Intended for healthcare professionals

Editorials

Challenges facing the health secretary in new Cabinet

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3960 (Published 18 July 2016) Cite this as: BMJ 2016;354:i3960
  1. Chris Ham, chief executive
  1. King’s Fund, London, UK
  1. C.Ham{at}kingsfund.org.uk

Valuing staff and supporting them to improve care should be the priority

The immediate challenge facing Jeremy Hunt, who has been reappointed as health secretary in the new Cabinet, is to confront the parlous state of NHS finances in England. The aggregate deficit of £1.85bn (€2.2bn; $2.5bn) in 2015-16 was the largest in NHS history and resulted from increasing demands on providers at a time of constrained funding.1 Savings from other parts of the Department of Health’s expenditure may help to offset NHS overspending but cannot be relied on to do the same in future.

Almost all of last year’s deficit was concentrated in acute hospitals and was driven by the appointment of additional clinical staff, many recruited from agencies, in response to the failures of patient care at Mid Staffordshire NHS Foundation Trust2 and concerns about Care Quality Commission inspections. The regulator of NHS providers, NHS Improvement, has intervened to control the costs of agency staff and has signalled that providers should cut the number of clinical staff they employ to restore financial balance.3 Unless managed carefully, staff cuts could compromise patient safety and the quality of care. Other actions to reduce deficits are expected imminently.

One of the consequences of overspending in acute hospitals is that most of the extra funding available in 2016-17 is being used to reduce their deficits. Little will be left over to fulfil commitments to increase spending on mental health services and general practice, or to cover the costs of new priorities such as implementing seven day services. There are also concerns that raids on capital budgets to reduce deficits are storing up problems for the future through cuts in maintenance of buildings and reduced investment in new facilities.

Equally troublesome are cuts in public health budgets and insufficient funding of social care. Allowing councils to increase council tax has offered some relief, albeit with the perverse consequence of raising the most resources in affluent areas that need them least. Social care leaders have warned that services are at breaking point after several years of cuts,4 and a fundamental realignment of spending on health and social care is growing more urgent.5

Enumerating the number and scale of the challenges facing the NHS and social care may help explain why Jeremy Hunt has returned to the Department of Health. A new health secretary would have needed time to master the brief, and the prime minister clearly decided time was at a premium in taking action to stabilise NHS finances and performance. Hunt also supported Theresa May’s bid to lead the Conservative Party, and his willingness to take a firm stance over the proposed junior doctors’ contract echoes her confrontation of the police service.

Scope for change

Hunt’s room for manoeuvre in addressing these challenges is limited, with NHS Improvement and NHS England’s plans to reduce deficits and improve performance at an advanced stage. Just as important is the close involvement of the Treasury, which has had increased influence over the NHS as finances have deteriorated. The new Chancellor of the Exchequer’s attitude towards the NHS will influence funding for the rest of this parliament. Early indications are that the government is willing to borrow to spend to deal with the economic consequences of Brexit, but this is money is likely to go on infrastructure projects rather than revenue spending, which is where the main pressures are being felt in health and social care.

Political realism about what the NHS is able to deliver is a necessary first step in facing up to the consequences of continuing austerity, painful as this may be. This means avoiding making new commitments that cannot be funded and deciding which existing commitments—for example, on waiting times—matter most. As well as realism about the state of the NHS funding and performance, the health secretary should have three other priorities.

The first is to rebuild bridges with NHS staff, especially junior doctors, after the damaging dispute over the new contract. Leaders at all levels urgently need to show that staff are valued, and this must start at the very top of the NHS. Not penalising NHS leaders who are struggling to achieve targets for patient care and balance budgets in increasingly difficult circumstances must be part of this.

A second priority is to support staff to bring about improvements in care and make better use of resources by focusing on changes in clinical practice. Work to tackle unwarranted variations in care led by respected clinicians like Tim Briggs and Tim Evans in NHS Improvement is starting to do this and requires the visible support of Treasury and health ministers. Clinical leadership is needed now more than ever.

Finally, the health secretary should continue to support work to implement new models of care better suited to the needs of the population and to produce sustainability and transformation plans in 44 areas of England.6 Some areas are beginning to show how care can be transformed through clinical integration and by organisations working together to plan for the future. Collaboration rather than competition holds out the best chance of the NHS and its partners navigating the treacherous waters that lie ahead.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References