That was the year that was: health policy in 2021 – with Lord Victor Adebowale and Hugh Alderwick Episode 15 of the Health Foundation podcast

Jennifer Dixon: Hello and welcome to a special Christmas edition of our podcast. We're calling it ‘that was the year that was: health policy in 2021’. We'll be chewing the cud on some key things that happened this year and what they might tell us for the future. And we'll be using a political lens to do it. So as usual, I have guests. We've invited the shrewd who can see through all the flimflam to clock the real goings on. So I'm really delighted to welcome Victor Adebowale, who is chair of the NHS Confederation and member of the House of Lords. Victor will be knocking some good sense we hope into the health bill, amongst many other things. And Hugh Alderwick, the very wise beyond his years Head of Policy here at the Health Foundation. Welcome both. We're going to talk about the NHS in a minute, but looking back over 2021, I think the place to start was probably the pandemic, isn't it? So I think the first sort of questions, I suppose, is your reflections on how the government's handled it broadly in 2021. I mean, if you think back to the year, to me it looks as if it's been a year in thirds. So the first third was the horrendous January and the peak of Delta. Then we had a middle third, which obviously the summer, with Hancock going, Stevens going, Pritchard arriving, Javid arriving, and a bit of a relative quiet. And then the last third, which has really had a sting in the tail with Omicron. And, of course, with all the Number 10 shenanigans. So your thoughts about the government handling, we'll get to the NHS in a minute. 

Victor Adebowale: On the one hand, we've never faced anything like this and the government could be excused indeed for making the errors of ignorance. You know, you haven't dealt with this before. But the thing about leadership that I've always noted is that generally, it's about leaving people from where they are to where we haven't been before. And the problem with the government's handling, and I think there is a problem with it, is that the handling of COVID has become politicised, the lack of consistency in messaging, and clarity. And I think there's been an increasing sense of political decisions being made on the back of scientific advice. And I understand, you know, the scientists are there to advise and the politicians decide. But in the absence of complete knowledge, when you're dealing with a pandemic, it seems to me that that utmost caution is the best principle. So the summer was wonderful in the sense that we had the vaccine, we were starting to release the restrictions, but the virus was still with us. And it was predictable that there'd be another wave and the government would have to make decisions about what steps we were going to take. The politicisation of the steps that need to be taken is worrying in this context, because we should have been wearing masks for a long period of time, we should have been cautious about going to work. I know there are economic consequences, but believe me, there's an economic consequence in the lockdown and the NHS going up in smoke. So I just think that the politicisation of the response has been a real problem. 

Jennifer Dixon: By politicisation Victor, do you mean that there's a discrepancy in the approach to risk taken by the scientists versus the  politicians? 

Victor Adebowale: Yeah, it seems to me to be, you know, this stuff is about visible leadership as much as anything else. You know, if you're watching television and you're told to wear a mask but every single member, you know, you look at the MPs not wearing masks, that sends a signal. There’s a dispute about whether the virus is, whether people should be working from home. I think the messages need to be consistent and clear. Otherwise, people become very confused very quickly. 

Jennifer Dixon: You've got a clutch of scientists and groups giving advice: SAGE, the UK Health Security Agency, you've got Chris Whitty, you've got Patrick Vallance, and in the sense that there's a lot of consensus isn't there between those groups based on the science. But you don't have the equivalent on the economic side to say, what is the evidence base for this or that decision in response to the... so you have politicians sort of almost freewheeling on what their interpretation of the economic evidence is? 

Victor Adebowale: Yeah, that's true. But I think that part of the problem is that we've kind of separated the economic consequences from the health consequences, as though they're very, very different. And actually, they're not. You know, if the pandemic runs riot, there's an economic consequence. You know, if the NHS collapses under the strain, there is a major economic consequence. I think we've got to deal with the health challenge, otherwise, we won’t have an economy. And yes, there is a lot of economic pain in doing that, as we've discovered, it's been very expensive and we've had to do things that no economy, well, the Conservative government has never done, which is spend an awful lot of money holding the economy up. But that's a consequence of the virus. 

Jennifer Dixon: Yeah, it seems as though when you're sort of staring a true emergency in the face, that's almost when the political judgments become more aligned with the scientific judgement, as we're in the situation now, isn't it? But if there's any chink of light between them, then of course the politicians have a different sort of assessment of risk that they're following.  

