Last Christmas
1
Virtual GPs
2018 will hold much heated exchange about access to general practice and whether video consultations add value to the population as a whole. Enthusiasts will insist this is the future and that we should get used to it. Sceptics will highlight the inequitable diversion of scarce staff and other resources to a healthier-than-average population. The NIHR-funded Alt-Con study will add some hard facts to the debate, but NHS England must commission rigorous analysis of quality and outcomes. The rest of us must continue to persuade newly qualified GPs that the hard yard of list-based general practice for people with complex problems is still worth committing to.
2018 update
Fractious Twitter spats about GP at Hand continued throughout the year, but have not yet informed a vision of how technology can best serve general practice. The emergence of various WhatsApp groups that support and energise people leading change in primary care demonstrate the positive role that tech can play in this sector. Work this year on continuity of care, the growth of the primary care home movement and the efforts of the ‘rethinking medicine’ group highlighted the value of ongoing therapeutic relationships, de-medicalisation and strong links between GPs and their local communities.
Last Christmas
2
Brexit negotiations
Next year the government will introduce an Immigration Bill, ending 47 years of free movement of people between Europe and the UK. It will make provisions to allow migrants already here to stay. These must provide security to more than 155,000 NHS and social care staff from the EU, whom we cannot afford to lose. The Bill will also set up a post-Brexit migration system. Given the shortages facing the NHS, this will need to continue to allow thousands of health and social care workers to join the service each year until we train enough people domestically.
2018 update
The end of 2018 did finally see the immigration white paper. As expected, it was mixed news. Scrapping the numerical cap and some of the red tape on skilled workers will be welcome, but a salary floor will cause problems for key groups. Social care loses out again, as lower paid migrants will be allowed only on a temporary and restricted basis. More positively, the agreement with the EU secured the position of 165,000 EEA staff already working in health and social care – although whether MPs will sign it off remains to be seen.
Last Christmas
3
Nuffield Trust Health Policy Summit
The beginning of March heralds our tenth annual health policy summit. You can look forward, in person or via our livestream, to 36 hours of debate, networking and challenge on the pressing issues facing health and social care. We will be featuring our work on acute medicine and smaller hospitals, taking a look at patient experience through the lens of clinicians who have experienced serious illness themselves, and considering how we hold on to what is most precious in primary care. Our guest speakers already include Matthew d’Ancona, Nick Timmins, Goran Henriks and Jon Glasby, with more to be announced in the next few months.
2018 update
The ‘Beast from the East’ struck the 2018 summit. We lost some sessions and speakers but for those who made it, the sense of overcoming adversity created a great atmosphere and our livestream definitely proved its worth. In 2019, we have Sir Andrew Dilnot as a keynote speaker; we’ll be looking at how our social care system could learn from Germany and Japan and our health system from Portugal. Should we squeeze in Brexit? Answers on a postcard…
Last Christmas
4
Northern Ireland
April marks the 20th anniversary of the Good Friday Agreement in Northern Ireland. This led to the creation of the Northern Irish Assembly, to which full powers over NHS and social care were devolved. Since then, a series of weighty reports have set out an ambitious vision for transforming care. This year, however, the power-sharing government as laid out in the agreement collapsed, and talks to create a new one have stalled. We have warned this deadlock is contributing to a failure to address poor performance that has seen one in four patients waiting over a year for an outpatient appointment.
2018 update
Last year we warned that the collapse of the power-sharing government in Northern Ireland was contributing to a failure to address poor performance in the NHS. 2018 saw key performance measures deteriorate further. This September, over a third of a million people – one in five of the population – were either waiting for an outpatient appointment or admission to hospital. With a continuing gap in national leadership, prospects for improvements in 2019 do not look hopeful.
Last Christmas
5
Pay review body
The NHS pay review body (PRB) will be making its recommendations to the government in April. The government has told the PRB it is adopting “a more flexible approach to public sector pay, to address areas of skills shortages and in return for improvements to public sector productivity”. There is also a commitment to provide additional funding for staff employed under Agenda for Change in exchange for contract reform. But the PRB need to “consider affordability when making their recommendations”. NHS staff in Scotland can expect a 3 per cent pay rise next year – we await the PRB verdict in England.
2018 update
This year’s pay review body recommendations recognised the growing concern about workforce pressures and risks. The deal brought the biggest pay increase for staff on Agenda for Change since the pay cap had been introduced, with real terms increases for most staff, but the biggest for the lowest paid. The value of the top pay points increased by 3%, and there were also changes to pay bands and rates of progression. The PRB argued their proposals were affordable and balanced the needs of staff and employers.
Last Christmas
6
NHS finances
We will have to wait until around May to discover in what state NHS trusts will end the 2017/18 financial year. The precise number is unknown, but one thing is absolutely certain: it will be negative. By halfway through the financial year, trusts were collectively overspending at the rate of £346 million a month, once one-off savings and bungs are stripped out of the numbers. That’s the equivalent to every hospital having no reliable income to cover their costs for the last one-and-a-half days of each month. With no sustainable solution in sight, it leaves trusts on track to end 2017/18 with an underlying deficit of £4 billion.
2018 update
Sadly, our prediction on the state of NHS provider finances last year was pretty accurate. In September, NHS Improvement took the bold step of finally publishing the underlying deficit held by NHS trusts at the end of 2017/18: £4.3 billion. That is the gap between the predictable, reliable income flowing into trusts and the regular costs flowing out. As there has been no structural change to address this in 2018/19, our current forecast is for the underlying position to remain largely unchanged by the end of this financial year.
