Four critical NHS issues that could keep Jeremy Hunt awake at night

Is the NHS ‘a wretched bowl of alphabetti spaghetti’, as David Cameron put it? James, CC BY

The NHS has faced numerous struggles in its 66-year history, from the financial crisis of the late 1980s, which prompted the Thatcher Review and led to the introduction of the NHS internal market in 1991, to the more recent Lansley reforms and the debacle of the 2012 Health and Social Care Act.

But surely none will compare with the challenges over the next five years. These include:

1. More reconfiguration of services

In a health system funded out of general taxation, it is important that politicians are held accountable to the public for the £115 billion NHS budget. Promises or pledges of up to £8 billion (equivalent to a funding increase of 1.1% a year) have been in response to a £30 billion shortfall by 2020, identified by NHS England in 2014. The “missing” £22 billion is supposed to come from productivity improvements and cost savings.

To achieve this, significant reconfiguration of services will be required. Although the Conservatives promised not to introduce a “top-down re-organisation” in 2010, the Health and Social Care Act introduced two years later resulted in the biggest ever NHS reorganisation (costing about £3 billion), implemented at the same time as financial cuts (for example, 35% of management costs).

The debacle of the 2012 act is salutary for all parties. But the absence of pledges of further reorganisation in 2015 may also be explained by other factors. First, staff workloads have increased, pay has been constrained, morale has declined, and “reform fatigue” is endemic. The consequences of these and other factors are being felt in the A&E crisis, longer waiting times, and poorer patient experience.

2. Further devolution of health budgets

Developments on the ground have often been moving ahead of the political debate. For example, NHS England’s Five Year Forward View, published in autumn 2014, presented new models for the future organisation of primary and secondary care services, which have been broadly accepted. Also, proposals to integrate health and social care in Manchester, announced rather hastily earlier this year, have prompted much debate elsewhere in the country.

It remains to be seen whether this “Devo Manc” model will work and whether its governance model is robust. Whether or not it is feasible, further integration of health and social care is desirable, not least because cuts in social care have knock-on consequences in the health sector.

3. Competition vs integration

The use of competition and the private sector in NHS service provision has long been contentious. The latest model of NHS commissioning – the Clinical Commissioning Groups (CCGs), a product of the 2012 act – sought to put GPs in charge of the majority of the NHS budget on the assumption that they were best placed to know the needs of their patients. However, only a minority of GPs were involved in CCG decision-making, and this clinical engagement seems to be waning. With challenging decisions ahead, the weak public accountability of CCGs may become exposed.

However privatisation is defined, the involvement of the private sector in delivering health services has increased in recent years, and the potential for further incursions in the future remains. The Labour Party and others have expressed their opposition to further growth of the private sector in the NHS, although its record in office from 1997 to 2010 did foster private companies.

Significantly, the public seem to be more relaxed about private providers delivering health services, as long as services remain free at the point of delivery. Given markets’ propensity for fragmentation, it will be challenging to continue with competition while also promoting integration. Also, it is significant that alternative organisational forms (such as social enterprises or mutuals) have been largely absent from the current debate.

4. Public and health inequality

What’s local government got to do with it? Fabio Venni, CC BY-SA

Focus of debate on health services has largely overshadowed discussion about public health and health inequalities. Although the previous coalition government adopted a voluntary system of regulation – so-called Responsibility Deals – between the government and the food and drink industry, they did transfer public health functions from the NHS to local government. This means that the end of ring-fenced public health funds in local authorities in 2016 will present a challenge to keep public health on the agenda in the face of cutbacks elsewhere in local government.

Promises now made

The impact of these challenges on public expectations of the NHS remains uncertain. Despite current high levels of public satisfaction with the NHS, how will the public react to politicians’ pledges of extra funding if services do not appear to improve in the coming years? Individuals’ own experiences of the NHS have traditionally been positive despite being concerned about the overall system. With such a challenging environment from now until 2020 (and beyond), will the public still subscribe to the notion of a publicly funded health service by the next election? Possibly – but it’s not guaranteed.

So, the NHS will face unprecedented challenges over the next five years. And it is certain that Jeremy Hunt, who keeps his brief as secretary of state for health, will have a full agenda.