Hugh Alderwick: Some of that chink of light is about timing as well. Because if you think about where we are now, we're in a pretty eerily similar position. So much has changed since last year: vaccinations, test and trace system has changed quite a lot. But we've got big concerns about a new variant before Christmas, we've got big pressure on the NHS, we're rushing to get people boosted. And the question about when's the right time to impose more restrictions, social restrictions, which is where we were last year. And often the disagreement seems to come in the timing, and lots of criticism for government acting too slowly this time last year. So the chink of light between science and politics is often when to act. But unfortunately, we know in a pandemic, quicker than you might expect is probably when you need to act. 

Jennifer Dixon: Now, we haven't had too much formal scrutiny of the government's response to COVID, but we did have in July the Public Accounts Committee report which outlines some initial lessons and they were very focused on, do you remember, the late lockdown. And they said the late lockdown in the early stages of the pandemic was, quote, one of the most important public health failures that the UK has ever experienced, is what they said, they didn't mince their words. So we're obviously in another situation where we've got Omicron ahead of us, well, present and about to kick off big time. So the question is, has the government learned? Does it show signs of having learned from that first lockdown? 

Victor Adebowale: I would argue that probably not actually. There's a saying that's often, I think it's a Jamaican saying actually, that if they don't hear it, they're going to feel it. And then there's the whole question of did we learn, is the question from the last lockdown about a) keeping measures on. I mean, the NHS Confed ran a ‘not too much to mask’ campaign, because masks work. Did we release too soon? Did we put restrictions on, cautionary restrictions on things like passports and what have you? No, we didn't, it was all very, very mealy mouthed, very, very politically charged. I think the lessons are being very, very slowly learned. And that's worrying.  

Jennifer Dixon: Yes. And we've also got a public inquiry that's supposed to be kicking off in the first half of next year with the chair appointed by Christmas. Victor, do you know any more? 

Victor Adebowale: I don’t, actually! You can bet your life that whoever it is...you would want someone to have a real public standing and real authority, someone who has a real unimpeachable sense of balance and what's right, such a person would really have to think very hard before… 

Jennifer Dixon: Well yes exactly. It could be a never never inquiry, couldn't it, with lessons sort of, you know, recommendations long list coming up in five years’ time. So you'd have to be pretty strong to be able to shape the terms of reference, wouldn't you, to just have something that would be meaningful? 

Victor Adebowale: I think you're right, you'd certainly have to be very strong to have terms of reference and a rational timetable, but you would also – and I don't think it takes a political analyst to work out that the amount of pressure that we put on that person, given that there's an election within probably the timeframe of any inquiry, the pressure that we put on that inquiry not to come up with something which is damaging to the government would be absolutely immense. Because any inquiry that looks at this objectively will find a myriad of errors and mistakes, issues, some of which we've discussed. 

Hugh Alderwick: I think the person clearly is important, but the scope, the terms of reference for the inquiry is going to be so critically important. Inquiries can have so many different aims: establishing the facts, trying to learn from what happened, sometimes catharsis for the groups affected, accountability. And I think the risk we've got with this one is that the scope will be so broad and vague that it takes decades to publish anything providing any lessons. Then you've got a counter risk is that the scope too narrow and doesn't focus on the big issues. There's quite a lot of lessons we know already. And so being really clear about, well what's the inquiry for? And what are we going to learn from it that's different to what we already know will be important. I think social care is a really good example, where some parts of the story are pretty well known. Government claim they've thrown a protective ring around care homes. The reality, our analysis shows, quite different. Action too slow, inadequate, policy issues persisted throughout the second wave as well as the first one. Establishing who knew what, when and how that shaped decisions should be one of the key focus, the risk is it becomes about absolutely everything and we wait ten years. And if one of the purposes is to learn for the next time this happens, we want to learn quite quickly. 

Victor Adebowale: We were caught on the hot by a pandemic, and it wasn't just health that was problematic. It was virtually every area of public service was affected by this. And they were all found wanting largely because we've had ten years of austerity. We need to learn some big public service, big lessons about how do you have capacity in public service systems to deal with the unexpected, or in the case of pandemics, the now expected because there are some people that have been predicting a pandemic at some point, and there will be another one. And so there are big lessons to learn for the resilience of public services, out with, you know, health and social care, which, as you pointed out. 

