NHS England throws down challenge to government

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The government’s Budget delivered more new funding for the NHS than many observers had expected but far less than needed to avoid further restrictions on services. At its recent board meeting, NHS England discussed the implications of the Budget and considered a paper that started from the premise that 'with its 2018/19 Budget the NHS will likely not be able to do everything being expected of it. This will therefore require realism and some difficult judgements about priorities.'

NHS England’s view is that commissioner and provider deficits should be the first call on the additional £1.6 billion revenue funding for 2018/19 announced in the Budget, followed by planned investment in mental health, cancer, and primary care. Beyond that, the paper presented to its board argued that new advisory NICE guidelines could be implemented if accompanied by a clear affordability and workforce assessment, but waiting time standards in the NHS constitution would not be fully funded or met in 2018/19.

The health secretary, Jeremy Hunt, responded by saying he was absolutely committed to these standards, while leaving open the question of when they could be achieved. Negotiations between the Department of Health and NHS England over the NHS mandate for 2018/19, the document that sets priorities for the NHS, will determine how these differences are resolved, assuming they can be.

The main point of contention will be the government's expectation that the NHS should use most of the additional resources provided in the Budget next year to meet the NHS constitution standard that 92 per cent of patients waiting for non-urgent care are treated within 18 weeks. The number of people waiting for non-urgent care has grown to 4.1 million. This growth, and the likelihood of operations being postponed as emergency care takes priority during this winter, make it inconceivable that the standard can be delivered during 2018/19, even if the NHS pays for thousands of patients to be treated in private hospitals.

Prioritisation

Although NHS England seems to have put itself on a collision course with the Department of Health, the reality is more nuanced. Hunt has played his part in seeking more funding for the NHS and acknowledges publicly the challenges it faces. The real fault line is between NHS England and the Department of Health on the one hand, and the Treasury and No 10 on the other, at a time when those at the heart of government are preoccupied with Brexit and convinced that more can be done to increase NHS efficiency.

The stance taken by NHS England on what the NHS can provide with its funding will serve a useful purpose if it forces politicians to be honest with the public that not everything can be done within an increasingly constrained budget. The difficulty will be to secure agreement on the services to be given lower priority beyond the limited list of medicines and interventions of low value that are routinely considered when rationing decisions come to the fore.

A good starting point would be to act on studies that show there is plenty of scope to release resources by reducing overtreatment, tackling waste, reducing unwarranted variations in care, and reflecting patient preferences in decision making. The challenge is the time it takes to make these changes, which in any case are unlikely to be sufficient to bridge the growing gap between the need for care and the supply of resources.

View to the future

Taking the longer view, debate about what the NHS can realistically provide will lay the groundwork for the government’s next spending review. No government would wish to approach a general election with NHS standards deteriorating, making it likely that further resources will be found to reassure the public that the NHS is in safe hands. Much will depend on the state of the public finances at the time and the willingness of the government to give priority to the claims of the NHS over other public services, as happened in the recent Budget.

Much will also depend on how the NHS uses the additional funding it has been allocated. The boss of NHS England, Simon Stevens, has raised the stakes in his public warnings on the prospects for the NHS, to the obvious irritation of some in the government. Stevens will want to show that the changes outlined in the NHS five year forward view are moderating demand for care and improving outcomes. The challenges he faces are at least as great as those confronting the government.

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