Autumn budget and spending review 2021: what you need to know

Chancellor Rishi Sunak announced the Autumn budget and spending review to Parliament on 27 October. Our briefing covers the need to know aspects for doctors, the NHS, social care and public health and our analysis.

Location: UK
Audience: All doctors
Updated: Tuesday 30 November 2021
NHS Structure Article Illustration

The spending review covers departmental budgets and spending plans for the next three years, from 2022/23 to 2024/25.

This briefing sets out what the budget and spending review mean for the NHS, public health and social care systems as well as individual doctors.

 

Key headlines

NHS funding

Department of Health and Social Care and core NHS spending will rise over the next three years, with NHS funding increasing to £162.6 billion, a real terms growth of 3.8%.

The Government has announced £9.6 billion for COVID-19 funding over the spending review period, for the health service to be able to respond to the pandemic.

£8.7 billion each year on average will be provided through the Barnett formula to devolved nations, although clarity is still needed on how much of this will go to health services.

Workforce

There is mention of hundreds of millions of pounds for funding into workforce, however there are no clear commitments to expanding the medical workforce, and hundreds of millions falls far short of the BMA's calls for billions in investment into the medical workforce.

Neither does the spending review address the crisis within primary care, with no clear plan for how the Government’s aim of 50 million more primary care appointments will be delivered.

Investment in the NHS

Capital spending in the NHS will increase to £11.2bn over three years, a significant and welcome investment.

Spending will to go towards increasing capacity and diagnostics services as well as significant investment for digital transformation.

The lack of workforce funding to safely staff any new sites or services is concerning, in addition to a lack of commitment to addressing the more than £9 billion maintenance backlog.

Population health

No actual additional investment into the public health grant has been announced, despite BMA calls for a £1 billion increase to restore cuts.

The mental health investment, while positive, is not nearly enough to move mental health services beyond recovery and allow them to meet the increased demand from the pandemic.

A new alcohol duty system will be implemented where tax will be based on alcohol content. While positive to see higher alcohol content products taxed more, it is discouraging that there will be a reduction of duty for draft beer and cider. The lack of mention of unhealthy food and drink is also disappointing.

The Government is also increasing the national living wage, as well as reducing the taper rate in Universal Credit, which although positive, there are concerns that these changes will not offset the decision to not restore the uplift to Universal Credit.

Financial impacts for individuals and employers

Much of the new funding for DHSC and the NHS is through the health and social care levy, which while providing essential funding for health services, will have an impact on both individuals and employers.

The spending review did not address the pension taxation issue, one that has been a longstanding issue for doctors and addressing it would be a key solution in increasing workforce retention.

The freeze on public sector pay was also lifted which, although NHS workers were exempt, is a positive move, particularly for those within social care and doctors and nurses working in the armed forces.

NHS core funding

  • DHSC (Department of Health and Social Care) and core NHS spending will rise over the next three years, with NHS funding increasing to £162.6 billion, a real terms growth of 3.8%.
  • The Government has announced £9.6 billion for COVID-19 funding over the spending review period, for the health service to be able to respond to the pandemic.
  • £8.7 billion each year on average will be provided through the Barnett formula to devolved nations, although clarity is still needed on how much of this will go to health services.
BMA analysis

The Government’s commitment to additional funding for the NHS is a positive step forward. However, it fails to fully account for the enormous challenges now facing the health service as it heads into the most challenging winter on record.

Prior to the pandemic, the BMA called for annual growth of 4.1% in DHSC funding.

COVID-19 funding

  • Within the spending review, the Government states that up to September 2021, £97 billion has been allocated for the COVID-19 response. Previously, £2 billion in 2021/22 was allocated to reduce the backlog in elective care.
  • £8 billion has been allocated for elective recovery in England within the health and social care levy for the next three years.
  • It announced £9.6 billion for COVID-19 funding over the spending review period, for the health service to be able to respond to the pandemic. There is a lack of clarity on exactly what this funding will go towards, however it will fund the continuation of the vaccine programme, in addition to £33 million for the deployment of COVID-19 antiviral treatments.
BMA analysis

The £10 billion that was previously announced is not fully adequate to deal with the still growing backlog of care.

