NHS will face unprecedented challenges over the next five years

With the NHS once again playing a central role in the current general election campaign, we are seeing some familiar issues being discussed in the health debate – with some subtle differences.

These issues have been most visibly on display during the health debates organised by the BBC’s Daily Politics programme and the King’s Fund. As health is a devolved competency to the Scottish Parliament and the Welsh Assembly, these two debates have focused only on England, with the SNP and Plaid Cymru absent.

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% per annum) 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 2012 Health and Social Care Act resulted in the biggest ever NHS re-organisation (costing about £3 billion), implemented at the same time as financial cuts (for example, 35% of management costs).

The debacle of the 2012 Act has been salutary for all parties in this campaign. The absence of pledges of further re-organisation 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.

Second, developments ‘on the ground’ have often been moving ahead of the political debate. For example, NHS England’s ‘Five year forward view’ document (published in autumn 2014) has presented new organisational 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 the ‘Devo Manc’ model will work and whether its governance model is robust. Whether or not this model 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.

The use of competition and the private sector in NHS service provision has long been contentious. The latest model of NHS commissioning – 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 has been significant that alternative organisational forms (such as social enterprises or mutuals) have been largely absent from the current debate.

The focus of debates on health services has largely overshadowed discussion about public health and health inequalities. Although the coalition government adopted a voluntary system of regulation (called ‘Responsibility Deals’) between the government and the food and drink industry, they did transfer public health functions from the NHS to local government. 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.

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.

The NHS has faced numerous struggles in its 66-year history, but surely none will compare with the challenges over the next five years. The incoming Secretary of State for Health will have a full agenda.

Professor Mark Exworthy, Professor of Health Policy and Management, University of Birmingham