Hugh Alderwick: The lessons we can learn are really to do with the interaction between the decisions before, the decade before the pandemic, public services, and then decisions during the pandemic and how they interact. So as Victor says, we’ve got some obvious factors to do with the pre-existing context that shaped the policy response: decade of austerity in public spending, which meant that a lot of the services to promote, protect health have been pretty radically diminished. Big constraints in NHS resources, fewer doctors, nurses, hospital beds, and so on than many comparable countries. Neglect of adult social care, the list goes on, pandemic planning that, you know, largely focused on pandemic influenza. And all of those things shaped then the decisions that were made during the pandemic. So, capacity in the NHS meant we shut down a lot of planned care, quite rightly, to deal with COVID. But that's had a longer term effect on the backlog, lack of capacity in adult social care has really constrained that part of the response, stocks of PPE, testing, to build a testing system. So that does then become a huge set of questions for an inquiry to answer. So being clear about where do we draw some lines to make this manageable will be really difficult. 

Jennifer Dixon: Let's just turn to the NHS for a minute, because that's obviously critical here. So what struck me about last year is that the previous year we were all out in force clapping, weren't we, the vaccine rollout, the gratitude of the staff, but this year seems to have been characterised by a few more grumblings. You know, obviously, the NHS has done a fine job, but it is struggling with recovery for obvious reasons, and relative to other countries as well. We've had some localised skirmishes like the campaign in the Mail against the poor old GPs about their supposed proportion of face-to-face consultations and so on. And then you've had growing grumblings again in the autumn about the NHS being a money pit, particularly after the Health and Social Care Levy is being raised and how the NHS is gobbling up all the public sector funding. And I think some of this came to a head didn't it in the Conservative party conference, there was a sort of ‘something must be done’ kind of head of steam that built up. And then we had Omicron. So until Omicron reared itself, we seem to have been having some kind of meme where the NHS was seen to be a problem and that reform could be on the cards, further reform. So we had Messenger brought in, who's doing a review of leadership and so on. Do you get the sense that those grumblings haven't gone away? And that actually more fundamental reform, more than the bill, is actually ahead? Or do you think that actually this was just sort of performative politics around the Conservative party election grumblings to do with the amount of money that the NHS has attracted through the levy? And actually, it'll go away because everyone's sort of dealing with the pandemic?  

Victor Adebowale: I don't think it has gone away, no. It's interesting, isn't it, we started this period of Conservative government with the sort of public sector expenditure message which we need to cut our cloth and we need to cut spending, and there's no magic money tree. And the pandemic has forced this government to behave not that different from a very, very left wing, Labour government in terms of it’s had to spend a lot of, a lot of money. And it is not surprising that that has caused some, more than raising of eyebrows. And there are some questions that are perfectly legitimate to ask, you know, are we getting value for money from the money spent in the NHS? I've been worried about an attempt to sort of move the Overton Window away from the notion of an NHS free at the point of access. Oddly enough, the government's response to that, certainly in relation to the Health and Social Care Bill, is to reassure people, doubly reassure people that that's not the case and it's not being privatised. And that's all to the good from where I'm sitting. But I think there's still a debate about public expenditure generally. Because the NHS spends a lot of money there will be debates around whether that's value or not. 

Jennifer Dixon: Hugh it would be interesting, your take, I mean, just a couple of sentences on the NHS as a money pit. I mean, actually, it isn't when you look at international standards and particularly next to Western Europe, and also our tax levels are lower as well. So for what we spend on it, the performance is good. So that doesn't tend to come across, does it, so what do you think about this reform, what's your take? 

Hugh Alderwick: A lot of this money pit stuff is just nonsense, isn't it? I think a lot of the debate, particularly on the right at the moment, pretty conveniently forgets that spending on the NHS has been lower than the historic average of the last decade. So going into the pandemic, we spent less on health care compared to many comparable countries, fewer doctors, nurses, hospital beds, equipment than most comparable countries, big staffing shortages. We've increased spending during the pandemic quickly because we needed to. But we should see that in the context of how hard we were hit by COVID. Very hard. The context for our system compared to other countries, so if we had low spending previously, we're rapidly having to increase capacity to deal with the pandemic. There are also some pretty boring differences in how countries report data. But the idea that, ‘oh, look, there's been a big jump in spending, particularly on test and trace’ shows that the NHS is poor value for money – it's just nonsense. But it's leading to a funny conversation about reform, which is not a new one, but the idea that something must be done. And that's often based on a very faulty assumption about how the NHS improves or how public services improve. So we've had that NHS leadership review launched with an undertone of an assumption that tougher, more businesslike leadership is what the NHS needs. We've had some pretty blunt policies to encourage GPs to increase the proportion of face-to-face appointments with some risk of naming and shaming. I think both of those approaches seem to assume that more shouting at the system from the top is the route to improving performance, when actually it's a much more boring blend of investment, support, management. So these are things that seem shiny to politicians or seem reasonable if you think about it for five minutes, but as soon as you understand what drives improvement in the NHS, how long it can take for spending to translate into increased capacity, you're looking at a much more boring, but much more important set of levers to improve performance. 