The latest data shows that as of August this year the waiting list reached a record high of 5.72 million. In addition to that, there have been 3.90 million fewer elective procedures and 26.78 million fewer outpatient attendances since the start of the pandemic.

The Health Foundation has estimated that it will cost almost £17 billion to clear the backlog. Hence, the BMA called for an additional £7 billion to reduce the waiting list and treat those patients who have not yet been seen.

Devolved nations funding

  • The spending review sets out that an additional £8.7 billion each year on average will be provided to devolved nations over the spending review period through the Barnett formula on top of baseline funding.
  • £4.6 billion a year to the Scottish Government, £2.5 billion a year to the Welsh Government and £1.6 billion a year to the Northern Ireland Executive.
  • A fairly significant amount of this will come from the health and social care levy. It was estimated in the Government’s Build Back Better report the levy will result in around £2 billion estimated Barnett consequentials each year, although it will not be ringfenced for health funding.
BMA analysis

It is essential that each of the UK nations is provided with the funding they need, particularly to provide health services.

Clarity is still needed on exact funding that will be provided through the health and social care levy to each of the devolved nations, and how much of this funding will go towards each of the nation’s health services.

Workforce

The spending review includes a reference to building a bigger better trained NHS workforce, however, it only mentions providing 'hundreds of millions of pounds in additional funding over the SR21 period to underpin:

  • funding the training of some of the biggest undergraduate intakes of medical students and nurses ever
  • in addition, continuing to support a strong pipeline of new midwives and allied health professionals, who are key to delivering the full range of NHS services
  • reaffirming the Government’s existing commitments for 50,000 more nurses and 50 million more primary care appointments.'
BMA analysis

No clear commitment has been made to increase the number of medical school places or the necessary infrastructure and resources to support this. There is no detail on the funding settlement for Health Education England.

Vague commitments

Reference was made again to the Government’s previous commitment to increase the nursing workforce by 50,000, yet no plan or firm commitment for further funding to reach this figure has been provided.

Equally, the Government has reiterated its commitment to increase the number of GPs by 6,000, yet compared to 2015, there are now 1,803 fewer qualified full-time GPs working in the NHS. The Government’s commitment is unlikely to reach its target while the number of fully qualified full-time GPs is falling.

Medical school places

The workforce gap cannot be bridged without the swift expansion of medical school places. The Royal College of Physicians, the Royal College of Psychiatrists, and the BMA have previously called for medical school places to be doubled to 15,000 per year within this decade.

BMA research shows that we would in fact need an additional 11,596 medical school places (on top of existing numbers) each year until 2029/30 to have equal standing with comparator nations in terms of doctor to population ratio by 2030.

Using the DHSC 2017 cost estimate of £230,000 per medical student, this would require at least £8 billion overall or around £2.7 billion per year across three consecutive years.

Pensions

There is also no mention of pension taxation reform, an issue that has been longstanding for doctors within the NHS and has severe implications for medical workforce retention.

General practice

Within the spending review, primary care is only mentioned in relation to the Government’s commitment to providing 50 million more appointments.

No commitments have been made to invest in the general practice estate or workforce.

BMA analysis

It is hugely disappointing that the spending review didn’t even mention general practice. The Government has failed to set out any credible plans for how 50 million more appointments can be delivered. It is expecting practices to deliver more and more without the workforce or investment to support the profession.

It is notable too that the budget did not include any meaningful measures to retain the workforce or grow it – including a lack of pensions tax reform and investment in growing medical school places.

Ahead of the spending review, the BMA had called for investment into general practice. Both for capital in order to improve GP premises to bring up the current standard and to transform the general practice estate, in addition to vital revenue funding to ensure adequate staffing.

Investment in the NHS

  • Capital spending in the NHS will increase to £11.2bn over three years, a significant and welcome investment. Spending will go towards increasing capacity and diagnostics services as well as positive investment for digital transformation. Although it is likely to fall short of delivering wholesale digital transformation.
  • Capital spending on health is set to increase to over £11.2 billion by the end of this parliament, an additional investment of £4.2 billion over three years. This is an average annual real terms growth over the spending review period of 3.8%. This includes operational capital investment to allow hospitals to maintain their infrastructure.
BMA analysis

The BMA called for a multiyear capital funding settlement for the NHS, to ensure there is additional capital funding each year into existing NHS sites, so the increase over the next three years is a positive step.

