Public satisfaction with the NHS is at rock bottom and waiting lists at record highs. Demand for services is soaring, but activity levels are still down on pre-Covid levels and massive investment is needed to bring the NHS’s ageing technology and crumbling estate up to scratch. Social care is on its knees, piling more pressure on hospitals and community services.
And there’s no money. A reluctant Treasury has already topped up NHS England’s squeezed budget once this year. According to the Nuffield Trust, the NHS is “lurching from one funding crisis to another… uncertain how much – if any – of the extra recurrent cost increases it has faced this year will be funded into the next”.
Reform rhetoric
What’s a politician to do? The stock response to many problems and no money is to talk about “reform”. Sure enough, Rishi Sunak told the Conservative conference in Manchester in October that “you measure your affection for the NHS not by how much money you spend on it, but by how you reform it.” In similar vein, Labour’s would-be health secretary Wes Streeting told his party’s gathering a week later in Liverpool that “reform is even more important than investment”. As Streeting himself admitted, such talk sends “shivers running down a million spines in the NHS”. After the disastrous Lansley reforms and with ICSs still bedding in, there’s precisely zero appetite for another round of disruptive re-organisation.
In reality, all three main parties have largely accepted both the ICS model and the 2019 NHS Long Term Plan as the main policy framework for the NHS in England. If anyone with a serious prospect of power wants to upend the NHS model or make radical changes to structures, they’re keeping quiet about it. This is political reality: polls clearly show there’s next to no support for any alternative model and that most voters just want the NHS to be properly funded and work better.
But there are real differences between the parties. They reflect different assessments of what the NHS needs and general party ideology but mostly what appeals to people who might vote for them.
Wasteful or underfunded?
Both Labour and Tory voters are dissatisfied with the NHS – but for very different reasons. Research by the Nuffield Trust and King’s Fund found that seven out of ten Conservative supporters think the NHS “wastes money” – a complaint made by only 20% of Labour supporters. Most Labour voters blame their dissatisfaction on “the government not spending enough money on the NHS”; only 18% of Tory voters agree.
That’s why, in what turned out to be his swansong as health secretary, Steve Barclay peppered his conference speech with references to “waste” and “bureaucracy” in the NHS, promising to “spend less money on the back office and more on the frontline”. The government was “taking on those who resist change”, he said, those who demand “massive pay rises”, oppose “shorter courses” and spend “huge sums” on hiring “bloated” equality, diversity and inclusion (EDI) teams. Two weeks later, Barclay instructed ICS chairs to stop recruiting to EDI posts and “redirect these resources into frontline patient care”.
By any standards the government has a poor record to defend on the NHS and public services generally. By blaming waste, ministers aim to show that the problem lies within the NHS itself, rather with how much money it has, while shoring up support among socially conservative voters by weaponising ‘culture war’ issues like EDI and single-sex wards.
Modest and short-term
Labour’s dilemma is how to convince voters it can make a difference to the NHS, which it says in crisis, without spending much money. At conference, Streeting announced a modest plan to cut waiting lists by expanding out-of-hours clinics, with the estimated £1.5 billion cost funded by abolishing non-dom tax status.
The plan was well but cautiously received in NHS circles. King’s Fund director of policy Sally Warren said the approach has worked in some hospitals but warned it was a short-term measure which relied “on the willingness of staff to work overtime… when many health care professionals are demoralised and burnt-out”.
Labour’s other eye-catching proposals are mental health hubs in every school, paid for by levying VAT on private school fees, and a ten-year plan to develop a ’national care service’ (NCS). Details remain sketchy and Streeting has avoided promising free social care for everyone, like in Scotland. But there will be a social care “workforce plan”, including measures to help recruitment and retention, improve professional status and “the first ever fair pay deal for care professionals”. It’s unclear how the NCS would be funded, with Labour figures repeatedly stressing that “there’s no point in pouring money into a broken system”.
Streeting said Labour would “refocus” the NHS towards non-acute services – something politicians have been promising for decades to very little effect – and told a fringe meeting that mental health, primary, community and social care services would be the “first port of call” for additional funding when (and presumably if) it becomes available.
Credibility gap
With an eye on stealing Labour’s clothes, the Liberal Democrats have by far the most expansive NHS plans. At the party’s September conference in Bournemouth, leader Ed Davey proposed a £4 billion boost to cancer services, with a guarantee of treatment within two months (matching the current target, last met in 2015). He also wants to guarantee everyone a GP appointment within seven days, or 24 hours if urgent.
Unlike Labour, the Lib Dems are promising to bring “free social care for all” to England. Somewhat optimistically, Davey claims the plans will cost £5 billion, with £3 billion clawed back through lower NHS spending. The party is also committed to restoring cuts to public health since 2015 and, like Labour, promises a mental health hub in every school.
It’s an appealing package, but there’s an obvious credibility gap. Some of the Lib Dem plans, like the GP appointment guarantee, are uncosted and look undeliverable with current staffing shortages, while it’s unclear how the party would fund the billions it wants to spend on cancer treatment, social care and public health. The party is traditionally more free with spending pledges than the two bigger parties – voters know they’re unlikely to end up being taxed by a Lib Dem chancellor. For now, all Davey will say is that a “fully-costed manifesto” will be published before the election.
The party platforms on show this autumn all feel very remote from reality. Short of cash and short of staff, the NHS is struggling meet existing demands; new targets and guarantees promised by politicians at conferences seem to come from another world. The Nuffield Trust says that, after the withdrawal of Covid support, England’s NHS is already £5 billion down in real terms on the budget set by the Long Term Plan, and the funding gap is set to grow wider still. This is an issue “no political party contemplating office in the next 15 months can responsibly ignore”, says the trust. But ignore it they have.
Neither Ed Davey nor Wes Streeting had anything significant to say about NHS staffing, pay or the recent strikes. Rishi Sunak extolled the the government’s workforce plan but was silent on how the NHS will attract the hundreds of thousands of extra staff the plan requires. Steve Barclay only mentioned NHS pay to criticise staff for demanding more of it.
Health Foundation chief executive Dr Jennifer Dixon warned recently about an “overwhelming perception in health circles of government inattention”. New health secretary Vicky Atkins at least seems to have more interest in her brief than Barclay, but neither the King’s Speech, nor Jeremy Hunt’s Autumn Statement did anything to dispel the sense of drift around NHS policy. The party conference season offered little hope that opposition politicians have grasped the scale of the challenge either.
- Craig Ryan is a freelance writer and editor of MiP's Healthcare Manager magazine.