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The new government arrived in office on 13 December 2019 with the health and care system facing significant and persistent challenges, many of which the government committed to addressing in its manifesto.
However, these challenges have been dwarfed by the Covid-19 (coronavirus) outbreak, which has emerged as the biggest public health emergency and most significant challenge to health and care services since the NHS was established. How the government responds to the outbreak will define its first few months in office and will have an impact that goes way beyond this period.
The time will come for an analysis of the impact of the outbreak and the response to it. However, at some stage in the months ahead, the country will return to something approaching normality. We therefore thought it would be useful to provide a record of the progress made towards meeting the government’s manifesto pledges and campaign commitments during its first 100 days in office.
NHS funding, capital investment and hospital building
What the manifesto promised
The Conservative Party manifesto pledged to increase the revenue budget for the NHS by £33.9 billion in cash terms by 2023/24 – in real terms this would be equivalent to the £20.5 billion increase pledged by the then Prime Minister, Theresa May, in June 2018. There was also a pledge to enshrine this commitment in law within the first three months of forming a government.
On capital investment, the manifesto pledged that 40 new hospitals would be built over the next decade, building on commitments to increase capital spending and upgrade hospitals announced in August 2019. It also pledged additional revenue and capital funding for hospital car parking, as well as investment in equipment to improve cancer diagnosis.
What has happened in the first 100 days?
The NHS Funding Bill to enshrine the 2018 revenue funding settlement in legislation was introduced to parliament on 15 January and has already been given Royal Assent, meeting the manifesto commitment for this to be on the Statute Book within three months. In the March Budget an additional £6 billion in NHS funding was announced, of which £5.4 billion is new revenue funding to help meet the government’s manifesto commitments. It is unclear from the Budget documents how this money will be distributed. The remainder, £683 million, is an increase to the Department of Health and Social Care’s capital budget to be spent on maintaining NHS buildings and vital equipment.
On the new hospital building commitments, the Budget confirmed the funding already announced for 2020/21 to help the NHS draw up plans to build 40 new hospitals.
The Budget also committed to investing in diagnostic equipment to improve cancer survival rates, with the second £100 million instalment of the two-year cancer screening equipment fund confirmed for 2020/21. To support public services in responding to the outbreak of Covid-19, the Chancellor announced a support package of £5 billion, covering the NHS and local authority services such as public health and social care. In doing so, he pledged that the NHS would be given ‘whatever it needs’ to deal with the outbreak.
What this means
The five-year funding deal for the NHS provides welcome relief after the longest sustained funding squeeze in its history. However, this deal does not extend to important areas of health spending, including education and training for staff, and leaves the NHS short of the resources it needs to both restore performance against key waiting times standards and transform services to deliver better care.
While the new government has been quick to address the urgent need for new capital investment, the level of funding announced does not yet come close to addressing the scale of the maintenance backlog in NHS buildings, much of which is critical and is putting staff and patients at risk. A substantial multi-year capital funding settlement is needed in the forthcoming Spending Review to address this.
The government has clearly recognised the enormity of the challenge facing health and care services as they respond to the Covid-19 outbreak. However, once the pandemic subsides, the government will need to return to addressing the challenges caused by years of under-funding.
Primary care access and workforce
What the manifesto promised
Access to general practice emerged as a headline issue during the campaign, and the Conservative Party manifesto pledged to resolve the issue by making 50 million more appointments available per year in GP surgeries by 2024/25. This is underpinned by a target to recruit and retain 6,000 more doctors and trainees alongside 6,000 more primary care professionals, such as physiotherapists and pharmacists.
What has happened in the first 100 days?
In January, a wide-ranging new GP contract was agreed that will implement the commitments in the NHS long-term plan and deliver the government’s manifesto pledges. This followed challenging negotiations that centred on a major disagreement about what GPs could be expected to deliver. The new contract includes a commitment to increase the number of new staff to 26,000 by 2023/24 and a range of measures to improve the recruitment and retention of GPs. It also sets out specifications for services that primary care networks (PCNs) will be expected to deliver, starting with enhanced health in care homes, structured medication reviews and early cancer diagnosis.