However, the BMA called for at least £9 billion to address the vast maintenance backlog in secondary care. In 2020/21 there were 6,812 clinical service incidents caused by estates and infrastructure failure. The BMA also called for additional capital investment into general practice.

Although the increase in capacity described in the spending review is welcome, the essential need for addressing the maintenance backlog in the NHS estate cannot be ignored. The yearly funding increases for capital fall far below the estimated £9 billion needed to address it.

New hospitals

  • The Government restated its aim to build 40 new hospitals, alongside a further 70 hospital upgrades.
  • £4.2 billion is to be made available over the next three years - which appears to only be limited additional funding to support this.
BMA analysis

It is unclear if this includes or is in addition to the £2.7 billion previously dedicated to the programme.

The BMA, IFS, the Health Foundation, and Nuffield Trust have all previously raised serious doubts regarding the amount needed to fully fund the programme. Estimates for the cost of construction alone for 40 new hospitals ranges between £12 billion and £24 billion – dwarfing the money set aside by the Government.

Further hospital upgrades will have only increased this total cost, with no clarity provided on how they will be funded or when they will be finished.

An average NHS trust employs around 500 full-time equivalent doctors, so again the Government needs to make clear how any new hospitals will be staffed safely.

Increased capacity

  • £1.5 billion has been announced to go towards bed capacity, equipment and surgical hubs over the next three years to tackle the waiting times for elective surgeries.
BMA analysis

There has been a reduction in general and acute beds in England over past decade. The Royal College of Surgeons are calling for the number of beds to be in line with the OECD (Organisation for Economic Cooperation and Development) average of 4.7 per 1,000 people, an increase from their estimate of 2.5 per 1,000 people.

Therefore an increase in capacity is a positive step, however, yet again, any new capacity must be met with commitments to address the workforce shortages.

Diagnostics

  • £2.3 billion to be provided for diagnostic services and equipment including CTs, MRIs and ultrasounds.
  • The introduction of at least 100 community diagnostic centres across England, including the 40 previously announced.
  • £325 million was announced in the previous spending review for investment into NHS diagnostics equipment.
BMA analysis

There has been declining investment in CT and MRI scanners in the last decade. The BMA has routinely called for more resources for facilities, equipment and the workforce, including community diagnostic hubs.

The announcement is a positive step towards continued investment into diagnostic equipment. It will address under-capacity of testing and will help productivity. However, it is unclear how these hubs will be staffed.

The Independent Review of Diagnostic Services has recommended that 4,000 radiographers and 2,000 additional radiologists will need to be employed to support the new streamlined care pathways, purchased equipment and the community diagnostic hubs.

Clarity is also still needed for how much of this funding ringfenced for diagnostic centres will go to NHS providers, and how much will go to independent private sector providers.

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Digital transformation

  • Around £2.1 billion will be invested in IT, technology and digitising the NHS - this is alongside the new funding arrangements proposed by NHSX to allocate digital funding directly to ICSs from 2022/23.
BMA analysis

The BMA called for an increase to digital funding and for NHSX to lead on their commitment in mapping the technical debt of the NHS.

£2.1 billion goes a considerable way towards the £2.9 billion in capital funding that was estimated by NHSE&I to be needed for digital transformation.

However, without full mapping of the technical debt, it will be difficult to allocate this funding in order to both maximise impact and ensure parity between providers, and therefore patients, in terms of digital maturity.

Consideration of the impact that additional necessary training might have on workforce capacity in the short term, even where it releases capacity in the long term, should be given.

Where training is necessary, clarity on whether costs will be shouldered by NHS organisations or will come from this new funding would be welcome.

Public health

  • The Government has committed to maintaining the current public health grant in real terms over the spending review period, which means that no further investment will be made into the public health grant. This is despite years of chronic underfunding resulting in reduced services.
  • Local government will receive £4.8 billion of new grant funding over the next three years.
BMA analysis

This is very disappointing, as we called for £1 billion to restore the cuts made to the public health grant since 2015, with further investment to increase the grant to £4.5 billion by 2023/24.

No further investment in public health will make focussing on improving the public’s health extremely challenging, as well as addressing the health inequalities that have been deepened by the pandemic. This is extremely short sighted.

