An entire generation of healthcare leaders has come and gone since the NHS faced a year as daunting as 2017. The service was able to live off the capacity and capability built up during the time of plenty in the noughties until the middle of this decade before the funding famine really made itself felt in last year.
Perhaps only Newcastle’s Sir Leonard Fenwick really knows what 2017 and subsequent years will mean for the service and what it takes to survive it as a healthcare leader.
But an NHS year is never simply all good or all bad: the Mid Staffs scandal happened while the service was awash with money and there will not be one reader of this article that cannot think of one aspect of the service that is better now than it was in 2010.
But let us examine the cloud before the silver lining.
Expect no financial rescue
Restricted funding and rising demand has created the perfect storm for the NHS.
On finance, the Treasury wolf will be kept from the door through a combination of genuine efficiency savings, non-recurrent cuts and clever accounting. But the hope that the provider sector will begin the next financial year in balance on a monthly run-rate basis has more or less vanished, while the commissioning sector will end the year with a sizeable deficit. New financial pressures created by the Apprentice Levy and changes to pension provision will add to the burden.
The amount of money available for transformation will be severely limited and focussed on a few areas which align with priorities and can produce the fastest results. The financial plans underpinning most sustainability and transformation plans will be re-defined as indicative exercises setting out a direction of travel rather than a robust framework for the future shape of services.
We may yet see more cash to help emergency care performance, for example the bringing forward of Better Care Fund cash from later in the spending review period to ease delayed discharges – but do not hold your breath. The major financial event of the year for the NHS – if any – is likely in the autumn with the announcement of some kind of 70th birthday present for the service.
The contracting round appears to have gone relatively smoothly to the credit of all involved. But HSJ understands it has generated some eye-watering cost improvement plans which could unravel very quickly should their delivery not be nailed very soon.
The various workstreams begun by the Carter efficiency review and the Getting it Right First Time programme led by Professor Tim Briggs are vital contributions to tackling waste in the NHS’s back office and frontline services respectively. But there is no doubt that aspects such as the rollout of Carter Care Hours Metric and the focus on “sub-scale” or “unsustainable” clinical services will make it a very uncomfortable year for some.
Staffing shortages – particularly nursing and GPs – will continue to undermine both performance and care model reform.
The improvement in the quality of NHS services, especially their accessibility, accelerated throughout the first decade of this century. This continued for the first half of this decade, but is now starting to reverse – again most noticeably on access.
The number of poor performers on emergency and elective waiting times will increase and the outliers become more alarming, and the elective waiting list will top four million. There is little immediate hope of the decline being reversed and the social care crisis appears intractable - it now seems likely the service will reach 2020 with a performance trajectory similar to that in 2000.
The pressures on the service will also mean the return of some problems the NHS thought it had seen the back of. Tackling healthcare acquired infections, driven by hospital over-crowding, could well soon return to the “must do” list of trust boards, while the quality of the healthcare estate will increasingly resemble the tatty and uncared-for NHS buildings of the 1990s.
There will be much talk of alternative sources of capital and of a new generation of public/private finance deals – but a risk-averse Treasury will rain on most of them.
Hope amid the darkness?
Is there really an upside among all this gloom? Possibly, though you have to look closely and have a strong belief in things turning out for the best.
In March there will be a major attempt to reboot the sustainability and transformation process and, at the same time, to remind the service of the goals of the Five Year Forward View. NHS England will attempt to highlight the progress made so far and set out a clearer definition of success in transforming care models.
The service’s reaction will be a key test in seeing if the consensus supporting the Forward View still holds. Government interest in the ambitions it sets out, especially from No10, will also tell us much about whether Simon Stevens has been successful in building bridges with the new government.
Service reconfiguration will attract controversy – some deserved, much not – and continue at a pace slower than originally hoped. However, it is likely NHS England will be able to point to real movement on new care models with the first multispeciality provider and primary and acute system contracts imminent, as well as the further roll out of the significant Primary Care Home model. They will not represent a tide of change or be without problems and controversy, but they will give hope that change is possible.
