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Health and care in 2021: what can we expect?


New Year’s Day 2021 finds the NHS, social care, public health and indeed the whole country even deeper in the Covid-19 crisis that began in March, now made massively more challenging by the new strain of Covid. This is true across health and care, whether its hospital staff struggling to provide care to the seriously ill (whether Covid-related or not), or primary care staff (in particular) aiming to pull off the country’s biggest mass vaccination in history. Of course, it is also a crisis for patients, service users and the public, with many struggling with disruption, economic hardship or mental health challenges.

Yet as severe as the crisis is right now, the vaccination programme offers hope that the worst will soon begin to recede even if the wider impact of the virus will be felt for a long time yet. Hard as it may be to look beyond the challenges of January and February, what may the rest of 2021 hold for health and care?

It’s not as if it was all plain sailing at the start of 2020. Deep workforce shortages, rising waiting times, and persistent inequalities were all present and of great concern. Added to that was a fear that the money on offer wasn’t enough to pay for everything politicians wanted and that the thorny nettle of social care reform might get dropped once more. Covid-19 has only magnified these concerns and added a few of its own.

Getting ahead of rising demand will need a medium- to long-term solution... setting a pragmatic trajectory over years rather than months.

Backlogs and interruptions to health and care have surged in 2020. While attention has so far focused on rising waiting times for hospital and diagnostics there will also have been major implications for ongoing care in the community for mental health and other long-term conditions and assessments for social care support. Yet the NHS was facing severe workforce shortages and was struggling to keep the lid on raising waits before Covid-19 struck. That same workforce (as well as those in social care) has been exhausted through the pandemic and will not be able to work even harder, for even longer, to push down on waiting times at speed. Getting ahead of rising demand will need a medium- to long-term solution (just as reducing waiting times did in the 2000s), setting a pragmatic trajectory over years rather than months. It will need to move in tandem with the availability of the workforce, which in turn will need government to complete the work of the NHS People Plan to pull all and any national levers to raise supply and re-design work. To state the obvious, it will also need paying for.

Covid-19 also shone a painful spotlight on inequalities. For many working in health and care making progress on reducing these inequities now feels essential and urgent. For a government that committed to a levelling up agenda only a year ago, failing to live up to its promises carries a clear political risk given both the worsened economic context and the experiences of the pandemic.

On a positive note, Covid-19 has also accelerated the strategic shift toward integrated services both within the NHS and with key partners in local government and the voluntary sector. NHS England and NHS Improvement have set out how they see this new drive toward integrated services focusing on population health and the associated changes to legislation. We’ve already set out our initial views on these changes, including on the legislative options. We need to remember that the current context for reform is fundamentally different to anything we have seen for a generation: the reforms of the 2000s took place against a backdrop of historically high and sustained growth in expenditure (and staff). Even the 2012 Act changes happened while the NHS was in financial surplus, waiting times low and stable and the workforce crisis yet to emerge (in the main). 2021 could hardly be more different.

Will the drive toward integration, system-working at place and in integrated care systems be sustained? Or will it – under the day-to-day challenges of managing the money, staff and backlog – simply turn out to be the spirit of the Blitz, evaporating as 2021 progresses and the immediate pressures of Covid subside? I think it is all to play for: many people we speak to in the system do think the experience of Covid-19 has accelerated better collaboration and integration (though recognising it will need time and commitment to maintain and enhance this way of working). National regulators do seem to recognise that aggressive, organisation-by-organisation performance management is not the way to encourage system-working. To deliver these changes we will also need a more inclusive and compassionate leadership style and culture. But it is exactly this leadership style and culture that can also help health and care overcome the long-standing weaknesses in diversity and treatment of staff from ethnic minority backgrounds, as well as create a more positive working environment in general that will encourage staff to join and stay in work.

To deliver these changes we will also need a more inclusive and compassionate leadership style and culture.

Though tackling the backlog, reducing inequalities and delivering on service change will involve leaders and staff throughout health and care, there are also a few things only Whitehall can do. One of course is providing the money. Another will be the plan for public health, remembering we are yet to see how government intends to replace Public Health England after its abolition was announced earlier in the year.

There is one further area many of us also hope government will also soon set out its stall. Covid-19 painfully revealed many of the long-standing weaknesses in social care, and perhaps more than ever before the pandemic has brought social care, its users and staff into the public eye. This could form the springboard into the fundamental reform social care so desperately needs and allow the government to fulfil its commitment to ‘fix’ social care where so many before have failed. What a result it would be to be able to write on New Year’s Day 2022 congratulating the government on finally sorting out social care. One can hope.