The end of a parliament is an opportune time to take stock of the state of health and social care. Policy here consists of meeting perennial challenges of maintaining access to services, improving quality of those services, and keeping costs under control.
Balancing this so-called "triple aim" is a familiar challenge for all governments, but what have been the defining features of the coalition government’s term of office? Can we discern a pattern which will have implications for the next parliament after the general election in May?
We’ve identified five “critical moments” between 2010 and 2015 which have shaped the course of the NHS and are likely to have impacts into the future.
The coalition agreement promised to "stop top-down re-organisations of the NHS" but the reforms introduced by Andrew Lansley, who was secretary of state for health until September 2012, were described as so big they could be seen from space.
The reforms proved costly – politically and financially – and were a distraction when attention might have been focused on maintaining access and quality as financial constraints were applied. Even laudable goals of clinical engagement, for example the clinical commissioning groups that put budgetary decisions in the hands of doctors, now seem to be waning.
As with other NHS scandals, the name Mid-Staffs has come to refer not only to the poor standard of care at the Mid-Staffordshire NHS Foundation Trust but the wider response to the issues raised in the formal inquiry by Robert Francis and published in a February 2013 report. Though clinicians do not escape opprobrium, the managerial regime during the 2000s was roundly criticised.
As seen by the recent Kirkup report into the deaths of mothers and babies at Furness General Hospital, other scandals will continue to be apparent elsewhere. The response of the NHS – its institutions and staff – to such scandals through the tightening of procedures following inquiries is indicative of how far quality improvement and patient safety have become embedded. However, despite the widespread sense of a need for change, greater transparency of performance in healthcare might lead to more poor headlines before improvements are seen or felt by patients.
For several months, the media were reporting on the state of Accident and Emergency (A&E) services across the UK. Ostensibly, this has been in response to failure (to varying degrees across the UK) to meet a four-hour waiting target, but it is indicative of wider pressures across the health and social care system.
A&E is simply the most visible sign of such widespread pressures in the health and social care system.
Reductions in the budgets of social care of about 15% between 2009 to 2012 have not only severely affected the quality and quantity of care for vulnerable groups, but they signify a wider restructuring of local government.
The transfer of public health functions from the NHS to local government in this parliament was a return to pre-1974 structures and, while this may augur well for addressing the social determinants of health, public health may suffer from competing pressures in local government.
The age-old question remains: whither the "national" health service? While much emphasis has been placed on local decision-making in the past five years (and especially, the widely-welcomed Five Year Forward View from NHS England in 2014), the locus of control has shifted centrally and regionally. Centrally, the new secretary of state, Jeremy Hunt, has taken a more centralist approach to managing issues, despite apparent decentralisation to local level and to NHS England.
Regionally, the fragmentation of the NHS (since the original market reforms of the early 1990s and exacerbated by the Lansley reforms) has left a void for oversight of local and regional system reconfiguration, with organisational individualism often acting as a barrier to reform. Integration of services across the NHS and services across health and social care has long been sought, but sometimes feels more of a rhetorical commitment than a reality at ground level.
This all makes the recent Manchester experiment and 29 Vanguard pilots – part of a £200m scheme to pilot integrated care models – all the more interesting as they become implemented in the coming years.
Thorny issues of governance and accountability will remain as well as the tension between free NHS care and means-tested social care. There remains, however, scope for learning about integration (and in England, non-market approaches) from the devolved administrations.
So, as this parliament draws to a close, what are the prospects for the next government? Finance will dominate. With a £30 billion funding gap, promises from political parties seem to fall well short of what will be required.
Radical solutions may thus come to fore. For example, re-structuring the boundary between health and social care might at last be a genuine possibility (in a way that hasn’t proved feasible in more benign funding environments). In one version of the future, integration might not simply be a search for better ways of delivering care to changing populations, but could also signal the demise (at least in relative significance) of market-based approaches.
Charging for NHS services may be touted but is unlikely – albeit that individuals may well have greater choice and control over how services are designed (through personal budgets, for example, which allocates funding to users to spend directly).
As many staff in health and social care organisations are tired of constant re-organisation, there is little appetite for further changes. However, reform appears inevitable. Whether this will be able to reconcile rising public expectations with the financial demands of the government remains uncertain.
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