The creation of hospital chains, groups or alliances offers a real opportunity to deal with the NHS’s shortage of leaders, as well as making efficiency and reconfiguration challenges more manageable, without the pain of mergers. It is not a solution applicable to every health economy, but it does offer part of the answer to some of the NHS’s most deep seated and long standing problems.
2017 ironically could turn out to be a good year for mental health. For a start it has never had a prime minister as a champion before. Much will depend on how robustly the centre polices spending commitments and how hard local commissioners push back or whether financial raids are staged to shore up performance elsewhere.
This year could also see funding for primary care start to rise as a proportion of health spending, reversing a decade long trend.
Although it is stretching the concept of progress beyond breaking point, the meltdown in social care is likely to spur the NHS into action as the penny drops that it has to try and deal with the problem itself. The enhanced health in care homes model will begin to be rolled out nationally and more trusts will begin directly employing social care staff, particularly to fix specific problems like the speed at which people in acute wards can be assessed.
Whether there is mass NHS entry into the social care market depends on whether the cautious NHS England view or the more radical proposition posited in the Carter review, apparently winning support at senior levels of government, prevails.
Again it may not feel like progress for those on the receiving end, but the launch of Healthcare Safety Investigation Board will shine a light into areas where NHS care is still lacking (and inadvertently help build the case for more NHS investment – as may the Care Quality Commission’s ratings on the “efficient use of resources”).
Local NHS leaders are more likely to be more immediately pleased by increasing integration between NHS England and NHS Improvement, hopefully reducing the regulatory burden, as the two organisations crawl towards a post-2020 merger.
The NHS, finally, arrives in the 21st century
But – and this is a very big but indeed – it may be the NHS’s use of new technology to meet the apparently insurmountable problems created by the shortage of funding which might provide the strongest glimmer in 2017.
Financial pressures inevitably present a barrier to the adoption of digital projects, as much as any other area of service development, and many STP technology plans are relatively worthless. But there is at least a cautious sense of optimism among some senior digital leaders that the goals of the centre, regional and local players are now better aligned than they have been in recent years.
There is also a £1.2bn ring-fenced fund for investment in new technology, although it is vulnerable to Treasury raids. Getting it allocated as soon as possible is the best way to protect it.
Technology continues to underpin the grand vision of how the NHS will deliver care for the next generation, with its focus on safety (incident monitoring), efficiency (real-time bed management), productivity (e-procurement and supply chain management), joined-up services critical to the delivery of our 44 STPs (electronic records which are interoperable), home-based care (telehealth), and self-management of long-term health conditions (apps for mental health and diabetes patients).
Every trust should have a decent electronic patient record system within the foreseeable future and already some services have been transformed by new technology – 90 per cent of prescriptions will be delivered through the electronic prescription service by mid-2017, for example, double that in 2016.
Launching a system similar to the US’s Blue Button” service which would allow the public to easily register with a GP, book appointments, and order e-prescriptions is close to Jeremy Hunt’s heart. The NHS will not deliver that fully this year, but it could take a significant step towards it and, as a result, transform perceptions in the public mind of the NHS as beloved institution, but one which has not yet joined the modern world.
It will also be worth keeping an eye on the growing number of NHS artificial intelligence pilots.
Critics will point to the well-publicised and significant issues around how patient data is shared, and how deals with private providers are constructed; supporters will counter that the potential for game changing clinical and productivity gains are equally significant.
It feels wrong however to conclude an overview of what will be a grindingly difficult year for the NHS on a positive note, however qualified. It could also turn out that the biggest NHS technology story of the year will be linked to a significant failure in cyber-security.
All organisations are vulnerable in the moment they move the critical mass of their operations to digital platforms. It takes time for good cyber-security habits to feel like part of the job rather than a nuisance, especially with so many ageing “legacy” systems in the mix. A major leak of patient data or a cyber-attack which means health services across an entire region are flying blind for many days is overdue and yet completely absent from the risk registers of most NHS organisations.
It is certainly a challenge the 2017 generation of healthcare leaders will be the first to face.