Jennifer Dixon: I suppose if you think about it, if there's an election in 2023, which is still kind of likely, isn't it? You can't really do anything, you can't really scare the horses on major reform before then, can you? So it strikes me that you're almost out of time now to even begin to moot that, even if you wanted to do it. Maybe the question is not can we afford the NHS, but why do we have an economy that struggles to support a cheap and cheerful service? 

Victor Adebowale: I think you hit the point, the fundamental question is, why are we asking these questions on the basis that we're not spending as much as many of our European and world competitors, but getting a good service. Surely we should be spending more, and we should be looking to increase its efficacy. And I do think that part of the problem is that the politics around the NHS has always presented the NHS as a burden, as a weight on everything else. And in fact, the NHS is exactly the opposite. It's not only an employer, but it's an economic driver for this country. So we've got this really strange narrative around the NHS, which doesn't help clear thinking about its future. And just to say that, you know, the Health and Social Care Bill is a real opportunity. It's also something the NHS, by and large, wants. My members want it, we’re the biggest representation of members, of leaders in the NHS. It was designed from within. And in a sense that puts pressure on the NHS to deliver within the context of the Health and Social Care Bill, deliver population health, integrate health and social care, show what can be done in some places where there's the resources to do them, while reminding the public that it is cheap. We're not spending enough, by a long way. 

Jennifer Dixon: So on to the specifics, the NHS is not reform-free at the moment, as you say, Victor. So what we've got is obviously the Health and Care Bill. And that really has sort of three bits, doesn't it? One is the setting up of integrated care systems across the country, 42 of those I think. And then the second bit is to alter the Secretary of State's powers over the NHS. And then the third bit is tidying up to do other bits and pieces, including competition, rules, and so on. So we've got that going through. But we've also got a few other bits as well. We've got white papers coming out of our ears. We've got the integration of the NHS and social care white paper, which is currently being written. We've just had a social care white paper that's been published. We've also got, have I got this right, Hugh? An inequalities white paper as well? 

Hugh Alderwick: You’re not allowed to say inequalities anymore, Jennifer. 

Jennifer Dixon: Oh sorry, disparities? 

Hugh Alderwick: It’s very American, disparities. 

Jennifer Dixon: So that's quite a lot, even in the middle of a pandemic, isn't it? So Hugh, where are we with the bill? 

Hugh Alderwick: Basically, story of three parts. So in the first part, these are the quite technical policy changes that NHS leaders largely wanted to encourage better collaboration in the health system. And those are the changes that broadly make sense because they build on what the NHS is already doing. But I think the benefits shouldn't be overstated. And really, as the bill’s gone through Parliament headed for the Lords not a large amount has changed on that part of the bill, we've had some additional things about CQC assessing these new integrated care systems, but that's largely intact. The second part of the story is a much more political set of changes. These are from government, not really the NHS, and they try and just increase political control over the day-to-day running of the NHS. I don't think those changes have a clear logic, rationale, they'd have been much better off ditched by Javid when he inherited them from Hancock. And again, they largely still remain, and so the Lords are going to be debating them, perhaps suggesting amendments for more checks and balances. And then part three is sort of everything else, the wider collection of stuff in the bill. Some stuff on workforce planning, data, public health, government also used the bill to amend the Care Act, the changes to the cap also thrown in there. And this is probably where some of the biggest debates happen. So Jeremy Hunt proposed an amendment to strengthen what the bill says on workforce planning, it's really pretty weak at the moment. But that wasn't accepted so that now goes to the Lords, the Lords have had a debate and now they're going to suggest some amendments. And the whole idea is this gets done by March so the changes can come into effect in April, so the timeline is really, really tight. And the makeup of the Lords, as Victor knows, could make it difficult for government. So that's, I think, where we are with it. 

