ethnic backgrounds face. The NHS People Plan for 2020/21 promised to improve the experience of staff from ethnic minority backgrounds and a host of NHS chief executives spoke out in support of greater inclusion and diversity. Public Health England’s review of the impact of Covid-19 on ethnic minorities was published, but not without some controversy with reports of the review being delayed and sections redacted. The Prime Minister later set up a Commission on Race and Ethnic Disparities to explore why disparities (including health outcomes) exist and how they can be addressed. and how they can be addressed.
This month the Prime Minister reinforced why ‘infrastructure’ had been added as the Secretary of State for Health and Social Care’s fourth priority (alongside prevention, workforce and technology) with a ‘Build, build, build’ speech that would see NHS capital investment rise by up to £1.5 billion in 2020 to help maintain hospital estate and eradicate dormitory-style mental health wards. And the government created a taskforce for the social care sector, led by the respected former Association of Directors of Adult Social Services (ADASS) president David Pearson, to oversee delivery of support packages for social care services during the pandemic and coming winter.
And turning to Covid-19, a row broke out over whether rapidly discharging high numbers of patients from hospital in March led to the virus taking hold in care homes; the NHSX contact tracing app piloted on the Isle of Wight ran into data privacy and accuracy concerns; ‘call-before-you-go-to-A&E’ pilots began in parts of England, asking patients with non-life-threatening conditions to book an appointment at A&E to reduce overcrowding.
Finally, data on the government’s Covid-19 testing programme came in for criticism. Sir David Norgove, chair of the UK Statistics Authority, wrote to the Health and Care Secretary to say the testing figures – including performance against the national target to carry out 100,000 tests a day by the end of April, ‘are still far from complete and comprehensible… The aim seems to be to show the largest possible number of tests, even at the expense of understanding.’
July was a bumper month for Covid-19 and non-Covid-19 health policy.
The summer statement (the middle act in 2020’s planned fiscal trilogy including the spring Budget and autumn Budget) brought Covid-19 health spending to £31.9 billion, including a staggering £10 billion on the Test-and-Trace programme and £15 billion on PPE. By the end of the month a further £3 billion of revenue funding was provided to help the NHS prepare for winter and recover performance – though this was far less than the rumoured £10 billion NHS leaders had asked for. A further £3.7 billion was given to local authorities to support adult social care services during the pandemic, with another £600 million to support infection control in care homes.
This same month, data from the Office for National Statistics showed the UK’s stark and unenviable international position on Covid-19 death rates (see Figure 7), and the potential long-term toll of the first Covid-19 wave on the health and care workforce with 58 per cent of surveyed workers meeting the criteria for either anxiety, depression or post-traumatic stress disorder.
Updated polling data showed rising confidence in using NHS services, with 77 per cent of people saying they would be comfortable using a hospital (compared to 52 per cent in May). But the ‘third-phase letter’ outlining NHS England and NHS Improvement’s ambitions for how much activity NHS organisations should perform in the autumn received a mixed response, with one senior NHS manager describing the expectations as ‘mad’.
And the government announced which occupations would be eligible for a new fast-track Health and Care Visa, though concerns were raised that most frontline social care roles would be ineligible for the skilled-worker immigration route which would put pressure back on the government to improve pay and conditions and make these roles more attractive to domestic staff.
The Prime Minister was accused of trying to shift the blame for Covid-19 deaths onto care homes after saying ‘too many care homes didn't really follow the procedures in the way that they could have’. And the government announced a backdated 2.8 per cent pay uplift for doctors and dentists (though it would have to be paid from existing health budgets).
July also brought three national publications. The government published its obesity strategy, introduced by the Prime Minister talking about being overweight, which he would later link to his experience of Covid-19: ‘The reason I had such a nasty experience with the disease is that although I was superficially in the peak of health when I caught it I had a very common underlying condition. My friends, I was too fat.’ However, the strategy itself shied away from strong tax and regulation measures to promote healthier lifestyles and was described as more of a ‘minor skirmish than a war on obesity’.
This month saw the publication of the ‘Our people promise’, which describes what NHS people should expect from their leaders and from each other, and includes commitments to recognise and reward staff and have everyone’s voice count. This month, the government abolished Public Health England, with most staff finding out about their uncertain job status through a pre-briefed Sunday newspaper article. Dismantling the national public health agency in the middle of an epoch-defining pandemic led to concerns that Public Health England had been found guilty without a trial. A new National Institute for Health Protection is being created under the interim leadership of Baroness Harding, to bring together the health protection functions of Public Health England with the new NHS Test-and-Trace system and the Joint Biosecurity Centre.
This month, the government provided £300 million to help A&E departments expand waiting areas and reduce overcrowding ahead of winter; Jeremy Hunt, Chair of the Health and Social Care Select Committee, announced he would be giving the government CQC-style ratings on how well it delivered pledges on areas such as cancer, mental health and patient safety; the contact tracing app pilots on the Isle of Wight were relaunched using systems developed by Apple and Google that were already in use in several other countries; and the Accelerating Detection of Disease programme was launched to support the use of artificial intelligence in detecting and preventing disease.
