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They say you wait for ages for a bus and then three come along at once. So, it seems, with NHS announcements.

Last week, the NHS has announced the following:

  • The lifting of the pay cap for NHS workers and a pay increase of 6.5 per cent for all NHS employees apart from doctors – some 1.3 million people.
  • Seven principles for social care that will underpin the green paper later this year and, perhaps more importantly, a confirmation that there will be a cap on the costs of care.
  • The publication of the Mandate for NHS England for 2018-19, highlighting deliverables on Brexit, Integrated Care Systems, as well as the conspicuous absence of deliverables on waiting times.

What does all this mean?

  • Health and social care is, and continues to be, a major policy area that affects and exercises a wide range of people; making is a subject the government cannot ignore.
  • The NHS is facing a wide range of challenges, from funding to increasing demand. There is a recognition on all sides that action – while perhaps not a crowd pleaser – is desperately needed.
  • The timing of these announcements, grouped together, is no coincidence and highlights an effort by Hunt, May and the rest of the government to establish a domestic policy agenda away from the ongoing Brexit machinations.

The Mandate

The Mandate is one of the cornerstones of how the NHS is run, and while the 2014-15 Mandate technically runs to 2020, each year the refresh reveals some of the changing priorities for the Department of Health and Social Care. In this year’s update, there was limited substantive change. The biggest change is a shift in tone throughout the document. For example, in setting out NHS England’s responsibilities with regard to implementing the Mandate, the 2017-18 document states that “NHS England is required [emphasise in the text] to comply with…the Framework Agreement”, while in the most recent document, this has shifted to “NHS England will need to comply with…”.

On the substantive changes, the most obvious is the inclusion of Brexit related objectives. In 2017-18, the EU was only mentioned once, but in 2018-19 there is an entire section on Exiting the EU and objective seven – “to support research, innovation and growth” – has morphed into “to support research, innovation and growth and to support the Government’s implementation of EU Exit in regard to health and care”. NHS England, here, has been tasked not only with supporting the government as it “takes forward” a life sciences strategy (another change – from “develops” to “takes forward”), but also to support the government and arms-length bodies to prepare for ‘day-one’ readiness. A welcome recognition from the Department of the impact of Brexit on the innovation economy, but somewhat disappointing as well, by lumping this in with preparing the wider NHS for Brexit rather than giving it a section on its own.

Integrated Care Systems (ICSs) also feature throughout, with references to the “voluntary rollout” of ICSs, as well as a deliverable to achieve 20 per cent coverage across England. In his forward, Jeremy Hunt refers to “the creation of new, integrated care systems as a way of delivering more joined up, co-ordinated health and social care across communities.” Integration features relatively heavily, with additional deliverables included on implementing the Better Care Fund, with a particular focus on ensuring that that funding is actually spent on social care. It is also interesting to note this in the context of Simon Stevens’ comments to the Health Committee in the Commons that ICSs might actually reduce private sector involvement in the NHS. While it is unclear how this will work, what is clear is that there is a real effort underway to inoculate ICSs from the kinds of ‘privatisation by stealth’ accusations their predecessor STPs faced. This only emphasises that they are here to stay and will become an increasingly important part of the NHS landscape.

Other noteworthy changes include a requirement to improve patient flow and reduce delayed transfer of care, the implementation of a variety of strategies for dementia, end of life care and brain injury that were published in the last year, and a recognition of the importance of embedding prevention to reduce illness – which is probably linked to the integration agenda. All in all, the Mandate does not deviate hugely from previous iterations, indicating a ‘steady as she goes’ approach from both NHS England and the Department of Health and Social Care.

One area of disappointment to many will be that deliverables on waiting times continue to be on hold. This commitment was also missing from the 2017-18 mandate and suggest that the NHS still anticipates tough times ahead with regard to demand. Simon Stevens has been adamant that more funding is needed to deliver against waiting times targets, and has noted that decisions to back away from those targets would mean the government would have to “publicly legally abolish patients’ national waiting times guarantee”. Expect condemnation from groups like the Patients Association.

