5 Sep 2022

As expected, Liz Truss has been anointed as the new Prime Minister. One of her major challenges is the NHS and, with only two years to another general election, she does not have much time to restore falling public confidence in the service.  

Truss has said that the NHS will be in her top three priorities. So, what do we know about her likely approach? 

Expect support and money for the NHS. But a government giving tougher rhetoric for efficiency, productivity and delivery targeted at managers running the system.

The NHS’s challenges are well known – long elective waiting lists and waiting times, poor ambulance response times, a tough winter approaching, staff vacancies and unions sabre rattling for industrial action and higher pay, crumbling infrastructure, and more. Social care is in need and capacity shortages are exacerbating the NHS’s situation by bed blocking hospital patients. The NHS is also affected by the cost of living crisis, with hospital heating bills and ambulance fuel costs rising, and inflation reducing the value of the NHS’s budget.   

Add to this the growing debate over excess deaths not attributed to COVID. The pandemic left many people undiagnosed or untreated for other ailments. Expect a growing debate about the poor health outcomes for patients with major diseases such as cancer, cardiovascular disease and more. 

Over recent decades the politician’s answer to any NHS challenge has always been to throw more money at the problem. How will Truss respond?  

During the leadership election, the Truss campaign was forced to adapt her low-tax, small-state conservatism in the face of the cost of living crisis – from initially saying she would give tax cuts but not ‘handouts’ she has now bowed to political reality and is promising a wider package of support for households.  

We should expect the same approach in health. Truss has pledged to tackle NHS waiting lists and, to enable greater and faster hospital discharges, she recently said she would take the £13 billion promised largely to the NHS via the Health and Social Care Levy and give it to the underfunded Social Care sector. The National Insurance based Levy is due to be scrapped but the equivalent money will still be given to Social Care.  

NHS bodies were up in arms about losing funding in a system crying out for more – and Truss insiders predict that the NHS will keep its allocation and that higher borrowing will be used to give money to Social Care and retain the NHS budget. Indeed, the NHS may even get more. Don’t be surprised if the NHS gets an additional bung to help it through the winter.  

Further financial challenges also await the NHS next year. Staffing is the biggest single cost in the NHS and every 1% pay rise costs about £1 billion in England. The higher than planned 5% pay increase this year blew a roughly £2 billion hole in NHS England’s (NHSE) finances – and NHSE leaders have highlighted real-terms budget cuts in-year and the likelihood of having to cut prevention programmes and planned expansion in diagnostics. With inflation predicted to be 15% or higher next summer, huge unplanned extra money will be needed just to pay staff. Truss has also pledged to solve the ongoing problem with NHS doctors’ pensions to support retention. 

Truss will take a sceptical view of the ability of the NHS to spend its money wisely (also a longstanding Treasury view). Truss has talked of a ‘war on Whitehall waste’ during her campaign and promised to tackle NHS efficiencies and the ‘layers of management’ to improve the system. Current and probably outgoing Health Secretary Steve Barclay mirrored this language last week by putting a hiring freeze on NHS England and other national NHS bodies, and promising a reduction and refocussing of top-down priorities and targets.   

NHS managers argue that, after nearly a decade of below average funding increases, the NHS is already lean. We hear that some NHS Trusts are planning to meet current year efficiency targets via a simple write-down on their staff vacancies – not a long-term solution for a service seeking to increase activity.  

We can expect a Truss government to be tougher on productivity and finding new efficiencies. For example, the NHS has been poor at adopting the digitisation which has delivered root and branch transformation in other sectors and organisations – 1 in 7 NHS trusts are still paper-based for their patient records and are unlikely to meet current deadlines for change. 

Fresh structural reform of the NHS is off the table (the current changes are still being implemented) but new ministers could push for more dynamic changes to operational ways of working. The Government took some new centralised powers in the recent legislation, yet they will still face an uphill battle to quickly change a service where control is largely devolved to hundreds of local NHS organisations, where more money is often the requested lever for change, and where there is limited bandwidth for thinking about innovation with waiting lists and winter dominating the agenda.   

There should be fresh opportunities for tech and pharmaceutical companies with solutions that could streamline ways of working and reduce the burden on hospitals.  

More fundamentally, Truss will need to defend the affordability of the NHS and take a position on patients going private. This subject is a minefield for politicians but one that is now entering the mainstream media.  

 YouGov found that 1 in 14 people have paid to see a private GP in the last two years and think tank IPPR warned recently that paying for treatment risks becoming ‘normalised’ if NHS waiting times are not resolved quickly – their research showed that 1 in 6 would be prepared to pay for treatment if the wait was longer than 18 weeks. Many people are currently waiting 12 or 18 months.  

Some in Conservative circles will press Truss to reinstate tax relief on private medical insurance – a highly contentious but potentially operationally astute move. When Labour Chancellor Gordon Brown triumphantly removed this tax relief in his first budget in 1997 senior DH officials shook their heads, saying it would simply add people to NHS waiting lists and increase pressure on hospitals. A move to reinstate it would be attacked by the Left, but would play to Truss’s Conservative base, and could form a small but contributing part in reducing NHS waiting lists.  

In recent decades, the NHS has always been the first or second most important issue in elections. A Sunday Times poll in August found only one third of voters felt confident they would receive timely treatment from the NHS. With an election due by the end of 2024, Truss will also be thinking politically. 

It will be impossible to change the fundamentals of the waiting list challenge. Come what may, there will still be millions waiting too long for elective care in two years’ time.  

Her administration will need to show a series of quicker wins to put alongside (or distract?) from the NHS backlog which show a service improving in other ways. 

She will need to solve ambulance waits. Overseas recruitment to fill staffing vacancies in health and social care will need to bear fruit. Giving more money to the NHS is always good politics (the same Sunday Times poll showed that 60% believe the NHS to be underfunded). We should expect ministers to be ribbon cutting new community diagnostic hubs and other new facilities. NHS deals for new cutting-edge therapies and medical technologies are also helpful positive PR stories.  

Truss has committed herself to the manifesto pledge to build 40 new ‘hospitals’ (only a minority are complete hospitals). This programme is behind schedule and HSJ recently reported that DHSC officials are reprioritising it to enable smaller projects to be kick started. A few open and operational facilities will be important. 

 There will also be battle lines. Whatever the rights and wrongs of cutting management jobs, attacking management and NHS bureaucracy has always been an easy win for politicians.  

 If waiting lists cannot be turned around then ministers may need someone to blame. It is impossible to blame doctors and nurses but easy to blame bureaucracy. 

When former Health Secretary Sajid Javid gave a speech in the spring, some in NHSE saw it as the opening salvo in the battle for blame ahead of the next general election.  

Expect support and money for the NHS. But expect a government less ‘captured’ by devotion to the system than in recent decades, and which gives tougher rhetoric for efficiency, productivity and delivery targeted at managers running the system.  

NHSE and Government recently celebrated the near elimination of 2 years waits – the first major milestone in the NHS Elective Recovery Plan – but there are tougher targets ahead and it will be harder to claim victory. 

The clock is ticking for when the public decides if the NHS is safe in Liz Truss’s hands.