The next battle for the NHS: Sajid Javid v Rishi Sunak

一世t has taken a combination of sheer grit, creativity and the adoption of some unprecedented emergency measures unthinkable at the start of last year. 后 18 months of dealing with the pandemic’s ravages, there are now hopes that the 国民保健服务, perhaps Britain’s most revered and beloved of institutions, has managed to withstand the worst of the Covid onslaught. Yet although cases remain at far lower levels than some feared they would this summer, frontline staff fear the service faces a troubling diagnosis.

Hospitals in many parts of the country have been struggling in recent weeks to cope with the “unprecedented” number of people seeking A&E care. One longstanding trust leader said he had never seen his services so busy. Another boss at a rural hospital in a holiday hotspot said: “We are the busiest we have been in a summer, 这是肯定的, and we have seen many record days of demand.” Elsewhere, private ambulance services have been enlisted to help NHS 999 crews concentrate on the sickest patients. In Cornwall, police have been helping the NHS arrange volunteers in 4×4 vehicles, usually only enlisted to help during severe weather, to take patients home when they are discharged from hospital, to reduce the strain on ambulances.

GPs talk of having to deal with ever greater numbers of patients in pain who are waiting for long-delayed procedures. “They’ve already gone through an assessment to get to the point of being listed for the surgery,” explained Lizzie Toberty, a GP in Newcastle. “然后, they’re living with pain, limited mobility, with effects on their working life, their home life, their social life. They get in a low mood and then as a GP, you’re then trying to manage that pain. Often, our options are limited and you’re also trying to deal with the side effects.”

While the NHS may have fought an enormous battle against Covid, people in the service who spoke to the 观察者 warned that it may lose a new war against an intimidating gang of opponents – what NHS bosses are calling a “clash of the titans”. A combination of Covid issues, the emergence of health problems hidden during the pandemic, soaring waiting lists, an exhausted workforce and the continued pressures on capacity caused by increased infection control now risk creating a crisis.

It all means that the long-term NHS budget settlement, agreed with much fanfare by Theresa May in 2018, has been comprehensively overtaken by reality, 与 3.4% annual increases it promised now gobbled up. A rethink is needed if the service is to recover in the next few years.

Yet just as NHS leaders believe they face unavoidable extra costs running into many billions, chancellor 里希·苏纳克 and the Treasury are desperately trying to bring the eye-watering state spending unleashed to tackle various aspects of the pandemic back under control. It means that while NHS budget negotiations usually result in a compromise, the clash in approaches this time around seems far harder to resolve. With this autumn’s spending review hoving into view, a major confrontation looms.

“There’s real danger of a very large gap between the Treasury and the NHS,” says Chris Hopson, the chief executive of NHS Providers. “The Treasury insisting that they have to regain control of the public finances and get back to the May settlement as quickly as possible – the NHS saying that the demands on the service have changed dramatically and they can’t provide the right quality of patient care in a world of Covid-19 unless those pressures are recognised. It’s difficult to see how those two views get reconciled.”

Hopson boils the pressure on the system down to five main causes: “a May settlement that was never as generous as some pretended; a set of expensive new manifesto commitments; a social care crisis that must now be solved; a massive care backlog to recover; and ongoing Covid costs. Any one of those by themselves would be a major pressure. The problem is the combination of all five of them at once.”

So just how bad is it? Britain’s leading health analysts paint a grim picture. When health secretary 萨吉德·贾维德 warned earlier this year that waiting lists could reach an eye-watering 13 million people before they started to fall, it was regarded by some in his party as the opening gambit in a difficult negotiation. 实际上, the Institute for Fiscal Studies (IFS) thinktank says that prediction could be an underestimate. Since March 2020, there appear to be about 7 million “missing patients” – the amount who would have been expected to join waiting lists according to pre-pandemic patterns. It is not known how many of those will now re-emerge, but the growing pressure on GPs and emergency departments since the spring shows that demand is reappearing.

According to the IFS, 如果 80% of the missing patients return over the next year, the NHS operates at 90% of its 2019 capacity this year and next and then at 100% capacity from 2023 向前, waiting lists would reach 14 million by the autumn of 2022 and then continue to climb. But if only 65% of the missing patients appear and the NHS operates at 95% for the next few years, waiting lists would rise to 11 million within a year and then to more than 15 million by the end of 2025.

