The big questions for the year ahead

11 January 2017

Chris Hopson


Every day brings fresh reminders of extraordinary pressures across the NHS. Trusts are working flat out, treating more patients than ever before but slipping further behind performance targets. Wherever we look there are pressing priorities: managing the finances, dealing with spiralling emergency demand and completing the Sustainability and Transformation Planning (STP) process.

In the midst of these pressures, it’s important to look at the big picture and ask the top level questions that often get lost in the day to day hurly burly.

First, can we all now agree there is a clear gap between what the NHS is expected to deliver and the funding available? Most people, including many senior leaders across the NHS, recognise the service can no longer deliver all its current priorities and performance standards within current funding. But we can’t properly plan for and meet this gap until we all agree that it exists. We currently seem stuck in a fruitless and sterile argument about whether the government has fully funded the NHS’s own plan. How do we move on and start properly addressing the gap that we know exists?

We currently seem stuck in a fruitless and sterile argument about whether the government has fully funded the NHS’s own plan

Let’s assume we can agree there is a gap. The government said in its Autumn Statement that it will not revisit NHS spending for the rest of the parliament. This leads to a further, fundamental, question. If the money is fixed, how do we identify what the NHS will stop doing? None of us in the NHS wants to deliver a poorer service. But if the money is fixed, we now face genuinely difficult choices that must be made. What are the options, how will we choose between them, and what kind of public debate will be needed to gain consent for those choices? Our political leaders will find it difficult to lead this debate, though this week’s statement on the A&E 4 hour standard was a good start. How can we help politicians ensure the required debate happens? Once the hard choices have been made, how do we marry up the national debate with local plans to ensure we actually deliver what we know will be unpopular?

The next top level question is on staffing. Our recent report The state of the NHS provider sector showed that, for some leaders, this has become the most pressing concern. More than half of chairs and chief executives were worried their trust may not have the right numbers, quality and mix of staff to deliver high quality care. Most expected the situation to get worse. The NHS is failing to deal with a series of workforce problems that threaten its long term sustainability. NHS pay is becoming increasingly uncompetitive at certain grades. We have uncertainties over recruitment and retention posed by Brexit. And there is the challenge of re-engaging disillusioned junior doctors. What are we going to do differently to overcome these problems?

We need to look at how our health and care system will cope beyond the current parliament in the face of demographic pressures already in clear sight

Taking a further step back, we need to ask when does the present operational pressure on the NHS trigger the more existential question about the future viability of our taxpayer funded system? We can never assume the longstanding political consensus behind our current model will stay in place indefinitely, particularly if the public feel the NHS is overwhelmed or failing to keep up. When will we reach that point? Can we avoid it, if the current trajectory continues over the next three years as the lower levels of NHS funding kick in? And, for those of us who are strongly wedded to the fundamental principles behind our NHS, what do we need to do, when, to ensure those principles are preserved? For example, other nations devote more of their national wealth to funding health services and opinion polls say the public is prepared to pay more tax to do so.

Finally, we need to look at how our health and care system will cope beyond the current parliament in the face of demographic pressures already in clear sight. Use of NHS and care services increases with age, and we are an ageing society. By 2039 more than 1 in 12 of the UK population is projected to be 80 or over. When and how are we going to develop a proper long term strategic framework to meet the significant increase in demand that we know is on the way, including genuinely joining up currently separate NHS and social care services? These pressures are already stretching services beyond capacity. But there is much more to come. If we’re struggling now, what will it be like in 10 or 20 years time? How do we plan properly to safeguard care not just for us, but for future generations?

2017 must be the year we confront these difficult dilemmas. We set out some of the required solutions in our State of the NHS provider sector report. What we can’t carry on doing is pretending that what we’re doing now is sustainable. It clearly isn’t.


This blog was first published in the HSJ on 11 January 2017



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