Labour has inherited an NHS and social care service in crisis. The new Government has a short window of opportunity to make a start on a serious and cost-conscious programme of recovery, argues Tony Hockey, but the challenge is immense. 

The new UK government has taking charge in very challenging circumstances. The difference with the economic backdrop to Tony Blair’s 1997 victory make any comparison of policy opportunities a false one. Expensive problems are set against unrealistic fiscal commitments, particularly the commitment not to increase taxes on “working people”. Nowhere will this clash be more obvious than in tackling the unprecedented challenges in health and social care.

Covid-19 exposed a creaking health system after a decade of austerity and exploited the political neglect of social care. The rise in waiting lists for elective NHS treatment up to 2020 accelerated to unprecedented levels. The poor condition of population health and health inequalities were reflected in mortality data. A pre-existing NHS and social care workforce challenge became a crisis.

Since the birth of the NHS the mantra has been much the same: more prevention/less treatment, better integration of health and social care, better use of the workforce and more technical innovation.

In these circumstances, devoid of “new money” Labour’s plans were limited largely to pressing on with existing reform projects and to adopt the perennial tactic of commissioning “reviews” of the most difficult strategic problems. Each review says much the same thing as its predecessor: more prevention/less treatment, better integration of health and social care, better use of the workforce and more technical innovation. Since the birth of the NHS the mantra has been much the same.

Each time, however, immediate pressures that make news headlines crush future reform. In 2016 even the chief executive of the NHS was arguing that any new money might be better spent on social care rather than on the NHS, in order to keep people out of hospital rather than treat them for avoidable problems. This ambition has to be fulfilled if health and care services are to emerge from the current crisis. The King’s Speech and the manifesto gave few clues as to how this huge turnaround will be achieved.

So far, the National Care Services looks limited to another programme of regulatory reforms for the sector.

More positively, there are several areas of health and care policy in which a new Labour government may deliver some tangible change in the new parliamentary term.

A National Care Service

Labour has promised a “National Care Service”. As with “Great British Energy”, different people have interpreted this in very different ways. At face value, it could imply anything from a European-style funding system based on some form of social insurance, with user choice across a diverse range of services and providers, to a full-blooded copy of the NHS, with tax funding of a state-run and rationed service (perhaps run as means-tested part of the NHS). The fear of being specific on basic details is understandable given the past politicisation of any proposals. So far, the National Care Services looks limited to another programme of regulatory reforms for the sector.

The most notable of these, for now, could be the introduction of a “Fair Pay Agreement”. Covid cast a light onto the working lives of those delivering social care. Improved pay and conditions are important to improving and expanding these vital and demanding services. Without conclusion of the funding aspects of a “programme of reform to create a national care service” a Fair Pay Agreement feels a lofty ambition.

Recourse to the private sector to clear waiting lists only worked well in the Blair years when the new money flowed (rather freely) into the Diagnosis and Treatment Centres.

NHS Waiting Lists

The Labour Party has promised increased hospital activity “by incentivising staff to carry out additional appointments out of hours”. Given that pressure on the NHS workforce, including cover for vacant posts, is a major part of the current problem, this seems more a hope than a plan, at least until the long-term workforce plan shows any effect. Similarly, recourse to the private sector to clear waiting lists only worked well in the Blair years when the new money flowed (rather freely) into the Diagnosis and Treatment Centres. Unless something changes in spending plans (as it did for Blair after the 2001 election) this too, seems unlikely to deliver substantive change. Political parties have long promised clampdowns on tax avoidance, but these always prove tough to deliver in practice.

For thirty years successive governments have produced plans to revive NHS adult dentistry, to cover geographic gaps in availability.

Public Health

Labour has implicitly recognised the substantial investment needed to improve public health and tackle inequalities. Somewhere in Whitehall lies the remnants of a 2021 mission to tackle the “health disparities”, and a white paper of proposals that were shelved in 2023. Labour promised to halve the gap in healthy life expectancy between England’s regions, albeit without specifics or timing for such a significant ambition.

NHS Dentistry

For thirty years successive governments have produced plans to revive NHS adult dentistry, to cover geographic gaps in availability. Labour promise to reform the dental contract to focus on prevention: This was the core premise behind the ill-fated 1990 contract that led to an exodus of NHS dentists and the development of new private services. The government will need to proceed with great caution in devising a new contract. It will need both to sustain and build on what it is left of the NHS general dental service, focusing resources where they are most effective to improving dental health. Getting the right incentives in the right place will be crucial to success in filling the gaps in care.

Mental Health

The King’s Speech as well as the Labour’s manifesto commitments on mental health rightly recognise the crisis state of NHS services, especially in relation to children’s services. As in every other area of care, the recruitment and retention of specialist staff will be the determining factor for success. At present it is likely that the open access “Young Futures hubs” would be overwhelmed by pent up demand without substantial investment.

Gender Policy

Back in 2019 the Conservative Party was privately polling “culture war” issues to use against Labour. Labour, with a small but vocal group of members critical of gender-inclusive policies has struggled to delivery clarity on the headline topics, whilst maintaining its inclusive principles and a conciliatory tone. This was reflected in the manifesto, using the headline “respect and equality for all” and a focused offering of policies for women: The commentator James Kirkup has even argued that a Labour government would “feminise the economy”

Although the Conservatives promised a ban on so-called “conversion therapy”, this was never delivered, as the party turned increasingly hostile on LGBTQ+ policies from 2019. Labour has committed to delivering on this commitment (although that was not included in the King’s Speech) and also to reforming the gender recognition process (whilst maintaining a diagnosis-based approach). Labour says also that it would maintain the Equality Act exceptions around single-sex spaces. The over-riding impression is that a Labour Government would do nothing to sustain a “culture war”. Keir Starmer gave an indication of this intent when he accused Rishi Sunak of using the transgender rights as a “political football”. The first real test of this will be in NHS delivery of the recommendations of the Cass Review on gender identity services, building capacity to provide holistic care.

The scale of the Labour majority, the recent pandemic experience, and the political survival of Jeremy Hunt, create a window of opportunity to pursue some consensus on the core issue of future health and care financing.

Sustainable finance

The over-riding issue for the new UK government will, of course, be funding future health and social care needs. A medium-term budget for care services is vital. In 2019 Nick Bosanquet  of Imperial College and I wrote to the then Chancellor making the case for an average of  two per annum growth in spending, reflecting the reality of care needs and technological advance (Nick Bosanquet has made this case consistently since the 1980s). Just as the government has a target for inflation, a similar approach in health and care spending could bring much-needed honesty and stability to the debate. It could also support strategic decisions on reform that could be delivered in practice, rather than rushed, botched and unpicked. Another clampdown on tax avoidance seems unlikely to deliver all that will be needed.

Governments have a short window of opportunity after an election to make a start on a serious and cost-conscious programme of recovery. Tony Blair waited his whole first term before asking Derek Wanless to review health spending needs: 2001 was four years too late. Rushed reforms risk being expensive and unsustainable. The scale of the Labour majority, the recent pandemic experience, and the political survival of Jeremy Hunt, create a window of opportunity to pursue some consensus on the core issue of future health and care financing. Despite a large parliamentary majority, a cross-party initiative to resolve this challenge would be evidence of the Starmer “country first, party second” mantra. Time is of the essence.

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

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