To support the delivery of these services, new funding totalling £1.4 billion by 2023/24 is attached to the contract. The contract is clear that this new money should increase access to services and help meet the government’s target of 50 million more appointments.
NHS England has suspended a number of activities, including some of the requirements in the GP contract that PCNs were expected to deliver, to free up capacity in primary care to respond to the Covid-19 pandemic.
What this means
The government has moved quickly to shore up primary care. PCNs are critical to delivering the ambitions in the NHS long-term plan, so the new GP contract is a significant step forward. General practice has been under huge strain, so we welcome the emphasis on recruiting new staff and recruiting and retaining GPs. However, delivering on these ambitions will be challenging; PCNs are still relatively new, and even if they can meet the ambitious targets around recruitment and retention, new roles and teams will need time and support before they can make a difference on the ground. First of all, however, primary care will need to respond to the Covid-19 outbreak. This is likely to leave a lasting legacy, for example, in moving to deliver more appointments online.
The NHS workforce
What the manifesto promised
Following on from commitments set out in the Interim NHS people plan, published in June 2019, the Conservative Party manifesto set out a range of commitments to grow and support the NHS workforce. These included a headline pledge for 50,000 more nurses to be working in the NHS by 2024/25, a new maintenance grant of between £5,000 and £8,000 for nursing students, more funding for professional training and supportive hospital management, and a fast-track visa scheme for foreign doctors, nurses and allied health professionals. There was also a commitment to address the pensions problem which has seen many senior doctors incur significant tax liabilities for working extra shifts.
First 100 days activity
Within a week of taking office, the government announced that the new nursing maintenance grant will be available to all new and continuing degree-level nursing, midwifery and allied health students from September 2020. All eligible students will receive a minimum grant of £5,000 a year, with students in disciplines that are particularly difficult to recruit to, such as mental health, entitled to additional funding of up to £3,000 a year.
The March Budget reiterated the government’s commitment to a significant funding package to improve the recruitment, training and retention of nurses, with an undisclosed amount of the £5.4 billion in new revenue funding allocated to support this. The Budget also announced changes to tax rules to address the pension problems faced by senior doctors.
The United Kingdom’s future immigration policy will also have a significant impact on the NHS workforce and in February 2020, a policy statement set out the government’s proposals for a points-based immigration system after the European Union exit transition phase comes to a close at the end of the year. Under the new proposals, a salary threshold of £25,600 will apply to migrant workers applying to work in the United Kingdom. However, nurses and other health care professionals are currently designated as shortage occupations by the Migration Advisory Committee, and as such are exempt from these rules. Under the current proposals, the Immigration Health Surcharge, which is levied on visa applicants, will be extended to citizens in the European Economic Area, including those coming to work in the NHS, and will increase to £624 per person.
The Covid-19 outbreak is placing new challenges on the health and care workforce. A drive to get thousands of former doctors and nurses to return to the NHS workforce has been launched, while legislation is being taken forward to allow third-year nursing and midwifery students to fill frontline clinical roles for the duration of the pandemic. The response has also led to the publication of the full NHS People Plan, originally due in April 2019, being postponed until later in the year.
What this means
Staffing is the make or break issue for the NHS in England, with the existing workforce under enormous strain as services struggle to recruit, train and retain enough staff. In the short term, the immediate workforce shortfall is so severe that it can only realistically be managed by recruiting staff from overseas, including ethically recruiting 5,000 nurses a year. This cannot be achieved without a supportive immigration policy. While the designation of nurses and other health care professionals as shortage occupations is welcome, the failure to exempt applicants from the Immigration Health Surcharge creates an unnecessary barrier to recruitment.
