New Year, new 'to do' list

There is nothing like the New Year for compiling a 'to do' list, and nothing more satisfying than to start the list with some things you already have under way, so that you can tick a few off immediately. Last week the coalition Government gave us their version in the form of the Mid-Term Review.

The NHS chapter pulls together a series of previously announced service initiatives (e.g. rolling out telehealth and telecare, implementing a 'friends and family test'); details of their performance meeting targets and initiatives put in place by the previous Labour Government; and information on the implementation of the Health and Social Care Act (such as progress establishing clinical commissioning groups, Healthwatch and health and wellbeing boards, abolishing strategic health authorities and primary care trusts).

Although seemingly aimed at political journalists and by extension the public, it is worthy of scrutiny for the clues it contains about the coming year.

The introduction to the NHS chapter asserts boldly that 'as well as protecting the health budget, we have reformed the NHS, giving patients and communities more choice and a stronger voice'. These two assertions merit some careful analysis.

Protecting the NHS from the cuts being meted out to other public services would seem to be in line with public attitudes and David Cameron appears to have decided that it makes political sense to continue to exert pressure on other public service budgets in order to be able to assert that he is firmly on the side of the NHS.

Not mentioned in the review however is the fact that the 'real terms funding increases' translate into flat funding for the NHS for the foreseeable future, something that represents a cut in funding once inflation and rising demand are taken into consideration.

Failing to discuss this productivity challenge may be understandable in political terms, but potentially creates a large perception gap between those in the NHS trying to balance budgets, preserve the quality of patient services, and plan for how to do this as the money gets progressively tighter and for a population with ever higher expectations, in part fanned by politicians.

There is also no mention in the review of integrated care (a coalition priority, we were led to understand), nor of the changes needed in hospital and primary care.

Respected voices within the NHS have spent the last year calling for 'transformed' services as the only solution to the money/quality conundrum, for which read centralising specialised services in a smaller number of large hospitals, and converting local district general hospitals into community hospitals that support both general practice and nursing homes.

Such calls usually ended with a plea for ‘bold political leadership’ envisaged as politicians explaining to the public (and NHS staff) why change is vital to providing the types of services that population projections say we will need.

The lack of reference to this central challenge is ominous, suggesting an unwillingness to expend political capital on thorny issues in the run up to the 2015 election.

As to their claim to be 'giving patients and communities more choice and a stronger voice', it remains to be seen how far clinical commissioning groups will be able to extend the range of service options available to local people, when the main preoccupation post-Francis Inquiry will be how to assure local people that existing services are safe and of appropriate quality.

New Healthwatch bodies may go some way towards increasing local voice in health services, but the scale of the service and financial challenge facing the NHS suggests that they will have a huge task ahead of them.

What would the Nuffield Trust version of this paper have looked like? It would have started with 1) a clear explanation of the financial challenge, 2) a pledge to set clear standards for quality of care and 3) an explanation of the consequences of these two tasks for local services.

In other words it would probably have more closely resembled the Mid Term Review’s preceding chapter, the one focussed on education, which set out a clear analysis of what is perceived to be wrong with education and then presented an agenda (albeit unpalatable to many) for addressing this.

The concern going forward must be that any previous sense of energy and urgency has drained out of the health sector following the bruising political battles and administrative uncertainties of the last two years.

The Government’s review certainly makes it clear they are hoping for a ‘quiet life’ on the NHS front. They will be disappointed if they skirt the real challenges.