The NHS stands at the threshold of a new decade facing both potentially its most difficult winter in decades and the most hopeful medium-term future since the 2008 financial crash.

The global economic meltdown at the end of this century’s first decade was significantly more important than anything that happened between 2010 and 2019. It led, though not directly, to public sector austerity, which undermined many of the gains made by the NHS during the New Labour years and decimated other areas of social provision on which the health service depends.

The aftermath of austerity will go on damaging the NHS for some time, not least because budget cuts for local authorities and other areas of expenditure have only been mitigated, but not ended. We have also yet to count the cost in staff morale and resilience from what may prove to be a cruel winter.

However, for the first time in nearly 10 years NHS leaders can look forward over a three-year period and reasonably expect to do more — albeit only a little — than manage decline and hope that a more logical and effective way of working may become a widespread reality.

About those “40 new hospitals”…

It is highly unlikely the revenue settlement for the NHS will be reopened in the government budget pencilled in for February or March. But the battle for a significant increase in capital spending is already being joined. Just as the Brexit bus pledge of “£350m a week for the NHS” was used to twist the government’s arm on revenue, so the “40 new hospitals” promise will feature significantly in negotiations with the Treasury.

HMT has set its face against private financing of public sector projects and therefore has denied itself the (largely theoretical) objection to many who made public capital bids in the past — that they should examine “alternative” financing routes.

If the NHS does not get what it wants — which is more or less what Boris Johnson and Dominic Cummings want it to get too – then the Treasury will carry the can.

HMT’s lack of action will be disguised by much huffing and puffing over “new metrics” which will be used to “hold the NHS leadership to account” – but the “people’s government” knows the electorate will not accept the heads of a few bureaucrats as a substitute for a noticeable improvement in access to care.

The NHS goes global in search of staff

The NHS can also be reasonably confident that the penny has finally dropped on the importance of workforce. Expect two meaningful outcomes to come from the long-awaited NHS People Plan.

The first will be a much firmer national grip on overseas recruitment. The need for national recruitment programmes agreed with governments and agencies in countries such as the Philippines and India to deliver is now pressing. At a local level, it is highly likely regional need will be aggregated and trusts with the best track record in overseas recruitment charged with the responsibility of delivering for all.

Retention will be driven by an attempt to create an informal “NHS offer” to staff. Expect tactics and strategies adopted in places such Leeds, Wigan or Milton Keynes that have successfully attracted clinical staff to return to practice, enabled staff to work flexibly, and/or helped them cope with financial demands to be promoted and in time, unofficially, mandated.

Expect the operational nature of these priorities to be recognised in the greater influence of NHS England/Improvement over that of Health Education England.

What replaces competition?

Then there is the prospect of an NHS bill sweeping away not only most of the remnants of the Lansley reforms, but also some of the key policy changes of the last three decades.

There will in fact be two NHS bills this year. The first – guaranteeing NHS funding levels – is largely symbolic, though it does give some protection from a Brexit-inspired economic collapse.

A separate bill, based on the proposed legal reforms from NHS England in line with the NHS long-term plan, will come later in the year and there are two areas where significant work must be done before the draft legislation is published.

The most important question is what will replace the Health and Social Care Act’s infamous section 75 on procurement and competition. The concept of deciding who will deliver a service based on a “best value” test will return from policy limbo – albeit under another name.

There is also the added complication of aligning any changes with Brexit trade negotiations. The NHS will not be “up for sale”, but trade deals require procurement practices to be transparent and consistent – and ‘the NHS will buy what it wants, how it wants’ is unlikely to cut it.

We are all about to be reminded that any way of spending public sector resources in an accountable fashion is complicated. To misquote South West Yorkshire Partnership Foundation Trust chief executive Rob Webster: “If you think competition is hard, try ‘contestability’.”

The other major debate will be the logic of giving integrated care systems statutory powers – through committees in common – without making them statutory organisations themselves.

Both NHS England and the government are determined to avoid the “top down reorganisation” which making ICSs legal bodies in their own right would entail, and hope they can build a more logical, less fragmented system on the foundations of the old one. Expect that idea to be an approach challenged by many – especially in the House of Lords.

We do not yet know whether — in light of the large government majority in the Commons — NHS England or ministers will now propose to widen the legislative proposals from those put forward by NHSE in the autumn. But with workforce such a constraint on NHS activity, it would not be surprising if ways were sought to get clinicians into practice as soon as possible in their careers.

The exact timing of the bill is down to the government’s Parliamentary business managers, but the hope at the centre is that it woud be passed by the end of the calendar year and that new laws could begin to come into effect from April 2021. Delays beyond those dates, however, could well occur especially if peers threaten to decorate it with amendments. It certainly will not happen by March as the Conservatives let the world believe during the election campaign.

Stay a little bit longer

A final piece of cheering news is that the 2020 departure of the newly knighted Sir Simon Stevens now seems a lot less likely than it did six months ago. A single-party government with a large majority and a desire to prove its worth by improving the NHS, led by a PM he has known since university and a strategist who backs bold reform is a much more attractive working environment than any he has had since becoming NHS England chief executive in 2014.

This is especially good news as Sir Simon speaks truth to power as effectively as any NHS leader past or present — and that will be especially valuable when the improvements the government desires inevitably prove to be more expensive and take longer than they had hoped.

The new dawn of 2020 is nowhere near as bright as that which broke in the spring of 2002 or even in 1997. It is more akin to the late eighties, when funding increased to head off a collapse in care standards.

The period that followed that funding boost saw Conservative governments embark on technical and misplaced health service reforms that were manna from heaven for a bruised opposition, while devoting most time to an obsession over the UK’s relationship with Europe. As a result, it lost first an iconic leader, then its grip of the economy and public services, and eventually, power.

There is every chance history could repeat itself — especially as there also appears to be no urgency in finding a solution to the disintegrating social care system. But given the grimness of the last few years and the positive developments mentioned above, perhaps NHS leaders may be forgiven in thinking that — this time — things can only get better.