In the long term, more staff will need to be trained domestically. The much-delayed NHS People Plan should set out how the NHS will become a better employer, for example, by tackling bullying and discrimination, providing a more attractive employment offer and developing compassionate and inclusive working cultures. Any strategy for shoring up the NHS workforce cannot be viewed in isolation from the need to invest in and support the wider health and care workforce, including people working in social care and in voluntary and community sector organisations. In the meantime, the Covid-19 outbreak will test the health and care workforce to the limit. However, we have also seen thousands of recent leavers respond positively to the government’s request for staff to re-join the health service to support its response to Covid-19, and the outbreak may itself bring about new ways of working in health and care at a pace few would previously have believed possible.
Adult social care
What the manifesto promised
To resolve the crisis in adult social care, the Conservative Party put forward a three-point plan: to invest an additional £1 billion a year in funding from April 2020; to pursue a cross-party consensus on long-term reform; and to guarantee that no one would have to sell their home to pay for social care. In a separate campaign pledge, the Conservative Party said that the cross-party talks would begin within the first 100 days of it forming a government.
What has happened in the first 100 days?
Social care services have continued to show signs of significant strain, and in February one of the largest providers of domiciliary care announced that it is leaving the home care market. These strains will be exacerbated by a 6.2 per cent increase in the National Living Wage, which will come into force from April.
The additional funding promised in the government’s manifesto was confirmed in the local government finance settlement for 2020/21. This consists of £1 billion in grant funding for children’s and adult services. Individual local authorities will decide how this money is divided, though in previous years the split has been approximately even. A proposed 2 per cent Council Tax precept could raise a further £500 million for adult services if implemented by all local authorities in England.
In early March, Secretary of State for Health and Social Care, Matt Hancock, wrote to parliamentarians to initiate cross-party discussions on social care reform. The letter set out a two-stage process, with MPs and peers first invited to outline their views and ‘structured talks’ to follow in May.
£2.9 billion of the funding made available in the Budget for public services to respond to the Covid-19 outbreak will be used to strengthen social care services and reduce pressure on hospitals. £1.6 billion of this funding will be provided to local authorities to respond to pressures on their services, with a further £1.3 billion used to speed up the discharge of patients from hospital.
What this means
Although social care services will be able to draw on the £5 billion Covid-19 response fund, the absence from the Budget of additional emergency funding for social care was disappointing. Once the current Covid-19 pandemic has passed, the challenges facing social care will be more pressing than ever.
Like the health service, social care is reliant on international recruitment, especially in London and the South East. With more than 120,000 vacancies, the sector is as much in need of a comprehensive workforce plan as the NHS. In the absence of any measures to boost the social care workforce in the government’s immigration proposals, the sector would need to significantly improve pay and conditions to attract more home-grown staff, something it cannot do without additional funding.
It is disappointing that, in seeking the views of parliamentarians, the government has not come forward with any credible and meaningful proposals for discussion. While cross-party support is important to ensure a sustainable long-term solution, the scale of the government’s majority provides an opportunity for it to lead the reform process. However, the emergence of Covid-19 as a priority for the government to manage means that the chances of significant progress on this issue, at least in the short term, are slim. As we emerge from Covid-19, it will be vital for the government to act quickly to ensure the short-term financial viability of the existing social care system, as well as urgently progressing the process for agreeing and enacting broader reforms.
Health inequalities, prevention and public health
Context
Recent years have seen life expectancies stall and health inequalities widen. To address these trends the Conservative Party manifesto pledged to extend healthy life expectancy by five years by 2035. There were commitments to ’invest in preventing disease as well as curing it’, reduce health inequalities and tackle the underlying causes of growing demand for health services, for example, by ‘empowering people with lifestyle-related conditions such as obesity to live healthier lives’.
What has happened in the first 100 days?
Secretary of State for Health and Social Care, Matt Hancock, used his first post-election speech to reaffirm prevention as one of his four key priorities, pledging to ‘re-double efforts’ to make the United Kingdom smoke-free, reduce obesity and ‘embed a more proactive, predictive and personalised approach across the NHS’.