On the funding front, the document includes a revision of NHS England’s indicative budget for 2018-19, including a £350 million cut to its administration costs. Of particular interest from a funding point of view is a small change in objective 3, where the Mandate stated in the 2017-18 document that the government is “increasing funding by £10 billion”. In the most recent version, this has changed to “at least [emphasis added] £10 billion”. Is more funding on the way? And will it go beyond the £5 billion expected to be raised by increasing National Insurance?

NHS funding

We do know of one funding increase. Jeremy Hunt has on Tuesday announced that 1.3 million NHS staff (i.e. almost all NHS employees excluding doctors and senior managers) can expect a pay rise worth at least 6.5 per cent over the next three years; a significant – and expensive – shift in government policy with the lifting of the one per cent pay cap. The pay rise will be fully funded by HM Treasury rather than coming out of existing NHS budgets, at a cost of more than £4.2 billion. This differs markedly from the pay rise awarded to police and prison officers only last year, which had to be funded within existing budgets.

Whilst the news has been met with some positive headlines and cautious optimism, there have already been concerns raised that in real terms the minimum increase over three years will be small – given inflation is forecast to be 2.4 per cent in 2018, 1.8 per cent in 2019 and 1.9 per cent in 2020. Many are also quick to point out that the rise for some will still fall short of making up the real terms cut in NHS staff’s pay since 2010 – the RCN estimates nurses’ pay has fallen by 14 per cent in real terms since 2010. The devil will also be in the detail around requirements for boosting productivity and the reform to automatic pay rises.

The pay rise deal opens up the wider question of pay rises for other public sector workers. Other bodies will surely be knocking on Philip Hammond’s door for a similar deal – leaving the Treasury with potentially a much bigger bill to pay over the longer term.

There’s also the question of what this deal means for the NHS being able to secure any further funding at the next Budget. Increasing National Insurance to raise additional funding for the NHS was rumoured the weekend before the announcements, which may give an indication of how more money for pay rises will be found. The story itself had the feel of a test balloon for Conservative MPs, as much as the public – and with support from Robert Halfon MP, it might be a goer. As it happens the amount that could be raised by a 1 per cent rise on National Insurance is £5 billion, more than enough to cover pay rises.

Social care

Social care torpedoed the Conservative’s election campaign last year, and attempts to detoxify the issue since have struggled or just made matters worse. But there is a growing recognition that urgent action is required to fix social care before the system collapses.

It is, therefore, no coincidence Jeremy Hunt confirmed any future funding system for social care will involve a cap on care costs in the Q&A session after his speech to a conference hall of social workers. It’s also no coincidence the first image the public sees when typing ‘social care’ into Google is a photo of Jeremy Hunt with an elderly woman. After negotiating the moniker of Secretary of State for Health and Social Care in January’s reshuffle, Hunt is clearly keen to get the optics right when it comes to the Conservatives and social care after their general election pledge bombed so spectacularly on the doorsteps of voters last year.

Last week Hunt outlined the seven principles that the social care Green Paper will cover, due this Summer. The Green Paper is also likely to address the generational political (as well as policy challenge) of social care funding, by suggesting a blended approach with social insurance for younger people, and possibly National Insurance rises for older people.

In making this announcement, Hunt has gained ground on all those pesky leaders of Conservative local authorities vocalising how they are struggling under the weight of social care delivery, ensuring that ahead of the local elections a sting has been taken out of this particular tail. At least for now.


The timing of these announcements is no coincidence, as the government and Theresa May, in particular, seek to set out a domestic policy agenda that starts to move away from Brexit being the be all and end of this government and parliament. To a large extent, this has worked. While Nigel Farage’s fish throwing stunt outside Parliament did garner some press, it was very limited compared to the flotilla in 2016. May is seeking to neutralise health and social care as the millstone around the Conservatives’ necks and bequeath a post-Brexit party that is in a good shape on domestic policy. With recent polls showing the Conservatives now back out in front on 44 per cent (compared to Labour’s 41 per cent), stealing a march on the NHS as an issue will stand both May and Hunt in good stead – Hunt as someone with much-rumoured leadership ambitions has a vested interest in getting this right.