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Nine major challenges facing health and care in England

The rollcall of health and care challenges facing the next government is long and daunting. Health systems around the world are still reeling from the effects of COVID-19 – and will be for years to come. But the underlying causes of the current crisis are much longer term – including a decade of underinvestment in the NHS and wider public services, weak capacity, staff shortages, political neglect of adult social care and more. Growing numbers of people are struggling to get the care they need today and pressures on services are only set to increase as more people live longer with major illness over the coming decades. The health of the population is stalling and inequalities between rich and poor are widening.

Responding to these challenges is not just about greater investment, but it will not happen without it. Services across the public sector are creaking after a decade of austerity112 and the outlook for economic growth that drives investment is weak.113,114 Policymakers face a choice: unless health spending grows over the long term in a way that reflects changing health needs, services will deteriorate, long waiting lists will be here to stay and the social contract underpinning the NHS may fray. But increasing spending on the NHS and other public services would likely require tax rises115 – and, even then, additional spending will take time and policy change to translate into better services. Government must also choose where to focus: for instance, how will it balance short-term objectives to increase access to NHS services with the longer term investment needed to improve social conditions shaping health?

Changes to how the health and care system works will be needed. Population ageing and the growing burden of disease mean longstanding policy objectives to strengthen disease prevention and deliver more coordinated services outside hospitals must become a reality. Past evidence shows this is easier said than done.116,117 But there are obvious places to start. For instance, successive governments have promised and then failed to reform England’s broken system of social care and support – leaving a gap in our welfare state. Stronger policy action is also needed to tackle the leading risk factors of preventable ill health and mortality, such as obesity. Population-level interventions – policies that impact everyone and do not rely on high levels of individual agency, such as a sugar and salt reformulation tax and expanding eligibility for free school meals – are most likely to be effective and equitable.119,120,121 Yet national policies implemented in England over the past decade have largely focused on individual behaviour instead.122 The next phase of Nesta’s 2040 Options project will look at these and other policy options to address the major challenges facing the nation’s health.

Debate about the future of NHS reform often focuses on the structure of the system. The NHS has been on an almost constant cycle of top-down reorganisations since the 1990s. And some media commentators and backbench MPs often point to the NHS’s funding model as a potential target for ‘radical’ reform – for instance, by introducing new user charges or switching to a different model for raising revenue. Evidence suggests these are the wrong places to look.123,124,125 The public have little appetite for them either. Instead, policymakers should focus on how they can best support the NHS to test and expand new ways of delivering care to meet the changing health needs of the population – including harnessing developments in data and technology and strengthening primary and community services, as well as learning from the rapid service changes implemented during the pandemic.126  

The trends we outline paint a gloomy picture. But how they play out in future is not inevitable. The NHS faced long waiting lists in the 1990s but brought them down through concerted policy action and investment over more than a decade.127,128 Long-run falls in UK smoking rates since the 1970s illustrate the impact of population-level interventions to reduce major health risks.129 And evidence on the impact of England’s health inequalities strategy in the 2000s shows progress on reducing inequalities is possible with sustained investment in public services and a mix of social programmes.130,131 For better or worse, policy choices made by the next government will shape the future of the nation’s health.

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