Building on this, the NHS Operational Planning and Contracting Guidance published in January 2020 set out what the NHS is expected to do in 2020/21 at a local level to improve public health. This includes specific targets like supporting 25,000 people to lose weight via the Diabetes Prevention Programme, as well as expanding alcohol-care teams and stop-smoking services in inpatient settings.
The public health grant allocations, which should have been made last year, were not released until 17 March 2020, just two weeks before the start of the new financial year. In 2020/21 the grant will be 2.6 per cent greater in real terms compared to last year. Meanwhile, a report on life expectancy from the All Party Parliamentary Group for Longevity along with an update to the landmark Marmot Review have highlighted the scale of the challenge in improving the population’s health.
As the biggest public health emergency the country has faced since the Second Word War, Covid-19 has overshadowed all of this.
What this means
Funding cuts in recent years have led to reductions in public health services, putting people at risk of poorer health and storing up problems for the future. Although the government’s commitment to increasing the public health grant in real terms is welcome, the increase for 2020/21 barely makes a dent in the £1 billion needed to restore spending to the same level as 2015/16. What is more the money comes with significant new duties for local authorities. While the long delay in confirming local authority grant allocations will have affected their ability to commission services for the coming year.
Once the crisis caused by the Covid-19 outbreak has passed, public health needs the certainty of a long-term funding settlement and should be a priority in the forthcoming Spending Review. This should be accompanied by a much stronger focus on improving population health that goes beyond the NHS and public health system to focus on the wider determinants of health and the role of people and communities. Full use should be made of all the levers available to policy-makers, including a bolder approach to using tax and regulation, learning from successful interventions such as the Soft Drinks Industry Levy. The government’s focus on ‘levelling up’ provides an opportunity to address the gap in life expectancy between rich and poor areas – this requires a cross-government strategy to address health inequalities.
Mental health
Context
Mental health services have received greater priority and attention in recent years. The Conservative Party manifesto committed to continue this by treating mental health ‘with the same urgency’ as physical health. It also promised to legislate in response to the findings of the review of the Mental Health Act commissioned by the previous Prime Minister, Theresa May, in response to the rising rates of detention and the disproportionate number of people from black and minority ethnic groups detained under the Act.
What has happened in the first 100 days?
The Queen’s Speech confirmed the government’s commitment to act on the recommendations made in the review of the Mental Health Act by publishing a White Paper and a Bill to reform the law in this area.
What this means
We welcome the government’s commitment to modernising and reforming the Mental Health Act. Although progress has been made, there is still a long way to go to achieve parity of esteem and people with mental health problems continue to face inequalities in quality and outcomes of care. Progress will only be made if sufficient numbers of suitably qualified and skilled staff are available; action is needed to address major workforce shortages by recruiting, training and retaining more staff, especially mental health nurses.
Conclusion
Given the impact of Covid-19 on individuals and families, the economy and public services, delivering on manifesto commitments will rightly take a step back while the focus is on responding to the outbreak. Once the current crisis is over, the government will need to return to the familiar task of improving health and care, as well as learning the lessons from one of the greatest peacetime challenges the country has ever faced.
The Conservative Party manifesto made the NHS a key priority. It is, of course, far too early to say whether the government is on track to deliver on its commitments. However, the first 100 days have shown ministers willing to invest the financial and political capital to begin to make good on some of their headline promises to the NHS.
On social care, the government has taken minimal steps to start the process of cross-party talks to find consensus. While this technically meets its manifesto commitment, the lack of direction or clear proposals for reform is disappointing. In the short term, responding to Covid-19 must be the government’s priority, but as we emerge from this outbreak it is vital that the government acts quickly to ensure the short-term financial viability of the social care system, as well as urgently progressing the process for agreeing and enacting broader reforms.