David Cameron likes to boast that not a day has been wasted since his unexpected triumph 100 days ago. That may be the case. But it’s also true that ministers are scampering around like jugglers keeping improbable numbers of plates balanced at the same time. In several departments, most of all at health, it is looking increasingly likely that even as agile a minister as Jeremy Hunt will be unable to avoid an almighty crash very soon.
Last month, Mr Hunt went to the King’s Fund, the impartial and long-established health policy thinktank, to set out his plans for the next five years. Mr Hunt is already unusual, a member of a small band of health secretaries (headed by the NHS’s founder Aneurin Bevan) who’s stayed in his job, one of the toughest in cabinet, after an election. But on Monday the King’s Fund is publishing its assessment of progress since May, and its conclusion is that he may be in office, but increasingly it is the Treasury that is in power. This marks the denouement of the ambition of Mr Cameron’s first health secretary, Andrew Lansley, to devolve power away from Whitehall. For all trusts, even the supposedly independent foundation trusts, and increasingly for patients facing lengthening waits, the result is already serious, and likely to get worse.
Even before the autumn spending review, which may well distribute some of the ring-fenced NHS budget to councils so that the plans to deliver joined-up health and social care can be kept afloat in the face of another round of cuts to local government budgets, the NHS is expected to finish the financial year £2bn in debt. Any pretence of allowing foundation trusts financial independence is gone. Hospitals are instructed to limit spending on agency staff while introducing seven-day working. Mr Hunt’s hopes of introducing more sophisticated performance measures to drive quality improvements may founder on demands from the Treasury to hang on to the targets that are more easily understood. Sceptics fear that George Osborne’s experiments in devolving responsibility for health budgets to Manchester and Cornwall, which come without any clear organogram explaining where power lies and who exercises accountability, may turn out to be more a matter of devolving painful cuts. Meanwhile, manifesto pledges are already fraying. Most blatantly, the commitment to cap spending on social care as recommended by the Dilnot commission early in the last parliament has been reneged on. There were serious doubts about whether local councils, where spending per person has already been cut by nearly a quarter, could have afforded to pick up the tab. Even without Dilnot, they will have to factor in the new living wage obligation, welcome in itself but another heavy burden on councils.
Last month, in a revealing public discussion between Mr Hunt and former health secretaries, Patricia Hewitt said that she considered the most effective thing she had done was to ban smoking in public places in 2007. Within a year, pressure on NHS cardiac units was slacking off and in a review after five years, it was considered to have protected the health of thousands of children as well as cutting heart attacks and lung disease in adults. Yet spending on public health, which is at the heart of NHS England’s five-year plan, is to be another casualty of Mr Osborne’s austerity. It will be cut in the coming year by £200m, while the promise of a strategy for tackling obesity in children, due later this year, has no budget attached. The King’s Fund, a measured expert commentator on successive governments’ plans for the health service, is unmistakably pessimistic. There is no sign of a £2bn transformation fund which it and the Health Foundation agreed was essential spending in order to reconfigure the NHS so that it could fulfil – after only 65 years – its orginal ambition to be a health rather than a sickness service.
This administration’s plans are laced with unresolved tensions that stem from the health secretary’s commitment to improve quality and the chancellor’s determination to impose more austerity. There will be many NHS professionals relieved that there will not be another upheaval like Mr Lansley’s revolution, or even that they are not wrestling, unavoidably against a continuing cash squeeze, with Andy Burnham’s manifesto plans to reform health and social care. But ploughing on trying to deliver incompatible objectives driven by different departments makes the task of running the NHS look like mission impossible.
