By Karen Taylor, Director of the Deloitte Centre for Health Solutions

Last week Deloitte’s Director of Public Sector Research, together with the Director at Reform, published their findings from the 12^th edition of Deloitte and Reform’s influential annual State of the State report. The report again blends two sets of insights: a view from the people who depend on the state; and a view from those who run it. To understand public attitudes, the research team commissioned Ipsos UK to conduct an online survey of over 5,000 adults in the UK and interviewed more than 100 leaders across government and public services.¹ This year’s report finds a public sector grappling with an accumulation of successive crises, reduced spending power, increases in demand and workforce challenges with a growing clamour for greater prioritisation. Since its launch, the NHS and social care have featured regularly as two of the public’s top concerns; this year’s report is no different. This blog focuses on the report’s specific findings on health and social care.

Public concerns have grown around waiting lists but also affordable housing, immigration and infrastructure

The Ipsos UK survey asked the public to name their top priorities for improvement in the UK (see Figure 1). For the second year running, the cost-of-living crisis is the public’s top concern (mentioned by 78 per cent of people), albeit three percentage points down on 2022. While economic concerns remain significant, with jobs and economic growth featuring in the top five concerns, in second place is the concern about NHS waiting lists (a seven-point increase to 73 per cent). Concerns over immigration and the country’s infrastructure have risen six percentage points (to 43 per cent) and affordable housing by five percentage points (to 45 per cent). As housing and employment are two of the crucial social determinants of health, these concerns inevitably have implications for the future of public health.

There are regional differences in the public’s concerns about social care

While social care for older people, vulnerable adults and children is ranked only in eighth place across the UK (mentioned by 42 per cent of respondents and two percentage points lower than 2022), however it is a higher priority in Wales (5^th priority) and Northern Ireland (3^rd priority). NHS waiting lists, however, is the second most mentioned concern in all four nations.

On many counts, the publics concerns about social care are surprisingly low compared to previous years surveys for State of the State.  Especially given our previous research (and the view of other published research) show that the challenges facing this sector have worsened significantly. Indeed, multiple sources of research show that until they need support for themselves or their families, most people don’t understand how difficult it is to access social care, how social care is funded (especially that it is means tested and not free at the point of need) or the impact that years of under-funding have wrought.

Senior leaders consider the public sector needs to change in fundamental ways

The 2024 report illustrates that the legacy of the last decade is evident in the views of public sector leaders interviewed. The leaders that were interviewed emphasised that the successive challenges of recent years have left their services fragile, their workforces tired and decision-making reactive. They also talked with incredible pride about what their people and organisations have delivered in recent years, but without exception were clear that the public sector needs to change and deliver in a way that optimises the use of resources. The report quotes one senior civil servant as saying: “It’s all about reform - when you look at how challenging things are in the world, we can’t stay as we are - over programmed with not enough money”.

The report notes that this fragility is especially true in health and social care which is still reeling from the pandemic even if it isn’t generating the same number of headlines. Moreover, multiple leaders remarked that the health service is in the worst condition they have ever experienced; at the same time, local government officials warned that social care waiting lists are in as much of a crisis as NHS lists yet are less visible (see Figure 2).

Concerns about health and social care have increased

While healthcare and the NHS featured as a top priority in many previous State of the State reports, concerns have grown. For example:

• The 7^th report (2018-19) emphasised that social care was ‘reaching a crisis point’ requiring more urgent attention as well as longer-term solutions. Leaders argued that current funding models were unsustainable, and government faced a choice: ‘either it takes decisive action to create a fair, sustainable funding system for social care or it will be forced into costly reactive measures as a series of crises unfold’.²
• The 10^th report (2021-22) found government and public services dealing with both COVID-19 and its wider effects with health and social care in the eye of the storm. As vaccinations, testing and other measures began to allow some normality to return to people’s lives, the public sector was itself finding ‘a new normal’. This meant dealing with some challenging legacies and picking up the momentum on policies that were side-lined by the pandemic. Funding made available in the Spending Review 2021 created a level of optimism, however, leaders recognised that the state would face tough funding decisions and taxpayers would expect a return on investment. When asked what the government should prioritise, the public’s top choices were unhesitatingly, health and social care.³
• In last year’s report (the 11^th report), health and care leaders emphasised that the NHS and social care system, ‘weakened by the pandemic’, had reached crisis point with the state of the social care workforce appearing repeatedly as a major concern due mainly to low wages failing to attract a sufficiently sustainable workforce. Importantly, leaders were concerned that social care problems would get pushed to one side and that it would take a disaster before government sat up and took it seriously.⁴

The overwhelming consensus among interviewees in this year’s report is that recent decades have seen government’s aspirations – whichever the party in power – over-reaching the resources available to it. They argue that the state cannot continue overstretching its budgets and overpromising to its citizens and ultimately government needs to start prioritising and making choices about what to do and not do.

Conclusion: lessons for the state from the state and their relevance to health and social care  

The 2024 report finds the public sector grappling with an accumulation of successive crises as well as reduced spending power, increases in demand and labour challenges. Nowhere was this more evident than in health and social care. Overwhelmingly, public sector leaders want to put these years behind them and find some stability and look to the future. They want central government to prioritise more effectively and concentrate attention on the most important issues facing the country, highlighting the need for long-term thinking, planning and funding. Specifically, leaders want to see a ‘reset’ of the public sector; its own CTRL+ALT+DEL. They identify five lessons for the UK public sector (see Figure 3).

While these are general lessons, they resonate strongly with what is needed in the health and social care sector. Specifically, giving the sector space, time and a longer term view of funding to help them move from crisis mode to longer term planning. Improving the productivity of health and social care is critically important and goes hand in hand with the need to have a relentless focus on digitalisation. Focusing on delivery as the north star is already a crucial driver of performance and should remain the overarching goal. And, as we have seen from recent announcements, the time has come to seize the moment and realise potential of NHS collective buying power to optimise the value for money for the system, taxpayer and service users.⁵

Karen Taylor - Director, UK Centre for Health Solutions

Karen is the Research Director of the Centre for Health Solutions. She supports the Healthcare and Life Sciences practice by driving independent and objective business research and analysis into key industry challenges and associated solutions; generating evidence based insights and points of view on issues from pharmaceuticals and technology innovation to healthcare management and reform.

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[1] The State of the State 2024 | Deloitte UK

[2] deloitte-uk-the-state-of-the-state-2018.pdf

[3] SOTS-2022_Interactive-Report_09_Compressed_1.pdf (reform.uk)

[4] State of the State 2022-23: From the pandemic to a cost-of-living crisis - The implications for health and social care - Thoughts from the Centre | Deloitte UK

[5] NHS England » Strategic framework for NHS Commercial