Even with significant extra funding, waiting lists look daunting. Should NHS capacity increase 5% 上 2019 levels this year and next, and then by 10% 在 2023 and beyond, the number of people waiting for treatment would rise to more than 9 million next year, and would only return to pre-pandemic levels in 2025. That would cost at least £2 billion, even before additional infrastructure costs.

同时, spending has ballooned already. Analysis from health thinktank the Nuffield Trust provided to the 观察者, and drawn from forthcoming research, shows that NHS trusts in England are on course to spend almost £5bn more in the next financial year than was anticipated when May set the NHS funding levels in 2018.

These higher spending pressures were calculated after taking out spending specific to the pandemic. “These extra costs beyond what the NHS anticipated will exist even once the onslaught of Covid-19 finally stops,” said its senior policy analyst Sally Gainsbury. “It is crucial that they are recognised in the forthcoming spending review. The NHS cannot expect the full gap to be wiped out by extra money, but the Treasury needs to be realistic about where the health service is starting from.”

On top of all that, the extra costs and needs are obvious. Covid tracking, vaccination programmes and long Covid clinics are just some of the directly related costs. For many who spoke to the 观察者, the state of mental health services was extremely worrying. Then there are the costs of training more staff and replacing hospitals and equipment – bills that were not previously included in NHS England’s last settlement.

This dilemma would be a huge challenge for any NHS leader, but it will fall to Amanda Pritchard, the newly appointed head of NHS England, to fight the service’s corner. She was a popular appointment within the service, but it is a major early test – especially coming after the political guile demonstrated by her predecessor Simon Stevens, which often saw him run rings around chancellors.

The other new actor in the saga is Javid, parachuted into the job in June after the resignation of Matt Hancock for breaching social distancing guidance. He is a former chancellor himself, known to be fiscally hawkish. While some in the NHS wonder if he will be fighting their corner, others have been reassured by speaking to their counterparts in local government. During his time as communities secretary, 他们说, Javid was a “doughty campaigner” for proper funding in a crisis. Ultimately, it will be a fight that involves Boris Johnson, 也.

“Some see Javid as a fiscal hawk, but as secretary of state, the buck stops with him on the eye-wateringly large NHS backlog, and it is safe to assume he will be pushing hard for more spending,” said Sally Warren, director of policy at health thinktank The King’s Fund. “There won’t just be wrangling between the Department of 健康 and Social Care and the Treasury. 不 10 always has a strong hand in NHS funding decisions and will have a keen interest in showing the electorate that a Conservative government can be trusted on the NHS.”

Will Sunak meet his pledge to give the NHS “whatever it needs, whatever it costs”? The government points out that it has been willing to meet costs. “This year alone we have already provided a further £29bn to support health and care services, including an extra £1 billion to tackle the backlog,” said a spokesperson. “This is on top of our historic settlement for the NHS in 2018, which will see its budget rise by £33.9bn by 2023-24.”

Yet those talking to the Treasury are not optimistic. The NHS has already burned through an extra £3bn it was given this year and Treasury officials have played hardball about further funds for the second half of the year. Officials fear the chancellor is using current talks as a dry run to show a determination to hold down costs when discussions turn to the new long-term settlement.

Experts believe the Treasury is trying to ensure the NHS pays for some extra costs out of its existing budgets. “The NHS has a five-year funding settlement that ends in March 2024,” said Anita Charlesworth, a former Treasury official who is now a leading health economist at the Health Foundation thinktank. “In the spending review the Treasury needs to decide how far it tries to hold the NHS to this pre-existing settlement and set a similar rate of NHS funding growth for election year 2024-25.

“The current signs are that the Treasury will push hard for at least some of the long-term costs of Covid and the waiting times backlog to be absorbed within current spending plans. But as the Office for Budget Responsibility has identified, the pandemic leaves significant unfunded legacy costs which could total around £7bn a year.”

The main hope for health officials is that political interest kicks in. The prospect of an election in 2024 at the latest may be the main advantage for those pushing for a more generous settlement. “They could hand the Labour party a real present if they get this wrong,” said one senior NHS figure. 同时, those on the frontline are trying to keep up their morale. “It’s that whole thing of trying to deal with things proactively and early, but we’re just not getting that because everything’s just drifting,” said Toberty. “Sometimes our patients have the perception that we can write to the consultant and get them moved up and that’s understandable. They’re desperate for their surgery, but we can’t.”