Jennifer Dixon: Hmm, Victor, what are your thoughts, given the fact that you spoke in the Lords Second Reading last Tuesday? 

Victor Adebowale: On the health bill, and I was there through most of the debate in the House, and I think you can categorise it into three chunks, really. Those that think it's another major change and don't want anything to do with it and want it abandoned. Those that can see the value of it and just want it to happen, because they know where its come from, and actually can see that it's not a restructuring as such in the old-fashioned way. And those that kind of get it and are being lobbied around the loss of power for certain things within the NHS and are really worried about that and want to deconstruct it in terms of timescale and what have you. I'm with the second, I think that we need to get on with it, because it's already happening. And it has been happening for some time. The 2012 Act was a dog's dinner and it didn't work. This is the NHS’ response in the sense ground up to that. And we need to get on with it. Notwithstanding proper parliamentary scrutiny. I think we should be able to do that. The big issues are the ministerial powers, which are significant and in a sense they could provide a chilling effect on the actions of ICSs to actually act in the interests of their populations. I don't think there's a plan B for the NHS. So I'm hoping that the Lords will find a way of pushing this through. I didn't see from the opposition benches or hear much that convinced me they had an argument for abandoning the bill. In the end, it was about scrutiny. And I, both myself and people like Lord Simon, Simon Stevens, will push the government on both ministerial powers and on the workforce because we think it’s weak.  

Jennifer Dixon: So for listeners who may not be so familiar, the worry is the Secretary of State powers gives extensive powers to the Secretary of State to intervene on a whole range of decisions up and down the NHS, from closures of hospitals to merging arm's length bodies. And then the other, the workforce issue is just to make sure that there are independent long-term projections that are made and published, rather than ones that aren't published and can be quashed, therefore, more easily by the Treasury for financial considerations, and then we of course find ourselves with shortages down the track as we have been doing. So just for me to finish up on the bill side, Victor, where do you think we'll end up on that come April? Can you stick your neck out and give us a prediction? 

Victor Adebowale: I'm not a predicting kind of person, generally. I mean, I think there's no reason why we can't get this bill through by April, you know I think it's possible, I think it's possible. Do I think it's likely? I think it's 50:50 at this moment, I really do. I think it's hard to call. I know you've asked me for a prediction. 

Jennifer Dixon: Okay, it's a pretty safe bet that one. What do you think, Hugh? 

Hugh Alderwick: Victor’s right in the sense that, the chunk of changes around getting different parts of the NHS to work together more, they're already happening to some degree. But I do think we shouldn't get carried away about the impacts of the changes. Over the last 30 years we've been on a bit of a treadmill of reform but if we look at the evidence it actually suggests that previous reorganisations or restructures in the NHS have delivered little in terms of measurable benefit. And they can also have negative effects like additional costs, destabilising services and relationships. I think it's quite heretical at the moment to say ICSs might not make all that much difference. But we've got to be realistic when we look back at the evidence. 

Victor Adebowale: We've appointed 42 chairs of ICSs, we've appointed near as dammit all the chief execs, we have set up ICBs, we have provider collaboratives, we have new ways, new services being designed in some places. Now, I'm not one of these people who think we're about to achieve a kumbaya moment and everything's going to be fine, I don't think that at all and I think people are right to be sceptical. However, the option of not going ahead with this change means that you have a major restructuring of the NHS on your hands, because it's happening, it's happened, a lot of this has been done already within the powers that the NHS has. All this bill is doing is putting a wrapper around it. 

Jennifer Dixon: Yes, I suppose the basic point here is that if any government is looking, politician is looking for a magic bullet to suddenly speed up, accelerate change in the, progress in the NHS, then no one thing is going to fit the bill, is it, to – forgive the pun. Because these are largely administrative changes, aren't they? If you look at the NHS in Scotland, relative to England since 97, despite quite different ways of administration up there, there isn't a massive difference in some of the outcomes being achieved. So it's not going to be a magic bullet, the big reform bullet, administration-defining. Just onto social care. I guess the big question there, given the white paper that we've already had, do you think there are many reasons to be cheerful, when we talk about how social care is going to change and are the changes in the social care white paper, quote, going to fix social care at once and for all? 

