What was intended to be a ‘Brexit election’ has turned into one focusing less on the negotiations and much more on health and social care. But do the manifestos grasp and address the real pressures the health service is under? Sally Ruane reviews the Labour and Conservative policies on funding, staffing, re-organisation, and privatisation.
The NHS is facing persistent rising costs and funding pressures. Health care needs continue to rise as a result both of an ageing population and of a changing profile of morbidity, with increasing numbers of people suffering multiple long-term conditions. Even more cost pressures arise from technology and medical advances, and the labour intensive nature of much health care means that the NHS rate of inflation is significantly higher than the general rate of inflation.
Yet neither the Labour nor the Conservative manifestos promise adequate funding. While the Conservatives are promising an extra £8bn a year by 2022, and Labour an extra £12bn in comparison with current funding, this represents in both cases a further decline in the proportion of the GDP being allocated to health care (from 7.3% in 2017/18 to 7.0% and 7.2% respectively, according to the Nuffield Trust). This is likely to reflect a commitment by Conservative-led administrations to reduce the share of the national income accruing to the NHS and, perhaps, a view in Labour circles that the NHS has so far got off lightly under austerity, compared to other departments’ cuts.
While the obduracy of the government and its ideological ambivalence concerning the NHS make the Conservative proposal unsurprising, Labour’s stance must be seen as a disappointment. The impact of the financial stress endured by those working in the service, and the mounting scale of cuts and closures to services consequent upon inadequate resourcing are effectively being disregarded.
Labour promises extra capital funding while the Conservatives promise £10bn of capital expenditure but do not say where the funds will come from. There is of course an irony in borrowing more expensively from the private sector when public borrowing is so cheap.
Mental health services
Commitments to funding are not a minor detail since they point to doubts as to whether the parties’ other health proposals can be achieved – and this is not just the re-pledged commitment by the Conservatives to a ‘truly seven-day NHS’. Labour promises ‘well-resourced services’, ‘safe staffing levels’ and ‘world-class quality of care’ despite the fact that inadequate funding may make these impossible to achieve. Labour will also attempt to ‘tackle’ the rationing of services and will end the ‘routine breach’ of safe bed occupancy levels but as each is likely to entail an expansion in capacity, the party’s stance on funding may impede their achievement.
This will be a source of particular anxiety to those keen to see improved mental health services. Here, Labour promise parity of esteem; ring-fence budgets; increase the proportion of the mental health budget spent on children; and end out-of-area placements. Oblivious to the consequences of their stance on funding, the Conservatives promise that those with mental health problems will get the ‘care and support they deserve’ and that medical training will ensure a deeper understanding of mental health.
Health care reorganisation
The Conservatives remain committed to the contentious Sustainability and Transformation Plans (STPs), drawn up in secret at a local level to reorganise services and simultaneously cut their costs. The privileging of financial sustainability has rather overtaken the promised transformation. But, contrary to government and NHS England assumptions, transferring services out of acute hospitals and into community settings is unlikely to achieve cheaper health care if they are to remain high quality services. Moreover, the transitional period itself requires additional funding. ‘Vanguard projects’ are currently piloting new ways of providing services and local NHS leaders are being expected to implement changes while an evidence base is still to be produced.
Labour does not promise a roll-back of STPs but instead a ‘halt and review’, with local people invited to participate in redrawing them. This feels an ambiguous passage in the manifesto which might reflect the competing pressures of cautious endorsement of STPs from some think-tanks, given the funding constraints and the perceived desirability of making more services available in community settings, on the one hand, and the fierce opposition, on the other, from local people who experience their STP as the vehicle by which large-scale cuts and closures are being implemented.
Quality services also require adequate staffing levels. Labour has costed its plans to reinstate bursaries for nurses and to lift the pay cap for NHS staff – some of whom have suffered more than a 10% reduction in the real terms value of their pay since the financial crash. Its commitments on NHS staffing – recruitment and retention – differ somewhat from those in the Conservative manifesto. Labour promises an immediate guarantee of the rights of EU staff, lifelong education and development for doctors, and reinstating the role of the independent pay review body. The Conservative Party promises 10,000 extra staff in mental health service, an extra 1500 doctors a year in training, stronger staff entitlement to work flexibly, and the development of new roles in health care. This is perhaps to facilitate the shift to more generic roles heralded in some STPs, and the greater use of unregistered nurse associates and physician associates to supplement (or supplant) the registered professionals. Where all these staff will come from remains unclear. The Conservatives offer EU nationals working in the NHS only the promise that they will do their best for them in the Brexit negotiations.
Those who have been campaigning against privatisation and the use of market forces in the NHS will welcome Labour’s commitment to reversing the privatisation of the NHS. They will also hope that this is compatible with Labour’s promise to introduce a new legal duty on the Secretary of State to ensure ‘excess private profits are not made out of the NHS at the expense of patient care’. They will certainly welcome the repeal of the infamous 2012 Health and Social Care Act.
The Conservative manifesto also points to the prospect of legislative change and indicates that the provisions of the Health and Social Care Act – a highly unpopular piece of legislation among both campaigners and professional associations – may not be sacrosanct where they interfere with the implementation of STPs. This hints at the fact that much STP activity has occurred outside statutory provision and is an implicit acknowledgment by the Conservatives that Accountable Care Organisations (ACOs) offer a better route to commercialisation than a model based on a competitive provider market in a time of financial constraint. Anti-privatisation campaigners, aware that ACOs can be contracted out to non-public organisations and always suspicious of Conservative intentions, will take little comfort from this.
Sally Ruane is Deputy Director of the Health Policy Research Unit at De Montfort University, Leicester.