The NHS in England in 2013

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.e8634 (Published 02 January 2013) Cite this as: BMJ 2013;346:e8634
  1. Chris Ham, chief executive
  1. 1King’s Fund, London W1G 0AN, UK
  1. c.ham{at}kingsfund.org.uk

Funding and service pressures are likely to have an impact on the quality of care

The end of 2012 saw the NHS in England facing increasing demands from patients as a result of winter pressures and the norovirus. These demands have been compounded by cuts in social care funding and support, which make it difficult to prevent hospital admissions and ensure timely discharge. Despite these pressures, the performance of the NHS is holding up well on most of the available indicators, although a growing number of providers are in deficit, and it is proving difficult to maintain short waiting times in emergency departments.1

What then are the prospects for the NHS in 2013? As it enters the third year in which its budget will grow only in line with inflation, financial and service pressures on England’s NHS seem certain to increase. A recent survey of finance directors found that, on the basis of their plans and those of other providers in their area, many thought that quality of patient care might be adversely affected in 2013.2

Providers may also find it difficult to balance their budgets when, as the National Audit Office reported recently, most of the “easy” efficiency savings have been achieved.3 The irony here is that prudent financial management over the past two years has resulted in the NHS as a whole under spending its budget by around £3bn (€3.7bn; $4.9bn) and this money being returned to the Treasury. Those responsible for overseeing the funding and provision of care in the newly established NHS Commissioning Board will need to be much smarter to avoid this happening again.

Financial constraints and service pressures within the NHS have been made more difficult by the ongoing reorganisation that has arisen from the Health and Social Care Act 2012. Major structural changes and the loss of many experienced managers are distractions that are occurring at the very moment when the NHS ought to be focusing relentlessly on the quality of care and improving productivity. It will take some time before clinical commissioning groups and the NHS Commissioning Board can assume their full responsibilities, which means that service providers will have to take responsibility for making difficult decisions about where to spend or save money and which services to prioritise.

The leaders of the Department of Health, the NHS Commissioning Board, Monitor, the Care Quality Commission, Public Health England, Health Education England, and the NHS Trust Development Authority will need to display an uncommon ability to work together effectively in the new structure. Unless they do, they risk duplicating effort and creating confusion. Poor alignment between the mandate provided by the government to the NHS Commissioning Board and the planning guidance issued by the NHS Commissioning Board to the NHS illustrates these potential risks well.4 5 A reorganisation that promised to reduce bureaucracy and streamline structures has achieved exactly the opposite, with consequences yet to be fully understood.

One of the most important events in 2013 will be publication of the final report of the Francis Inquiry into the Mid Staffordshire NHS Foundation Trust. The report is expected to be critical of some senior NHS leaders and of the systems of regulation and commissioning in place at the time patients died or were harmed at Stafford Hospital. In formulating his recommendations, Robert Francis must avoid the temptation to see regulation as the main solution to the problems that arose at the hospital. He should focus instead on the role of leadership and culture in creating environments in which clinical teams can provide the best possible care within available resources.

How the government responds to the Francis Inquiry report will be the first big test for the new health secretary, Jeremy Hunt. In a speech in November, Hunt referred to “the crisis in standards of care that exist in parts of the health and social care system” amounting to the “normalisation of cruelty.”6 He emphasised that to deal with these challenges managers would need to be more accountable, patient experience and the quality of care would need to be measured and reported on, and staff training and support would need strengthening. The announcement by the chief nursing officer of a new vision for nurses, linked to investment in leadership development, offers an indication of how the government will turn the health secretary’s aspirations into practice.7

Another major challenge in 2013 is to convert ministerial commitments to integrated care into meaningful change on the ground. Integrated care is particularly important in meeting the needs of older people, who are major users of health and social care services. Studies have shown that there is considerable scope for improving care for older people by tackling unwarranted variations in how services are used in different areas and ensuring effective coordination during transitions in care.8 Making good integrated care a reality depends on overcoming the fragmentation of commissioning budgets resulting from funds previously allocated to primary care trusts being divided between clinical commissioning groups, the NHS Commissioning Board, and local authorities.

Taking the broader view, 2013 will be a pivotal year for the coalition government as it launches its programme for the rest of the parliament and embarks on the spending review. The government’s programme will provide an indication of how the government will respond to the Dilnot Report on the funding of long term care, whereas the spending review will determine the level of funding for the NHS for 2015-16. The language of “difficult choices” fails to do justice to the decisions that will have to be made in the spending review, with public services other than the NHS and education facing further deep cuts. These cuts will, inevitably and rightly, increase the pressure on the NHS to show that it delivers value for money for its protected budget. Doing more than maintaining current levels of performance will be extremely challenging at a time of unprecedented financial constraints. Delivering “the best customer service in the world,” to quote the planning guidance for the NHS in England,5 is a laudable aim, but it will be a minor miracle if it is achieved.


Cite this as: BMJ 2013;346:e8634


  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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


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