NHS long-term plan: this is very far from “job done”

After nine years of austerity, 2019 is the year of extra funding for the NHS. Back in June 2018, the prime minister marked the NHS’s 70^thanniversary with a pledge to increase health service funding by £20.5bn above inflation over five years. A new long-term plan on how to spend the money was launched on Monday with commitments to improve mental health, cancer and maternity care.

For the NHS and its patients, the extra money can’t come soon enough: services are struggling at or beyond full capacity, waiting lists are above four million and growing, and performance targets are being missed all year round.

But the government shouldn’t consider this “job done” on the NHS. Far from it. The £20.5bn gift for the NHS—while welcome—is not as generous as it first sounds. Health care spending is a constantly moving target: as the population grows, ages, and develops more chronic diseases, extra funding is needed just to stand still. The additional funding promised by the government is simultaneously a lot of money and too little. £20.5bn by 2023/24 is an average annual increase of 3.4 per cent in real terms for front-line services—below the historic average and just about enough to keep pace with growing demand, estimated at 3.3 per cent a year. So, maintaining NHS standards—let alone meeting the raised public expectations that come with extra funding and the long-term plan—will be a challenge.

The government is also making the NHS’s job harder through persistent policy failures in three key areas: public health, workforce and migration, and social care.

First, the prime minister’s £20.5bn funding announcement for the NHS excluded public health (which includes health visiting, stop smoking support, drug, alcohol and sexual health services). Public health budgets have faced persistent cuts in recent years. The core public health grant has fallen by 25 per cent per person since 2014/15. From April 2019, the grant is to be cut by a further £240m in real terms. This is despite public health interventions being some of the most cost-effective ways to improve health, and prevention being a stated government priority. Decisions on longer-term funding are for the 2019 Spending Review, but without significant additional resources we risk missing another chance to improve people’s health and are storing up problems for the NHS.

Second, years of policy neglect of workforce issues mean that the NHS is plagued with major staffing shortages. The NHS currently needs 100,000 more staff. Recent research suggests this gap is likely to grow to almost 250,000 over the next decade. The long-term plan will be no more than a wish list if that gap can’t be closed. Like public health, decisions on funding for the future NHS workforce were kicked into the spending review. The omens are not good: the mood music is that the NHS has had its share of the cake and shouldn’t expect much more.

Not investing in the pipeline of new staff would be a big mistake. There is a global shortage of doctors and nurses—and Brexit and the government’s new migration white paper may make the task of attracting health workers even harder. International recruitment is the only feasible way to address the NHS’s workforce shortages in the short-term. The migration white paper establishes the principle of uncapped migration for the “high skilled.” Doctors, nurses and radiographers would seem to most people to be highly skilled, but the problem is that high skill doesn’t equate neatly to high pay: starting salaries for the staff that the NHS needs often fall below the Migration Advisory Committee’s proposed threshold of £30,000.

Third, beyond the NHS lies an even bigger policy failure with profound implications for the health and wellbeing of many of the most vulnerable in society: social care. Successive governments have ducked hard choices on social care reform and the current government is no different. It promised a green paper back in 2017 yet there is no sign of progress. For the last four years, there’s been a series of short-term cash injections so that the service limps through, but it has fallen short of any long-term solution. In the meantime, access to care has been cut repeatedly, with Age Concern estimating that 1.4m people can’t get the care they need. The current system is unfair and unsustainable.

Brexit and the new migration policy may finally bring things to a head. Social care services rely on low paid workers—many from the EU—to stretch inadequate funding. The migration white paper would substantially reduce the availability of such staff. While there is a promise of a short-term route for lower-paid migration, this would compound problems of high staff turnover and low continuity of care in a service that desperately needs stability.

Without policy action on public health, the workforce, and social care, 2019 risks being the year in which the government gave with one hand but took away with the other.