Tony Hockley reviews the Conservative and Labour pledges on health and social care and writes that both fail to offer a sustainable vision for long-term NHS funding. What’s worse, the two main parties continue to treat the NHS only as a treatment service, and so their promises neither reflect nor envision changes that would promote a more active living.
The two major parties’ manifestos show all the hallmarks of a rushed job. They offer a mix of conflicting specific initiatives with little to unite them, together with vague statements on the biggest challenges. Once again, all parties fail to offer a sustainable vision for long-term funding or better integrated health and social care, or any real shift to a healthier nation. The fiasco of the Conservative manifesto announcement that quickly became the “dementia tax” is simply a consequence of this failure. That the Labour Party should choose to focus on hospital car park charges also typifies the random and short-sighted nature of current health policy. Even the Liberal Democrats, who show no signs of a popular recovery since 2015, offer just a temporary plug of 1p on the rate of income tax, with yet more talk of great inquiries into future funding needs.
Of course, this pretence of concern for a long-term solution is nothing new. Since the creation of the NHS the story has been one of repeated deficits, inquiries, and structural reforms. The worry is that manifesto promises often make the task of balancing demand and supply harder rather than easier. Parties divert huge resources to meeting arbitrary promises made during elections.
For its part, a Corbyn government would strive to engage in major ideological reform in order to put the NHS under “expert public control”; replace private providers of care and management services, whilst also halting the Sustainability and Transformation Plans that are now underway. Furthermore, the Labour manifesto hints that funds will be diverted from England to Wales, as part of a funding system reform to ensure that “no nation or region is unfairly disadvantaged”. In an echo of past Labour pledges, the party would again pursue an arbitrary target to remove a million people from NHS waiting lists. Ironically, it was a similar target regime that saw Labour resort to importing private providers to clear elective treatment lists, at considerable expense. For its part, the Conservative Party is pressing on with its focus on evening and weekend care, which is proving to be a much harder task to justify and implement than anyone had imagined.
The majority of health and social care costs arise from the workforce. As one of the largest employers in the world, the NHS is very sensitive to changes in labour costs. At one extreme, the NHS would need to manage the consequences of Labour’s proposed increases in income tax for those earning over £80,000, which would hit much of the medical profession and many in health service management. There would be a very real risk of an acceleration of early retirement or an exodus of highly-trained staff overseas. At the other end of the spectrum, the Living Wage is already having a significant impact on the care sector. Labour claim that the Living Wage would be extended to all workers aged over 18, the cap on public sector wage rises would be scrapped, and current rights for permanent staff extended to all. On top of this, Labour will also beset the health and care system with the costs of an additional public holiday every year.
It seems that both parties will drive up workforce costs, meaning that new funds for investment in facilities or treatments will remain very limited. The workforce challenge is, of course, made more immediate by the uncertainty related to Brexit. Labour has promised that it will provide immediate protection to EU workers in the public sectors, whilst the Conservatives aim that the NHS should invest in training with the ambition that it will become less reliant on imported workers. The Labour Party will need to address questions as to whether the reintroduction of bursaries for nursing students will also mean the reintroduction of a cap on numbers being trained.
Despite near universal recognition that current arrangements for social care are inequitable, inefficient, and unsustainable, neither party is offering anything that reflects this recognition. The Conservative Party appears to remain fixated with questions of inheritance rather than with sustainable and fair funding for long-term care. This has long been the party’s problem, looking at the issue through the wrong lens, but it had appeared that the Dilnot Commission Report had finally shifted this perspective with the Conservatives promising a cap on care costs.
The Dilnot proposals to provide a lifetime limit on care costs should, after all, appeal to Conservatives: by removing the open-ended risk of care costs, the state would effectively become the insurer of last resort. This would transform the bulk of care costs from an uninsurable risk into an incurable one. The manifesto proposals do nothing to encourage private risk coverage. They did, however, offer a more explicit statement than Labour’s vague suggestion of recourse to a “wealth tax, employer care contribution, or social care levy”, now matched by the Conservatives’ return to an (unspecified) cap on care costs, but at an unspecified level.
The most disappointing aspect of the manifestos is that, for all the debate over public health, the focus of specific policy promises remains on the NHS as a treatment service, with little vision of the health service as part of an ambition for a healthier nation. There is little vision for real change to support more active living. Walking to school might be a better priority than car parking at hospital.
Tony Hockley is a Visiting Senior Fellow in the Department of Social Policy at the LSE. He is former Special Adviser at the Department of Health, for Virginia Bottomley and Stephen Dorrell.
Some of the ways that costs have been cut in care is in the training budget, too much reliance on elearning
It is too much to expect radical thinking in manifestos drawn up for an unexpected election. But the start of a new 5 year Parliament is the ideal time for an independent review of how best to achieve integrated health and social care systems. If only Treasury would permit.