August also saw a new funding package of £172 million for nurse apprenticeships announced – though strangely a week after (and not as part of) the NHS People Plan for 2020/21. The national block booking of private hospital capacity ended in London and some other parts of England. A survey by the Royal Society of Arts, Manufactures and Commerce (RSA) found that of all key workers, social care workers were the most concerned about their level of household debt and borrowing, and were the most likely to say that during the Covid-19 pandemic they had to borrow or go without food or heating.
And finally, data from NHS Digital showed how, as Sir Simon Stevens said, ‘the current generation, the previous generation and the next generation’ of clinical staff came together to support frontline services during Covid-19 (see Figure 8).
The beginning of autumn saw a worrying rise in the number of Covid-19 cases across the UK and the Prime Minister acknowledge that the Covid-19 national testing programme ‘has huge problems’.
This month the government also published its winter support plan for adult social care – including additional financial support to prevent outbreaks in care settings. One month before the General Medical Council’s national doctors in training survey found 74 per cent of medical trainees had experienced disruption to their formal training because of Covid-19, a deal was struck to allow junior NHS doctors to train in private sector hospitals. The National Audit Office assessed the government’s success in securing more ventilators for the NHS (though noting that having more ventilators also requires having enough skilled staff in place to use them).
In wider health policy news, the Migration Advisory Committee (MAC) recommended senior care workers and nursing assistants be added to the Shortage Occupancy List to relieve pressure when freedom of movement ends. The government would later respond to say none of the MAC recommendations would be taken forward immediately because the UK labour market is changing rapidly. A new report this month also argued that supporting greater autonomy and belonging could transform the experience of nurses and midwives. And the new National Genomic Healthcare Strategy was launched to set ambitions for how genomic medicine could improve diagnosis, treatment and prevention of disease.
And this month brought a trio of leadership-related news: a review of NHS boards found female representation on NHS boards rose to 45 per cent, though the report’s authors noted ‘there is much yet to do’ with representation ranging from 15 to 78 per cent across 213 NHS boards; national NHS arm’s length bodies made virtually no improvement in the numbers of ethnic minority staff in senior roles; and new-look HSJ lists of the most powerful people in health care and health policy saw George Orwell and Marcus Rashford take spots traditionally occupied by the Secretary of State for Health and Social Care and NHS England chief executive (see Figure 9).
October started with news that 16,000 Covid-19 cases had been unreported in England because of a spreadsheet error. The Prime Minister said he shared people’s frustrations with the NHS test-and-trace system. Baroness Harding, Executive Chair of Test and Trace, noted that a national programme the size of Asda’s food business had been built in only five months, but the programme remained dogged by criticism that it was overly centralised, slow to provide test results and trace contacts of people with Covid-19, and was having only a ‘marginal impact’ on the spread of the disease.
The rest of the month was marked by contentious debates – particularly between the government and Greater Manchester Mayor Andy Burnham – as regions England agreed or had lockdowns imposed to contain growing numbers of Covid-19 cases. And the month ended with England entering a national lockdown again.
October also saw the NHS announce new clinics to treat patients suffering from persistent symptoms of ‘long Covid’ and a new framework to allow the NHS to buy capacity in independent hospitals over the next four years. NHS England and NHS Improvement published a riposte to allegations that intensive care had been rationed during the first wave of the pandemic, and a report by National Voices on how people experienced shielding described the sobering reality of feeling ‘unheard, stuck and helpless’.
Because of the uncertain economic environment, the autumn Budget was cancelled and the planned Comprehensive Spending Review that was intended to set budgets for the rest of this parliament became a one-year spending round to set budgets for 2021/22 alone.
And over the course of this month the Health and Social Care Select Committee called for an extra £7 billion a year to prevent the social care system collapsing and the CQC State of Care annual report said 'Failure to find a consensus for a future funding model continues to drive instability' in social care. All this coming just one month after a health minister observed, ‘I cannot commit to a social care plan before the end of the year,’ and in a month where the Prime Minister promised to ‘fix the injustice of care home funding, bringing the magic of averages to the rescue of millions’.
Finally, the NHS set an ambition to become the world’s first carbon net-zero national health system; figures from NHS Digital showed detention rates under the Mental Health Act in 2019/20 were four times higher for Black or Black British people compared to white people; the digital-first provider GP at Hand took a step closer to becoming England’s largest GP practice; and the Secretary of State for Health and Social Care announced a ‘new blueprint for better hospital food’ following a review by restauranteur Prue Leith (the 22nd initiative to improve hospital food since 1992 by some counts). Although hospital food has moved on from the days of fish custard and spleen pulp being served, reports continue to show that patients want hospital food to be fresher and healthier (see Figure 10).
