Why 2012 will be a big year for the NHS

The NHS is often referred to as the nation's most treasured asset - and as such it is never far from the headlines.

Thursday's story about thefuture of hospital careis proof of that.

But where care is provided is not the only big issue facing the NHS in the next 12 months.

There are a host of challenges looming. Whether it is cuts, reforms or money, there will be plenty for staff, patients and ministers to ponder.

The fall-out from a scandal

Regulation of the health service may under go a shake-up

After 139 days of public hearings, the Mid Staffordshire Public Inquiry closed on 1 December. There is no date yet for the publication of the final report. But already Robert Francis QC, the head of the inquiry, has said the issue threatens to unleash a "tsunami of anger".

The inquiry has been looking at what happened at Stafford Hospital from 2005 to 2008 during which hundreds of patients died needlessly and why it went undetected for so long. In particular, the findings promise to have major implications for regulation of the health service.

In recent months, the Care Quality Commission, which now regulates quality in the NHS after taking on responsibility for it from the Healthcare Commission in 2009, has come under criticism from the House of Commons health committee for losing sight of what it should be doing. Ominously, the prime minister was quick to givehis backingto the findings.

What is more, during the inquiry the culture and vision of the regulator came under attack from its own officials, prompting the health secretary to order an investigation himself. It seems unlikely that the CQC will survive unchanged.

Lansley's dream

Politically, the government's reform of the NHS in England may be over the worst hurdles, but that does not mean it will be an easy ride from now until the big bang in 2013 when GPs finally get control over the purse strings.

The bill underpinning the changes is still in the Lords and will no doubt come under renewed attack in the Commons. But, more worryingly for ministers, are the noises coming from the front-line.

There is growing frustration among doctors who are getting involved in the new clinical commission groups. In many ways, they should be the greatest advocates of the plans as they are supposed to be getting more power than ever before.

But the Clinical Commissioning Coalition, which represents the GPs who are piloting the new arrangements, has startedreportingthat they are being bullied by senior managers in the health service. They say they are interfering with their structures and decision-making process - and this in turn is threatening the whole project. Expect another 12 months of arguments and controversy.

Social care - will it be reformed at last?

Ministers have promised a social care white paper by the spring

Although it is not part of the NHS, the social care system is closely linked to the fortunes of the health service. Whether it is arranging discharge from hospital or preventing falls in the home, when social services are not working as they should, the effect is felt in the NHS.

And that is why there is a great deal of interest in whether the system is finally going to get the revamp it has been crying out for for years.

When Tony Blair came to power in 1997 he talked about improving social care. But at the end of Labour's 13 years in power, ministers were still arguing about the best way forward.

The current government has now promised to publish plans for change in the spring. But serious doubts remain about how radical ministers will be.

The system is suffering from chronic under-funding. While the NHS enjoys a budget in excess of £100bn, adult social care has to get by on about £14bn.

This is topped up by individual contributions - the system is means-tested - but nonetheless councils across the country are cutting back on what they can offer. And so reform will require extra money - something which is of course in short supply at the moment.

It is also likely to require cross-party consensus, but there is still some bad blood between the health secretary and his Labour opponent Andy Burnham over thedeath tax rowwhich effectively scuppered the shadow health secretary's plans to reform social care when he was in power.

It promises to be far from the smooth ride many involved in the sector would hope for.

Looking after the pennies

The government came to power promising the NHS budget would be protected. It was, but only just.

The budget is increasing by an average of 0.1%, but as inflation in the health service is rising at a much quicker rate to cover costs associated with the ageing population and rising levels of obesity, savings are having to be made.

The NHS has a target of £20bn by 2015, the equivalent of about 4% a year. That means there is pressure on jobs - unions say tens of thousands are being lost - and front-line services.

In particular, hospitals are coming under pressure. Advances in medicine and the nature of illnesses in the 21st century - many more people are suffering from chronic conditions like diabetes - means more and more can be done in the community.

It has meant an increasing number of hospitals are piling up debts because they are not getting enough patients through the door.

This in turn means managers and ministers are having to make difficult decisions about closing departments and even whole centres. The process will continue in 2012, particularly in and around London which was recently described as being in a"shocking"state by a committee of MPs.

The target that isn't a target

Hospitals are expected to see patients within 18 weeks in England

Under Labour, an 18-week waiting time target was set for non-emergency hospital treatment, such as knee and hip operations. Within months of the coalition being formed, ministers said it was being relaxed to move away from the tick-box culture that they say had developed.

Instead, it was to be referred to as a standard and health managers would no longer feel the Department of Health breathing down their necks.

But when the government was knee-deep in criticism over its reforms the prime minister made the specific pledge that waiting times would not be allowed to slip. This has resulted in more attention than ever being given to waiting times.

And signs are emerging that hospitals are beginning to struggle to keep up with the 18-week goal. Overall, the NHS is still meeting the target - they only have to achieve it for 90% of patients to reflect the fact there are valid reasons why some wait longer.

But that masks the fact that there is a rising number of places where it is being breached, leaving the best-performers to bring the national figure up.

It means there could be growing dissatisfaction with the waits patients are facing, although it must be remembered a return to the 1990s when waits of six months and even a year were the norm for many patients is still a long, long way off.