The country is only just starting to emerge from a major pandemic for which our public health services were underprepared. Not investing in them properly will put the country at a disadvantage when the next pandemic hits.

An uplift to local government funding is very welcome and is crucial in meeting the current demand facing public services. It will also be important for the Government’s levelling up agenda.

However, this increase only goes some way in reversing years of cuts to local government funding, and the reduction of vital public services.

Health inequalities

  • The Government is investing £1.7 billion into the Levelling Up Fund, to fund 105 projects in local area.
  • It has committed to £4.7 billion by 2024-25 for the core schools budget in England.
  • On 1 April 2022 the national living wage will rise by 6.6% to £9.50 an hour. There will also be increases in the national minimum wage rates.
  • The Government is reducing the taper rate in UC (Universal Credit) from 63% to 55%, as well as increasing work allowances in UC by £500 a year.
BMA analysis

This investment into improving living conditions reflects some progress in addressing the social determinants of health.

However, the Government choosing not to restore the UC uplift is a blow to the poorest in society.

The Government has chosen the cheapest option between raising the national minimum wage (at a cost of £2 billion) and maintaining the universal credit uplift (at a cost of £6 billion).

We are concerned by analysis from the IFS, and other economics think tanks, that the rise in the national living wage will not offset the loss of the UC uplift.

Maintaining the UC uplift, which brought relief to the thousands of families living in poverty across the UK, would have made more sense with the Government’s levelling up agenda.

Alcohol

  • A new alcohol duty system will be implemented where products are taxed in proportion to their alcohol content. This means the price of spirits and wine will increase, while beer will become cheaper.
  • Duty rates on draught beer and cider purchased in pubs will be cut by 5% which will reduce the cost by 3p per pint.
  • Additionally, alcohol duty rates on beer, cider, wine and spirits will be frozen for another year.
BMA analysis

While it is encouraging that the new alcohol duty system will increase the price of products with a higher alcohol content, the reduction of duty on draft beer and cider and a continued alcohol duty freeze on beer, cider, wine and spirits is very disappointing.

The BMA has called for an increase in duty on all alcohol products by at least 2% above the rate of inflation to compensate for year-on-year increased affordability of alcohol, a known driver of consumption.

Increased consumption contributes to increased alcohol related harm and deepens health inequalities already worsened by the pandemic. Also, a continued freeze on alcohol duty will come at a significant cost to the Treasury, money which is urgently need in other areas.

The announcement includes no mention of the introduction of a minimum pricing unit, which is a wasted opportunity to bring England in line with other areas of the UK. For example, Scotland has a minimum pricing unit of 50p which has shown to reduce alcohol sales by 8%.

This is a measure the BMA has previously called for and would set a baseline price at which a unit of alcohol can be sold. This targets the cheapest and strongest products without impacting price in the hospitality sector.

Tobacco

  • Duty rates on all tobacco products will increase by RPI plus 2%.
  • The rate on hand-rolling tobacco will increase by RPI plus 6%.
  • The minimum excise tax will increase by RPI plus 3% this year.

    These changes took effect from 6pm on 27 October 2021.
BMA analysis

While the BMA supports the increased taxation of tobacco products above the rate of inflation, our ask for an increase of the tobacco tax escalator from 2% to 5% has not been met for all tobacco products.

We would have ideally also liked to have seen a larger increase in the rate on hand rolling tobacco to bring them closer in line with pre-rolled cigarettes.

Unhealthy food and drink

The announcement does not mention any changes to taxation on unhealthy food and drink, despite the BMA’s call for this in combination with subsidisation of healthier options to encourage healthy eating patterns in the UK.

This is a wasted opportunity to expand the successful soft drinks industry levy to include other product categories.

 

Mental health

  • £100m is being promised for mental health support for expectant parents.
  • £95m will go towards researching methods for treating cancer, obesity and mental health.
  • £150 million over the spending review period will be used to invest in NHS mental health facilities linked to A&E and to enhance patient safety in mental health units.
  • Reiterations of previous commitments include £5 million in 2022-23 for research into support for veterans, including into new treatments for mental health issues, including post-traumatic stress disorder.
  • Around £300 million over the spending review period to complete the programme to replace mental health dormitories with single ensuite rooms.
BMA analysis

The announcement falls significantly short of the BMA’s call for investment of at least £4.6 billion a year by 2023/24.

