ELECTION 2024: The next UK health secretary will face an in-tray stacked with knotty problems, many of which the NHS can’t solve on its own. Craig Ryan looks at four potential trouble spots you won’t hear much about during the campaign.

Local NHS finances are under water

One of the first headaches for new health ministers will be the growing gap between the NHS budget for England and the spending plans of trusts and ICSs. In May, NHS England rejected as “unaffordable” financial plans from the 42 ICS areas which showed a £3 billion deficit. Last year, it topped up ICS budgets twice as the deficit swelled from a projected £700 million to £2 billion, with more than half of ICSs overspending.

Many local NHS leaders say they were pressured into unrealistic plans for 2023-24 and have nothing left in reserve to plug holes in this year’s budget. Some trusts are already cutting jobs, with even some clinical posts said to be at risk.

The Nuffield Trust’s Sally Gainsbury says politicians need to be more realistic about NHS funding: “Last year the gap was only closed as a result of raids on the capital budget, planned spending on service improvements being suspended, and elective recovery targets being substantially relaxed. None of those were things anyone in the NHS wants to see happen on repeat, yet with a funding settlement that looks unlikely to absorb the expected inflationary pressures this year, that’s where everything is pointing.”

Children’s mental health services are in crisis

According to NHS Digital, 20% of children aged eight to 16 have a probable mental health disorder, but most get no support from child and adolescent mental health services (CAHMS). At 1.2 million, referrals are up 50% since before the pandemic but, shamefully, two in five children have their referrals closed when they reach 18 without receiving any support. Failure to diagnose and treat children’s mental health problems can lead to a lifetime of poor mental and physical health, costing the NHS much more in the long run.

Experts blame the crisis on funding, chronic workforce shortages and the lack of services for children who don’t meet the CAHMS threshold but still need support. Children’s mental health services being split between an overstretched NHS, cash-strapped councils and struggling private and voluntary providers doesn’t help.

“Behind every number is a young person facing impossible challenges,” says Laura Bunt, chief executive of mental health charity Young Minds. “We cannot allow this to be accepted as the new normal: every day without action is another day thousands of young people are without the mental health support they need.”

Private care providers and charities are struggling

Private providers and charities make a big contribution to health and care services in the UK, but many are at risk of going under — potentially piling more pressure on NHS and local council services.

According to the Nuffield Trust, care costs for ‘self-funders’ — people who don’t meet tight criteria for state funding — are “spiralling” as providers try to shore up their finances. “Several providers have gone out of business due to… financial pressures exacerbated by the Covid-19 pandemic, staffing shortages and market instability,” the trust reports. The CQC’s 2023 State of Care report found that local authority budgets were failing to meet rising costs and care home profitability was at historically low levels.

Meanwhile, charities are struggling with rising costs and sharp falls in donations. Four health and care related charities closed in May 2024 alone: Age UK West Cumbria, Jo’s Cervical Cancer Trust, mental health charity Listen Well Scotland and eating disorder charity the Molly McLaren Foundation. The Charities Aid Foundation says over half of charities are worried about their ability to survive and only 48% can meet current demand. Many NHS and local council contracts are “underfunded and no longer viable for charities”, it warns.

The situation is “more perilous than ever”, warns Martin Green, chief executive of Care England, which represents independent care providers. “As we count down to a general election, the government must now make good on their promise to fix our sector.”

Health inequalities getting worse

Health inequalities between different areas, social classes and ethnic groups have all been widening in recent years. According to the King’s Fund, people in the most deprived parts of the UK experience on average 20 years less good health than those in the least deprived areas, while death rates from Covid were twice as high. Health disadvantage is baked in from the very beginning of life: black parents or those living in the poorest areas are twice as likely to have a stillborn baby as white parents or those living in the most prosperous neighbourhoods.

“Successive governments have shied away from the bold action needed to tackle inequalities,” says the Health Foundation. It calls on the next government to “make bolder use of tax and regulation” and spend more on public health to reduce smoking, alcohol use, unhealthy diets and physical inactivity. The foundation also wants measures to tackle economic inactivity and more local council funding targeted at the poorest areas.

In its 2023 report Targeting Health Inequalities, the foundation called for targets to “drive action” on health inequalities, similar to those for waiting lists and cancer care. “While difficult, reducing health inequalities has been done before and can be done again,” the report said.

• Craig Ryan is editor of MiP’s Healthcare Manager magazine.