Hugh Alderwick: Okay, so some small reasons to be cheerful, but not a fix, is the summary. If we think about the current social care system, in England, it's a pretty threadbare safety net and it's been put under even more strain by the pandemic. So the issues in the system are not simple. There's lots of them, they’re to do with not having enough money, not having enough staff, long term political neglect high levels of unmet need. I think what the government has offered so far – a mix of things, the white paper, the cap – are a long way off something that’s going to fix the system. So the new cap on care costs, which is basically a limit on how much an individual might spend on care over their lifetime is going to help some people avoid very high cost of care. But as it currently stands, because of changes to what we expected the cap to be, it won't help many people with lower levels of wealth. The white paper had some sensible measures in it, some small pots of money, but no big reforms that are going to radically change how the system works. And it's going to do very little to address the big challenges facing the system now, like big workforce shortages and so on. I think the big issue here at the moment is money. So the funding provided by government for social care over the next few years, once the extra money has gone towards the new cap, there’s barely enough to meet growing demand for care, the changing population and so on, let alone improve expand the system and provide more care to people who need it. So some reforms and it's great that government has introduced this cap, but the cap now is a very limited measure compared to what we thought it would be, and much less fair than we thought it would be. So a long, long way to go, I'd say, before the prime minister can say he’s delivered his promise to fix the system, and huge pressures right now as we head into winter. 

Jennifer Dixon: And of course, it doesn't do very much, does it, to provide more access to better social care, which is needed to try to not only support the population, but also to support the NHS as it's trying to recover. 

Victor Adebowale: Well, I mean, what we've got so far is nothing like a solution. It lacks a vision that's relevant to the needs of today, as far as social care is concerned. The money's welcome, it’s always welcome. And they know they had better throw some money at it, but it's just not good enough. And, as has been pointed out, it has some rather unintended consequences that people reckon are deeply unfair, and they are. So I just think we're going to have to accept this is where we are, I do think they're going to have to rethink the whole model of social care. I think you can't do that without an integrated view of the whole system. Because as you've pointed out, without social care system, then you’re putting massive weight on the NHS. So we're going to have to come back to it. And I think they will come back to it, they'll be forced to because it's such a necessary part of the health care system. And it almost gets to a point where you have to ask the question, what's the problem? You know, why can't they resolve it? What is the issue? 

Hugh Alderwick: It's so deeply depressing, because if you think back to last year, where it was so obvious that there was major public policy failure on social care before and during the pandemic, and so obvious to the public, it seemed. In the headlines we had what was happening in social care, the amount of people that unfortunately died in social care, the strain on carers and unpaid care, it felt like, crikey, we're going to reform this system now and politicians are going to reform the system. And perhaps we should have looked back in the past and said that reform hasn't happened for lots of different reasons and perhaps we shouldn't be so optimistic. But the fact that after all of that what we've had in these last two years, and what we still have is a pretty piecemeal...we've got drip, drip, drip of funding from government when they just need to turn the tap on.

Victor Adebowale: If there is a good thing about it, I'm using the word good very advisedly, it's that social care has now been thrust into the public's gaze, you know, the debate of social care has been thrown really live into people's living rooms. And I think that's going to drive another look, because the solutions that they've put forward actually make it worse for many people. And I think they're going to have to revisit it. And there are now people who are deeply affected by the lack of funding in social care, and a pandemic, who now understand the link between social care and health in a way that's visceral.  

Hugh Alderwick: This is just down to political choices in the end. So clever people in the Health Foundation do estimates of how much it might cost to reform the system. So I think the latest estimate is if we're going to properly reform social care, improve quality, address unmet need, improve staff pay, might be about another £9bn by 2024/25, on top of money already provided. So that sounds like a lot. But it's not unaffordable. We're one of the richest countries on earth. And we're often hearing that reform’s unaffordable, but we can afford to provide more generous care and support. And it's just choices, improving the way we, the system, you know, what we've talked about adds up to about 1%, less than 1% of GDP. We are a rich country that's choosing not to do this, and we shouldn’t let the government off the hook for that. 

Jennifer Dixon: I always remember Liz Kendall, when she was, I can't remember it must have been about 10 or 15 years ago, saying that, that her postbag was not full of letters on this, at least at that point. It was fuller on forests and forestry than it was on social care. So will it change to provide some voter pressure, is the question isn't it? 

Hugh Alderwick: You can hear the ambulances and you can see them piling up outside hospital at the moment, but it's much more of a silent crisis in social care. So the challenge is visibility. You'd have thought the pandemic made social care and the crisis in social care more visible. But it's much less visible. 