It was particularly important to invest in mental health services for adults, children and young people given previous pressures and underfunding. However, the budget has not announced more than the inadequate £500m previously promised in March as part of the mental health recovery plan.

Equally important for those treated are being treated close to support networks. The Government’s target to eliminate inappropriate out of area mental health placements by April 2021 has not been met and the budget has not announced how this will be tackled.

Given the compounding effect of COVID-19 on the population’s mental health, with a 29% increase in the number of people referred to mental health services for their first suspected episode of psychosis between 2019 and 2021, urgent investment is needed in this area.

The BMA has called for an increase of 1,000 mental health beds, and increased investment in community mental health services.

The BMA does, however, welcome the announced investment in perinatal mental health services.

Social care

  • The Government announced it will invest £5.4 billion in adult social care over the next three years.
  • An additional £500 million investment was also announced to support and develop the adult social care workforce.
  • This investment will be directed towards improving qualifications, skills, and wellbeing across the workforce. These announcements have been previously made and will be funded through the new health and social care levy.
  • From October 2023, the Government will introduce a new £86,000 cap on the amount anyone in England will need to spend on their personal care over their lifetime.
  • The Government will fully fund social care for those with assets of less than £20,000 (compared to 23,250 currently) and will provide means tested support for those with assets between £20,000 and £100,000.
BMA analysis

The additional funding for social care services is welcome but falls short of what we and others called for. In our report Calling for action in social care in England, we have called for an extra investment of £12.2 billion in social care in England in 2023/24.

Additional funding will be needed on top of this to ensure better access to care by providing more services free at point of need. An additional £5 billion would be needed in England, for example, to implement free personal care in 2023/24.

Latest data shows around 112,000 vacancies in England in 2019/20 in the social care sector. The additional investment to support the workforce, while welcome, does not address these current workforce gaps.

The Health Foundation estimates that £6.1 billion investment per year is needed to meet future demand, and that improving and expanding care to those who need it will require investment of more than £14 billion.

Importantly, there remains a lack of clarity around how much money will be dedicated to social care in the long term.

The Government has indicated that it expects a larger share of revenue raised by the health and social care levy in future years beyond this spending review to be invested in social care.

However, this would mean Government cutting NHS spending, which is unrealistic.

National insurance contributions (NICs)

  • On September 7 2021, the Government announced a new UK-wide 1.25% health and social care levy to fund the NHS and social care.
  • From April 2022, NICs for working age employees, self-employed people and employers will increase by 1.25%.
  • From April 2023, once HMRC’s systems are updated, the 1.25% levy will be formally separated out from NICs and will also apply to the earnings of individuals working above state pension age, and NICs rates will return to their 2021-22 levels.
BMA analysis

The levy will provide much needed revenue for health and social care services in the UK. 

However, the rise in NICs will have an impact on both individual and employer finances.

Pensions

Within the spending review no mentions were made of pension taxation reform, an issue that has been longstanding for doctors within the NHS and has severe implications for medical workforce retention. 

BMA analysis

The introduction of the annual allowance taper in 2016 had unintended consequences for public sector defined benefit schemes. It meant that many doctors now face financial detriment if they undertake additional work or work for longer in the NHS.

As a result, doctors have been left with little alternative but to reduce their working hours at a time when waiting lists are at their highest for many years and the NHS is already facing a huge staffing crisis.

In light of the absence of committed funding for medical workforce expansion via new medical schools places, retaining the existing workforce is of paramount importance.

The Government has therefore missed a key opportunity to address the issues within pension taxation and retain doctors working within the NHS at this crucial time.

Public sector pay

  • The freeze on public sector pay has been lifted, which was estimated to have affected 2.6 million people, including those in the armed forces.
BMA analysis

NHS workers were exempt from the freeze on public sector pay announced last year.

While it was right not to freeze pay during the COVID-19 pandemic of doctors and NHS workers, as they have been going above and beyond continuously to provide care, the BMA supports the removal of the freeze on public sector pay. Particularly for those within the social care sector or doctors and nurses working in the armed forces who have also been affected.

