Long-term neglect meets short-term politics

HSJ’s finding that a paltry 3 per cent of the funding for NHS building projects approved by government since 2017 has actually been released illuminates a dysfunctional state of affairs.

Providers have not been able to get hold of the vast majority of the capital they need – even once it has in theory already been given the nod and “allocated” by what has been a very cautious government.

This is before you consider the proposals which have been denied outright; those now having to be axed in-year; or the long tail of would-be projects which, like many from mental health trusts with substandard and sometimes dangerous wards, never bothered asking because refusal seemed inevitable. Or indeed look at the desperate state of much of the NHS’s core technology.

The capital shopping list is long and it is not populated with nice-to-haves.

It can’t be fulfilled overnight. This kind of infrastructure programme would involve a major multiyear settlement, not a one-off bung or a single-year budget boost.

As Boris Johnson gets to work as PM, a number of the other areas where the NHS most needs help from government aren’t necessarily quick or straightforward either. Training GPs and nurses takes years; on social care funding the history of failed attempts is as long as it is dispiriting; and for public health, there are the cuts to undo, but just as importantly, issues like housing, obesity, early years, and growing financial disparity. Hence the desire last year for a wide-reaching “long-term plan”.

In contrast, unfortunately, political commentators are mostly agreed the Johnson government is one “in a hurry”, rushing towards the 31 October Brexit day, and very probably a general election this year or next, with not much thought for what comes after.

Its window for action – and its policies’ shelf life – will probably be measured in months at most. 

Is this a curse for the NHS and its prospects for getting itself back on on even keel? Quite probably yes, especially when combined with the anticipated effect of Brexit itself.

But that does not mean there will be no short-term decisions the new government can and might well take which would help the service.

At the centre of the NHS, hopes are not high, but they do exist. Knowing the new administration’s pressing political need to show “front line” improvement, it is arguing this can be delivered – and “transformation” will start to take hold – if previously notified requirements on capital, workforce and social care are met (under Mr Johnson, hopes for public health are rock bottom).

The NHS is prominent in the worldview of the new prime minister and his team. Mr Johnson is said to be acutely conscious of and sensitive about his “£350m a week for the NHS” statement during the Brexit campaign. Dominic Cummings, the new key Number 10 adviser and ex-Vote Leave lead, recognised the power of the NHS in that campaign and acknowledged “leave” would not have won without the infamous claim.

They think hospital build announcements could be very useful for their short-term political imperatives of winning Commons votes from reluctant MPs, then winning Commons seats in an election, especially in “left behind” areas which often voted Leave, are suffering economically, and are sometimes swing seats. (Simon Stevens, who knows Mr Johnson, has previously spoken about the importance of district general hospitals in “at risk communities”.)

The new regime is also keen to turn on the spending taps, especially for infrastructure.

These are the reasons Mr Johnson mentioned the prospect of 20 “hospital upgrades”, as well as winter funding, in his early speeches (along with several competing spending priorities); and why members of the new government have already given thought (however superficial) to workforce funding too.

If there is to be a genuine Johnson NHS building programme, where it will fall on the spectrum from the routine few hundred million for winter patch-ups, to a comprehensive 10-year £50bn plan, is the big question. Those making the case for the service will likely need to push hard to get it towards the latter.

What might other short-term wins from this government look like?

If nothing else, a loosening of the strangling stringency the Treasury has applied to NHS requests in recent times (especially after its hand was forced on revenue last year) would at least create a bit of movement in the existing pipeline of schemes. National leaders are keen to push through some sorely needed upgrades to tech, not only premises.

Another good move would be a reversal of the draconian demand made earlier this month to cut 20 per cent from this year’s urgent capital plans, with a more flexible approach to Treasury-policed capital spending limits (and it won’t be long before details of these axed schemes are landed at the door of the new administration). 

Elsewhere, Mr Johnson said during his leadership campaign that the pensions’ tax changes hitting doctors and other higher paid staff, said to be damaging elective care performance, are “obviously wrong” and: “We will fix it.” Number 10 and the Treasury will now receive calls for the current insufficient proposal to be binned, and replaced with a rapid and genuine resolution.

For staffing, some inroads can be achieved – on continuing professional development to help retention and transformation, for example, and expanding training places – without committing vast sums.

And on social care, the best hope is to supplement the new PM’s doubtful early promise to “fix the crisis in social care once and for all with a clear plan we have prepared” into the more plausible outcome of a short-term but substantial boost in care funding in the coming months; while the longer term debate rumbles on.