Representation to the Comprehensive Spending Review 2021

Executive summary and key asks

The COVID-19 pandemic is arguably the biggest challenge the NHS has ever faced, with unprecedented demand and pressure on the system resulting in worsening health inequalities, performance against targets and funding shortfalls.

Over 5.6 million people are now on treatment waiting lists, including 1.6 million for mental health services, and the efficiency targets from the NHS Long Term Plan (LTP) remain unmet in the previous two years.

To recover from the pandemic, the NHS must transform what care it delivers and how it is delivered. That means now is the moment to scale up recent innovations in digital care and patient experience and embed integration to improve patient outcomes and reduce inequalities as intended by the health and care bill.

As the membership body representing health leaders across the NHS, we ask that the government supports the NHS to meet this challenge by:

• finishing the service funding task started by the September funding announcement – we need at least £10 billion in service funding next year to cover ongoing COVID-19 costs (£4.6 billion), recover care backlogs (£4-£5 billion), and make appropriate allowance for lost efficiency savings, with inflation and demand adjusted settlements to 2024/25
• creating a multi-year capital funding settlement for the entire NHS – to reduce the backlog, ensure the safety of the NHS estate, embed positive pandemic-era changes and truly make inroads to reducing inequalities by transforming models of care, the Department of Health and Social Care (DHSC) capital departmental expenditure limit (CDEL) budget should rise to at least £10.3 billion in 2024/25. This funding will also help drive the NHS towards the UK’s net zero target
• addressing workforce issues such as lack of a multiyear funding settlement, pension issues, unfunded pay uplift and unclear future commissioning arrangements – to reduce the elective backlog and meet increasing demand, the workforce must increase by around a fifth by 2024/25; this means increasing Health Education England’s budget to £5.5 billion by 2024/25.
• allowing primary care to lead in helping people wait well – as we move to integrated care systems, the role of primary care will be more important than ever in driving better patient outcomes; however, leaders need more funding to deliver vital services – the current five-year funding settlement was agreed before COVID-19 and so does not consider the significant additional costs the pandemic has brought
• making discharge-to-assess funding permanent so community providers can help reduce inequalities and address long COVID – lifting local authority and public health budgets will mean that community providers do not have to absorb the recent unfunded Agenda for Pay uplift costs unfairly and, further, for community care providers to play their key role in reducing the backlog, they must be included in wider medium-to-long-term plans
• helping mental health providers address the increased mental ill health of the population – mental health services will need between £1.6–£3.6 billion, an annual average of £410–£900 million per year until 2023/24 (depending on demand) over and above existing funding to deal with this surge in people seeking support; however, in the absence of a new specific allocation in the spending review, mental health providers risk being left out of the recent funding announcement 
• equipping public health and social care to work effectively with the NHS and integrate care – a successful health and care system needs a well-funded social care and public health system, yet both have been neglected in recent years, creating greater demand for NHS services as a result; both need more funding, with local authority funding vital for a successful public health system.

More than ever, the past 18 months show the NHS to be a significant economic force, an ‘anchor institution’ that can level up the country, which positively impacts on people’s wellbeing, providing employment and boosting local economies.

With adequate funding they will be able to do so even more effectively. As large employers, purchasers, and capital asset holders, NHS organisations are well positioned to use their spending power and resources to address the adverse social, economic, and environmental factors that widen inequalities and contribute to poor health outcomes.

Finally, while the Spending Review relates to England, COVID-19 again demonstrates the importance and interconnectedness of the UK’s health and care system.

As such, the spending announcements must consider not only the Barnett consequential and the additional funding provided to devolved administrations, but the strategic and collective needs of the entire UK in fighting inequalities, population health and chronic health issues.

Throughout the submission, we draw heavily on the economic modelling undertaken by the Health Foundation’s REAL Centre.