This change in approach to public sector pay may offer some benefit to armed forces doctors next year.

However, it does nothing to remedy the fact that the AFPRB(Armed Forces Pay Review Body) recommended a pay freeze to uniformed doctors this year, despite the extraordinary contributions they have made in response to the pandemic.

The BMA will make representations to the AFPRB in the next pay award round to urge them to belatedly make recommendations to ensure that their efforts for both this year and the next are appropriately recognised and rewarded.

Health research

  • The Government announced that investment into public R&D (research and development) is increasing to £20 billion by 2024/25.
  • This includes £5 billion for health-related research and development and translates into a cash increase of £605 million compared to 2021/22.
BMA analysis

This is a positive announcement, as it is significant additional investment into health research specifically. The total R&D investment of £20 billion is relatively close to calls from AMRC and other organisations for investment of £22 billion by 2024/25.

There are concerns that some of this funding will be negated by the loss of income for medical research charities during the pandemic, however. The AMRC estimated earlier this year that could have been around £292 million.

The BMA would want to see that training posts and research opportunities that charitable income provides are assured for the spending review period from this investment.

International aid

  • The Chancellor announced that he expects the UK’s commitment to international aid should increase back up to 0.7% of GNI (gross national income), after being cut to 0.5% by the end of this parliament.

    However, this was caveated with the need for meeting economic tests, which were not expected to be met until 2024-25.
BMA analysis

We would welcome a firmer and earlier commitment to increase international aid back to the UN recommended 0.7%.

The reduction to 0.5% GNI is a real terms loss of around one-third of the aid budget relative to pre-pandemic funding levels, as the cut is compounded by the contraction of the UK economy during the pandemic.

This reduction will have significant consequences in a number of vulnerable settings globally, hindering efforts to control the spread of the virus and to build back better, as well as undermining the UK’s strategic and humanitarian goals.

The BMA was a joint signatory - alongside the RCM, RCOG, RCN, RCP, RCPCH and RCGP - to a letter to prime minister in June this year calling for the Government to increase aid back up to 0.7%.

Green agenda and climate change

  • From 1 April 2023, the Government will cut air passenger duty by 50% for flights between airports within the UK.
  • The Government will increase air passenger duty for long haul flights and introduce a new increased ultra-long-haul band, covering destinations with capitals located more than 5,500 miles from London.
  • The Government will keep fuel duty frozen at 57.95 pence per litre UK-wide for 2022-23.
  • Alongside this, the Government announced £4 billion in new investments in the green agenda.
  • The Government has committed £1.7 billion to develop a new nuclear reactor.
  • The remaining funds will be invested in decarbonising transport and improving biodiversity.
  • The National Infrastructure Commission was also given an objective to examine how it can deliver the UK’s target to achieve net zero by 2050.
  • The Government also reiterated £26 billion public capital investments previously announced in the net zero strategy and various departmental spending commitments.
  • £3.9 billion will be invested in improving the sustainability of heating and insulation, and £3 billion will be invested in active travel.
  • There is also a commitment to increase research and development expense spend, which could have an impact on climate policies and technology that will enable the UK to reach net zero more quickly.
BMA analysis

The budget itself is quite light on references to net zero or sustainability policies and in fact contains some policies that will have a negative effect on the UK achieving net zero.

Effectively subsidising domestic air travel is particularly damaging, given the widespread agreement that the UK should be minimising air travel. The duty reduction for domestic flights goes against efforts to decarbonise the transport sector.

Aside from a few new policies, there is a lack of new money promised in this spending review and budget. This is unsurprising given the recent publication of the Government’s net zero strategy and other green policies in the lead up to this budget.

We welcome the Government’s commitment to the electrification of buses. The BMA does not have policy supportive of nuclear energy, however it is difficult to imagine a scenario where the UK achieves net zero by 2050 without an increase in nuclear power output.

The net zero strategy itself was welcome and pointed out some of the failings in the Government’s approach to climate policy, including the committee on climate change’s warning in the 5th and 6th carbon budgets that the UK was not on course to meet its net zero targets.

Overall however, the net zero strategy is limited in that while it spells out what will be required in tonnes of carbon dioxide reduction per sector to reach net zero, it is not a concrete plan of the type of policies that will get us there.