Many of the uncertainties that made 2019 so exciting or stressful (depending on your point of view) have been resolved. We have a secure – dare I say, strong and stable – government with a clear majority in parliament. For the most part, NHS funding for the next few years is clear and the associated long-term plan remains the focus for the NHS. So what is there left to look out for in 2020?
The early months of the year will see some important stakes in the ground. First, it’s hard to understate the importance of the long-awaited People Plan, key as it is to confronting the current workforce crisis in health (but not social care, unfortunately). The same timeframe will see whether we keep Matt Hancock as Secretary of State for Health and Social Care in the upcoming reshuffle. Shortly after the Budget we may have clarity on the budgets excluded from the Conservative’s spending pledge – ie, the budgets for capital, workforce training and public health. While such clarity would normally come later in the year as part of the Spending Review, given some of the most eye-catching Conservative commitments (50,000 extra nurses; a capital building programme) rely on these other budgets, we may get some certainty sooner rather than later. NHS England’s proposals for legislation to help integration and joint working were also noted in the Queen’s Speech, even if this fell short of a specific commitment to simply passing them.
The chances of fundamental reform are arguably rather better now that one party has a commanding majority to put forward definitive proposals and push through legislation.
The same busy early months should reveal how the government intends to organise cross-party talks on the long-term reform of social care. This will be no mean feat as Labour and the Liberal Democrats appoint new leaders and simultaneously try to learn the lessons of their recent defeat. Perhaps fortunately, given these complexities, the chances of fundamental reform are arguably rather better now that one party has a commanding majority to put forward definitive proposals and push through legislation. Matt Hancock has already stated that prevention is one of his top priorities and we are due a response to the consultation on the prevention Green Paper, even if this process was set off under a different Prime Minister.
So lots to look for in the early months, perhaps as we would expect given the sea change in the political dynamics. However, there are two other things at play that could determine the path of health, the NHS, and social care this year and in the years to come. The first of these is, to state the blindingly obvious, that most of the progress on sorting the workforce crisis, stabilising performance and finance, and developing new ways of working that release the potential of system working on population health (I could go on) lies at local level. This is both an enduring (but often overlooked) fact of life, but also never truer than now, as local leaders – of the NHS, local government, patients, the voluntary, community and social enterprise sector and others – must find a way to work together and will need to do so without a detailed route map from the centre. Finding ways to share best practice and learn from each other will surely help everyone make progress, whether on how to improve staff morale and retention, or how to work across sectors to focus on health inequalities. For those wanting to understand the future, keeping an eye on Wigan rather than Westminster may hold the key. Again, in his first post-election speech, Matt Hancock did underline the government’s support for this broader integration and population health agenda.
Finding ways to share best practice and learn from each other will surely help everyone make progress.
But I said two things were important. At the opposite end of the spectrum (and, I accept, possibly working in the other direction, after I have emphasised the importance of local self-determination), there has been an important change in the political context. The government has fought the general election with the NHS at its centre. The day after the result, speaking outside No 10, the Prime Minister repeated not only the specific commitments made on the NHS but also the broader goal of being a ‘one nation’ government, perhaps made even more important by his very success in the Midlands and the north of England. These are all commitments the government has backed with more money than the NHS has seen since 2010 (measured in real terms growth) and with more coming to pay for the additional commitments in its manifesto. That the government means business was quickly underlined when within a week of winning the election, Matt Hancock delivered on the commitment to new maintenance grants for nurses, getting the announcement out before the closing date for students looking to start in 2020.
This focus on the NHS is likely to bring a renewed degree of scrutiny from the centre and may spark fears in many minds of a redoubled round of aggressive micro-management. Yet while there is such a risk of reverting to type, this is far from a certainty. There is a big difference between aggressive performance management and genuinely holding the system to account. After all, the recent years have already seen a lot of such aggressive performance management (just largely not from the Department of Health and Social Care), but management that frankly, does not seem to have borne much fruit. We expect the imminent NHS People Plan will make clear that to make progress a change of culture and approach is necessary, moving toward a more collective and inclusive style that focuses on supporting staff. After all, it was the Conservative manifesto that committed to improving staff morale by more supportive management, a statement that again, in his first speech, Matt Hancock expanded to cover a more positive, compassionate leadership and culture. Let’s hope reality follows the rhetoric.