Jennifer Dixon: We've got onto a bit of a gloomy note, which I suppose is inevitable. But let's think about reasons to be cheerful for 2022. Predictions that you both have, maybe one or two predictions that you would like to stick your neck out and say for 2022, about how things are going to pan out and maybe throw in one or two things that you think should happen, so maybe start off with Victor. 

Victor Adebowale: Now, I think there's a couple of things. One, I think we'll start seeing interesting signs of repeatable life from systems that are more advanced than others in population health care, which will have an impact on demand if repeated. Secondly, I think that there will be a challenge and a good challenge to the way we use digital in health and social care. We haven't talked about that but I think there will be a challenge to the way we've used it and how we used it, and a demand for clarity, not least from the clinicians and patients. I think that the social care issue will return and it'll return big time. I think people, middle classes, people who need the service, can afford to pay for it but can't get access to it, that will be an issue and it'll be a big issue, people will feel cheated. And I think the sad point will be there'll be continued demand on the NHS, on the frontline, which I think will lead to some really worrying events around patient care. And it will become the political issue going forward. My concern would be that the NHS gets blamed for that and I don't think that's fair. But I think it will be a major political issue throughout ‘22 and probably into ‘23. I think that'd be my predictions as far as that go. 

Jennifer Dixon: Great stuff. Thank you, Victor, what about you, Hugh? 

Hugh Alderwick: I think, one hope and perhaps a prediction is on social care. I think Victor's right, I think government might revisit their plans, for instance, on the new cap and hopefully make it fairer, more generous to people with lower levels of wealth. I think the reason to be perhaps cheerful is that although levelling up is very, very vague at the moment, we have still a levelling up white paper to come, and perhaps another white paper on inequalities. So we should be positive that these big issues of unfairness in health and society are now part of the political policy debate. So the job of people like us is to make sure it focuses on addressing big structural socioeconomic drivers of inequality, like income, education, housing, and so on, not too narrowly focused on individuals and behaviour. But there's a big opportunity there to do something much bigger, much bolder on health inequalities, which I think we should be cautious about, because we haven't really seen the detail yet, but perhaps excited about if we can shape it in the right direction. 

Jennifer Dixon: Yeah, I agree with that. And I think I might stick my neck out even further and say that I think reform, bigger reform will be off the cards and it will be totally displaced by recovery. And I think those two things will be decoupled, except for around the time of party conferences season where everything gets very performative. So I think recovery will be the lodestar, not reform. I think politics, I predict, will become even hotter than this year as we get into the reaches of the next election. And I think that that will take over a lot of heat and light, which otherwise would be on the public sector. I agree that they just can't ignore social care, they won't be able to ignore that, because of the knock on effect on everybody, not least the NHS. And I do think that health inequality has been branded onto us as a result of the pandemic. And that‘s not going to go away. How much effort is going to be put into it is another matter. But I'm wondering whether health inequalities is the new green agenda really, you know, we made a lot of progress so far on green: complex, dynamic, difficult, multiple factors. But we have made progress and I'm wondering whether health might somehow be linked to that. That's my kind of hopeful thought for 2022. So sadly, we're now out of time, so let's leave it there. A big thank you to Hugh and Victor for their insights. And a big thank you to you, our listeners for joining us on this podcast. And we really hope we can do this festive special next year in the flesh, hopefully with a glass of wine and a mince pie and a live audience. As ever, please check the show notes for further reading on events in this last year that we covered in our podcast and have a browse while you're there at our previous podcasts. If you like this one, you'll probably like them as well. And if you could give us a friendly rating, wherever you get your podcasts, we'd be very happy. So meantime, have a very good Christmas break. Stay safe and well and see you the other side in January when we'll be talking in that podcast on what businesses and investors can do to help us stay healthy, on top of what government can do. So in the meantime, Merry Christmas everyone, stay safe and see you in Jan. 

• Read about the Health Foundation's COVID-19 Impact Inquiry, including the final report.
• Explore the Health Foundation's ongoing work on the Health and Care Bill.
• Lady Hallett was announced as chair of the COVID Inquiry following our recording. Read more.
• Taxes and health care funding: how does the UK compare? (The Health Foundation, 2021)
• Adult social care and COVID-19 after the first wave: assessing the policy response in England (The Health Foundation, 2021)
• New vision for social care will feel like hollow words without the money to deliver it (The Health Foundation, 2021)