This month saw parliament’s Public Accounts Committee publish a report into digital transformation in the NHS. While recognising the increased role health technology has played during Covid-19, the committee said it remained ‘far from convinced that the Department and NHS bodies have learned the lessons from previous IT programmes’. This came just as news broke that McKinsey had been asked to review national leadership of technology in the NHS that would potentially lead to a new ‘NHS transformation taskforce’ to sit alongside NHSX and NHS Digital.
Speaking of new bodies, two NHS trusts in Somerset unveiled merger plans that would create the first public provider of primary, acute, community and mental health services. And a day after publishing its annual assessment of clinical commissioning group (CCG) performance that saw two-thirds of CCGs rated as good or outstanding, NHS England and NHS Improvement published proposals to effectively abolish CCGs, establish more formal collaborations between NHS providers, and put integrated care systems (ICSs) on a statutory footing by April 2022 – foreshadowing the first major NHS legislation since the much maligned Health and Social Care Act 2012. Though with sentences like this, you couldn’t help but think more work will be needed to clarify just exactly where power lies in this new regime: ‘ICS leaders, working with provider collaboratives, must have the freedom – and indeed the duty – to distribute those resources in line with national rules.’
Croydon Council issued a Section 114 notice because it would not balance its books in 2020. This was reportedly only the second time in 20 years a council had issued a Section 114 notice – providing a sharp contrast with the annual deficits that are more frequently reported in NHS organisations. A Radio 4 study found one quarter of UK home care providers were at risk of closure and a survey by ADASS found nearly a quarter of directors of adult social services had no confidence that their budgets would be enough to cover their statutory duties in 2020/21.
This month, Alan Mak MP introduced a bill to propose a new ‘NHS reserves’ system (similar to the Territorial Army and RNLI lifeboat crews). And the Secretary of State for Health and Social Care Matt Hancock announced the latest strategy to bust bureaucracy on the NHS front line, noting in his speech ‘You might be thinking: Matt, I’ve heard this all before.’
November also brought the autumn Spending Review to set most government spending for 2021/22. The absence of a multi-annual funding for health and care staffing plans, public health services and adult social care reform were notable in a Spending Review that did provide multi-year settlements for defence and confirm the tremendous rise in the Department of Health and Social Care’s budget as a result of Covid-19 (see Figure 11).
Turning to Covid-19, mass testing of the population began in Liverpool; homecare workers were finally included in government’s routine testing programme; the National Audit Office published two reports into the government’s procurement of PPE and other essential Covid-19 supplies, which suggested the government had been dealt a very difficult hand but could have acted more effectively; and new government data showed people with learning disabilities in England had death rates up to six times higher than the general population in the first wave of Covid-19.
But the biggest news of the month was the result of Covid-19 vaccine trials. The unexpectedly high effectiveness of these new vaccines – some of which were developed using the new mRNA approach – changed the question from when or if a vaccine could be developed, to the complex but altogether more welcome questions of regulating, producing and delivering the vaccines to health and care staff and the wider population.
For more detail, click on the large circles to see the proportion of core funding compared to Covid-19 funding for each government department.
December (up to 15 December)
After the Medicines and Healthcare products Regulatory Agency (MHRA) reviewed the safety and effectiveness of the Pfizer-BioNTech vaccine, the UK became the first Western country to approve a Covid-19 vaccine for use in the general population. On ‘V-day’, Margaret Keenan became the first person in the world to be given this vaccine outside of a clinical trial and the Secretary of State for Health and Social Care appeared moved to tears by the sight of more patients being vaccinated.
The start of the vaccine roll-out was not without some controversy. There was some uncertainty over whether care home staff and residents, health care staff or vulnerable patients would be at the front of the queue for the vaccine; a senior GP warned the vaccine programme could become ‘a dog’s breakfast’ if local and national IT programmes for booking vaccination appointments did not talk to each other; and concerns were raised over how a potential ‘infodemic’ of misinformation might affect take-up of Covid-19 vaccines.
This month the Prime Minister headed to Brussels for crisis Brexit talks as prospects of a no-deal exit rapidly increased. Some Cabinet ministered appeared to link the approval of the Covid-19 vaccine and Brexit, suggesting the UK’s ability to approve the vaccine more quickly was a result of Brexit (and being ‘a much better country’). However, June Raine, head of the MHRA, observed that the Pfizer-BioNTech vaccine – which was developed by a US-German partnership – was authorised under the existing provisions of European law.
In other news this month, Deborah Sturdy was appointed as the first Chief Nurse for Adult Social Care; and the emerging findings from an independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust detailed shocking failings of care for mothers and babies.
And a leaked report suggested two-thirds of the private sector capacity the NHS had block-booked at the height of the pandemic went unused. Waiting times for planned elective care in England were already worsening before Covid-19, and the impact of the pandemic saw these waiting times slip back to levels last seen more than a decade ago (see Figure 12).
Improving waiting times for care, together with everything from preventing staff burnout to ‘fixing social care’, are among the issues of 2020 that will roll into 2021. We can only hope that the coming year will also see Covid-19 resigned to the rear-view mirror – even if the impact it has had on staff, patients and the public will be felt for years to come.