Last Christmas
7
Technology
In 2018 we will see the government put a new infrastructure in place to help the NHS adopt technological, digital and pharmaceutical innovations. This includes transformed Academic Health Science Networks with a bigger change management function, new ‘innovation exchanges’ hoping to support the 15 AHSNs work more collaboratively, and an Accelerated Access Pathway intended to expedite certain innovations entering the NHS. The thing to watch out for though is how far these new bodies will help the NHS move from a product-focused, supply-driven approach to innovation to one that helps the NHS identify its most pressing problems and look for solutions to solve them.
2018 update
The new innovation infrastructure promised at the end of last year is, for the most part, now in place. An Accelerated Access Collaborative has been appointed to develop an accelerated access pathway. Innovation exchanges, led by AHSNs, exist across the country with four distinct tasks: needs definition, innovator support and signposting, real-world validation and spread and adoption of supported innovations. While it’s not clear how these tasks have been interpreted and prioritised, we’re seeing exciting developments in how the NHS develops and adopts innovations, which looks set to continue.
Last Christmas
8
The NHS at 70
On 5 July the NHS will turn 70. This occasion will be marked by a mixture of celebration and soul searching. The celebration will focus on the inspiring things the NHS does every day to improve and save lives, and the soul searching on the phenomenal challenges ahead. The typical NHS patient has changed beyond all recognition since 1948, with medical advances meaning we are living longer but not always in good health. The health service of the future will need to balance expanding patient needs with our insatiable appetite for new drugs and treatments and the reality of fiscal and political constraints. A challenge indeed. Happy birthday NHS!
2018 update
In July the NHS turned 70, to much fanfare, celebration and, of course, that £20.5 billion birthday present from the Prime Minister. Our work for the BBC with other leading think tanks looked at how the health service performs compared to 18 similar countries internationally, asking the timely question: How good is the NHS? We found a mixed picture: it is world leading at protecting people from catastrophic care costs and is relatively efficient, but lags behind other countries in survival rates for common killer diseases like cancer and heart attacks.
Last Christmas
9
Social care
Next summer, the government is set to launch its long-awaited green paper on social care for older people. This will be the latest in a long line of consultations and reviews about the thorny issue of social care funding and provision. With the NHS under growing pressure and cuts to local authority budgets biting, there is an increasingly urgent need for agreement on a sustainable system of social care for our ageing population that works alongside health care. For proposals to gain traction, it will be essential that the government garners genuine cross-party support, stakeholder endorsement and, crucially, public buy-in.
2018 update
And we’re still waiting. Despite high expectations, not much has changed for social care. A small injection of cash for winter and promises of more next year, while welcome, are widely regarded as insufficient. Councils continue to face tough decisions and several care providers have closed. Cross-party commitment to change remains elusive and public awareness remains low. Rumour has it the green paper will be extremely, well, green, but our hope is that when it is published, it will be a positive starting point for a genuine debate about the future of social care.
Last Christmas
10
Accountable care
Proposals to develop different types of accountable care organisations (ACOs) or systems (ACSs) form an important part of local plans for the future of the NHS. Eight regions in England are set to evolve into ACSs during 2018, but many practical aspects of making these systems work are challenging. The legal challenges ACOs currently face are premised on the mistaken notion that they represent privatisation, with a more significant and unanswered question being how, without the competitive forces that shape ACOs in the USA, do we avoid creating cosy geographical monopolies that favour member organisations rather than focusing on patient preferences and population outcomes.
2018 update
The legal challenge failed but did have the effect of leading to a name change – the designation of integrated care partnerships and systems adding two new TLAs (three letter acronyms) to the NHS’s collection. Along with measures to bring NHS England and NHS Improvement together, these seem to be increasingly seen as part of a significant rethinking of the structure of the health service. My concerns about monopolies remain, and I add to that a worry the NHS is in danger of repeating its tendency to obsess on governance and structure at the expense of rethinking how care is delivered.
Last Christmas
11
Quality and Outcomes Framework
NHS England is ‘committed in principle’ to scrapping the Quality and Outcomes Framework for GP practices, but it’s still unclear what alternative might be put in place. There is a lot at stake here. Many practices view funding via QOF part of their ‘core’ income, yet evidence shows it hasn’t really achieved the improvements in care it set out to. There may be benefits to a ‘retained but reformed’ version of QOF, but the downside of this approach is that we may miss the window of opportunity to do something better, both for GP practices and for patients.
2018 update
In the end NHS England’s review opted to hit the ‘refresh’ button, rather than consign QOF to the scrapheap entirely. Proposed changes are unlikely to transform patient outcomes (but then, neither did QOF) and some, such as the reframing of exception reporting as ‘personalised care adjustment’, may simply add to GP end-of-year workload. The focus on improving quality – rather than simply measuring it – is welcome, but is there more we could also be learning from Scotland’s experiment with quality clusters?
Last Christmas
12
Winter A&E targets
The Government’s mandate to NHS England for 2017/18 set a key deliverable that, by March 2018, at least 95 per cent of people attending A&E must be seen within four hours in the majority of trusts. In November this year, 126 out of 137 major A&E departments missed the four-hour target, and this number is expected to rise over the winter as in previous years. This raises the question whether the extra £335 million for winter pressures announced in the Autumn Budget is enough for NHS England to meet the A&E performance objectives, or whether it’s too little too late.
2018 update
Last winter was one of the worst ever for the NHS in England. In March, over 15% of people attending A&E waited longer than the four-hour target. Only five major A&E departments met the target – far from a majority. This resulted in NHS England and NHS Improvement refreshing their plans for 2018/19. But with early targets still missed, and given the immense pressure the health system is under, it seems inevitable that performance will decline again.
Suggested citation
Nuffield Trust (2018) “2018: so what did happen in health and social care?” Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/2018-so-what-did-happen-in-health-and-social-care