The NHS has known grimmer years than the one in which it will mark its 70th birthday, but probably not one that will feel as tough.
Care performance and quality has been worse in living memory. Patients on average get a better deal now than they did in the early to mid-noughties for example. But after seven years of austerity staff morale is much poorer than in that period of plenty. Access is already declining across the board and care standards could slip rapidly in this context. Public expectation, of course, continues to rise.
As far as predictions for the year go, some issues need little further illumination here: the NHS’s financial plight will not meaningfully improve; efficiency asks will be eye-watering (and often unrealistic, as will be many of the resulting financial projections from NHS organisations); and the Treasury’s grip on the service will increase.
Below, however, HSJ’s expert correspondents have identified the important trends and issues that you may not yet have had time (or courage) to consider.
For waiting times: Amongst the appropriate bonhomie of Sir Bruce Keogh’s leaving do there was one moment of frostiness. After Jeremy Hunt had paid warm tribute to the departing NHS England medical director, Simon Stevens stepped up to deliver his eulogy. He began: “As happens so often these days, I find myself agreeing with Jeremy.”
The joke – which sent gales of laughter through the assembled NHS good and great – seemed to be lost on the health secretary. Mr Hunt and Mr Stevens have not (in a meaningful way) been on speaking terms ever since the chancellor blew his top over the NHS England chief executive’s pre-budget intervention. But both men know they must find agreement on a narrative that works for all.
Sometime before the end of March, NHS England will make it clear that the service will not hit the 95 per cent four-hour A&E target during 2018-19 or make any more than a marginal dent in the elective waiting list. This may be sold as simply a repeat of the message given in the early spring of 2017 that the NHS would have to prioritise – although back then it was suggested the NHS would hit the A&E target and there is also the small matter of £1.6bn gifted to the service for 18/19 in November’s budget.
The government must prove this cash has made a difference. A likely compromise could see the funds being used to deliver tangible, targeted wins like introducing a ‘hard maximum’ limit on elective waits or dealing with those basket case A&Es whose performance dramatically skews the NHS’s overall performance.
For care quality and access: If this happens the row over patient guarantees on elective waiting times which Mr Stevens threatened the government with is likely to be resolved with a whimper not a bang.
A bigger running story in 2018 will be rows and legal challenges over growing restrictions on drugs and treatments which NHS England declare “unaffordable” or of “low clinical value”. NHS England will need to secure Department of Health support for these and other measures to help it keep a lid on spending.
For hospitals: The expansion in elective work will be focused on operations that do not impact on bed capacity (such as day case work) – good news if you need a cataract removing, less so if you need a hip replacement. This will be a tacit admission that even if hospitals could find the capital to open more beds, they would struggle to recruit the nurses and doctors to staff them.
Alliances, chains or even the much maligned merger are very much back in favour and 2018 will see peak activity in this area as the sector tries to reconfigure its cost base.
The emphasis in Care Quality Commission inspections will switch from the methodical ticking off every NHS organisation, to deeper dives in themed areas such as maternity and radiology. This change of tack will run alongside reports from the relatively new Health and Safety Investigation Board. Both may cut across the conventional wisdom which promotes centralisation and specialisation of acute services, adding a further layer of complexity to the NHS’s struggles with the reconfiguration of secondary care.
For accountable care and CCGs: “Accountable care” as a label within the NHS will die before the first new organisation gets going. The American source of the name and the connotations of “privatisation” it brings is an irritation NHS England could do without. This is likely to be the most notable victory for the anti-ACO campaigners, though the lack of statutory footing for new systems will continue to plague their development, especially when it comes to how the quality of the care they oversee should be monitored.
Whatever accountable care systems are renamed (‘integrated health and care systems’ perhaps or ‘People’s health co-operatives’ to please the Corbynistas) they are likely to cover half the country by the end of the year. Fully-fledged accountable care organisations, however, will be able to be counted on one hand, and maybe one finger.
The rationalisation of CCG management will continue apace, with the number of chief officers halving again to about 70 (the same ballpark as the number leading “clustered” primary care trusts immediately before CCGs were born). There will also be a flurry of mergers.
For primary care: Primary care could well see its “Uber moment” in 2018, with the use of GP apps being rapidly adopted by a younger patient cohort.
The primary care “at scale” bandwagon will continue to roll, with NHS England increasingly open about identifying the local groups and organisations it will be backing in this new ecosystem.
For mental health: 2018 is the crunch year for mental health’s new prominence on the policy agenda. The penny is beginning to drop with hospitals and their commissioners that mental health interventions are an effective way to manage demand on emergency services, but the sector will still face a running year-long battle to protect its new, relative, wealth.
Lord Carter will publish his efficiency review of mental health and community trusts, identifying an estimated £200m of possible back office savings.
For the workforce: The source of much noise in 2018 as the contracts for most NHS staff are renegotiated. There is a deal to be done between the government and unions over Agenda for Change (perhaps a three per cent rise in return for accepting changes to working patterns and pay increments). The biggest threat to this is the all-powerful Momentum group in the Labour party deciding to make this a cause celebre and forcing the unions to take a harder line.
As the Brexit talks reach a new level of intensity, so will the NHS’s attempts to recruit staff from overseas.
For organisations trading with NHS: Getting paid by the NHS will become increasingly difficult as cash flow is squeezed. This combined with efficiency drives in areas such as agency staffing may push some suppliers to the wall. The trusts concerned will blame their commissioners.
Private healthcare providers will exist in parallel universes in which commissioners are both encouraged to channel work towards NHS organisations to manage deficits, while at the same time gunning down waiting lists in any way they can.
Procurement towers will replace NHS Supply Chain in October 2018. That means instability in the market as suppliers react and adjust, as well as pressures on the category (towers) providers to get the right workforce in to secure the best deals (which could be trickier than they think).
The care reform and efficiency agendas will continue to drive opportunities for suppliers – especially where NHS partners can access newly freed-up capital funding.
A lot of money will (hopefully) be spent on new technology through the global digital exemplars, their fast followers and the emerging ACSs. In parallel, expect a reignited row about the use of NHS patient data, especially around: the national data opt-out scheme, which the Department of Health is set to publish in March; the new national NHS data collection drive; and any deal with digital suppliers to share NHS patient data that fails the public taste test.
For the leadership of the NHS: Jeremy Hunt will become the longest-serving senior minister in NHS history on June 3. Simon Stevens will still be chief executive of NHS England at the end of the year. The merger which dare not speak its name between NHS England and NHS Improvement will continue, but not at a pace to please most.
HSJ apologises for the fact that many of our predictions will be about as welcome as being given the on-call shift on New Year’s Eve. There will be success and innovation in 2018, and the service is still developing broadly in the right direction. There will also (we trust) be time to celebrate the NHS’s achievements since 1948, which have seen it established unchallenged as the pride of the nation.
But perhaps the thing we will welcome most on 31 December 2018 is being 365 days closer to a time when a government might have the ability and stability to properly invest in England’s health services.
The HSJ correspondents who contributed to this piece were: Sharon Brennan, Nick Carding, Ben Clover, Lawrence Dunhill, Joe Gammie, Ben Heather, James Illman, Shaun Lintern, Rebecca Thomas, Dave West and David Williams.