To coin a phrase from former US defence secretary Donald Rumsfeld there remained a lot of ‘unknown unknowns' for health and social care following the Autumn Budget. 

Technology funding 

In terms of funding, the Government signalled its priorities with £300m for technology. 

‘It's so unusual that extra hundreds of millions are given outside a Spending Review so quickly,' Anandaciva noted. ‘It just shows what a big strategic importance the Government's making on technology, helping to deliver the 10-Year Plan, helping to deliver greater productivity, helping to deliver everything.'

While supporting technological advances, Anandaciva said he was unconvinced how much difference this will make to reaching the Government's goals on productivity and elective care. 

‘A better NHS App will absolutely change patient experience,' he said. ‘It might show up in things like polls of public satisfaction with the NHS, where people say, do you know what, the experience of contacting services, getting advice was much better.

‘Is it the thing that's going to really bring down waiting lists to the point where we notice that? Is it that sort of a game changer? I'd say no, partly because of the amount of money we're talking about.'

Anandaciva said there was a danger of the Government not being clear enough on what its real target was whether that be GP access, NHS reform or bringing down waiting lists. 

Neighbourhood health 

The second eye catching policy in an Autumn Budget where so much was leaked, was setting the target of 120 out of 250 neighbourhood health centres being operational in 2030. 

Although some of the centres may be refurbishments or upgrades of existing buildings, the policy director cautioned there were ‘still too many unknowns' about whether the Government will be able to go into the next General Election having created 120 new facilities. 

What has attracted opposition in some circles is the Government's commitment to fund the projects partly through public private partnerships (PPP) while promising to learn from past failed experiments with private finance initiatives (PFIs). Again, Anandaciva said this was an area where more clarity was required. 

‘The positive side is access to finance you might otherwise not have,' he observed. 

‘The downside is who controls the asset? How easy is it to make changes? How much is this a genuine design partnership? Is what we want to deliver based on the model of care, versus people saying, well, this is what we can build - do you want it or not? 

‘And that's a hell of a lot to work out over three years if you're going to build 70 of them and refurb another 50.'

On PFI, the policy director said the Government needed to be clear on what the issues were and how it's going to be different this time. 

‘I remember politicians and the current Government saying, look, we've learned the lessons of the past, we're not going to restructure the NHS and look where we are now,' Anandaciva noted. 

NHS redundancies 

One of the many leaked policies ahead of the Autumn Budget was the announcement the Government was bringing forward £860m in funding to pay for NHS redundancies. 

Anandaciva said it was unclear whether this sum will be enough to cover the total cost of restructuring. 

‘We're talking to local leaders and there's a lot of uncertainty,' he said. ‘They're saying "we're not sure if we're still viable as a standalone ICB, so we might have to merge further".'

He added: ‘One way of looking at this is it could be the biggest reduction in talent, knowledge and skills in NHS, leadership and management that we've seen for a generation and because of the callback arrangements people will be strongly incentivised not to take more jobs in the NHS. So I guess there's a question of, where will they go? What happens to those skills?

‘If we were talking about the commercial loss of a factory, we wouldn't be talking about this as necessarily a good thing. We'd be saying where are all these people going to find gainful employment for the skills they have?

Public health 

While the Autumn Budget featured a number of wider health measures, including the extension of the Sugar Tax Levy and uprating alcohol and tobacco duty, Anandaciva said the Government had not gone far enough on public health. 

The policy director cited the failure to restore the Public Health Grant, which has suffered a cut of 27% in real terms since 2015/16, as evidence of the paucity of its vision. 

‘We're not talking about huge sums of money,' he commented. 

‘It would also make a difference on societal value for investment, if we put it into smoking cessation clinics and all the other things that the Public Health Grant funds.'

Social care 

Social care also remained the ‘Cinderella' service following the Budget having again not even gained a mention. 

‘It now feels that you have something like the Autumn Budget that doesn't mention adult social care at all, which is not a good place for countries be in,' Anandaciva observed. 

He noted the lack of transparency on progress on the Casey Commission into social care reform, which is not due to report its first findings until 2026 with its final report in 2028, as well as increasing pressures on the sector as a result of immigration. 

Still too many unknowns 

Concluding, Anandaciva said there remained an alarming degree of uncertainty over how progress on the Government's performance on the 10-Year Health Plan will be measured. 

‘Could I tell you right now, here are the five measures that will show us that the 10-Year Plan is working? No. I still think that's pretty stunning with this being the Government's major reform plan. 

‘How do they know if they're going to pull it off? 

‘How do they know if it's working? 

‘There's still too many unknowns and not much time before the next election.'