Whether by surprise outright majority or by late-night coalition negotiations, a new government is set to win power in the UK and with it take the reigns of the NHS. The manifestos of the three largest parties — the Conservatives, Labour and the Liberal Democrats — paint similar pictures of what they want the health service to look like. But campaign commitments to give the NHS more money may not be enough for the parties to keep their promises, say several health organisations.
Over the past five years, the era of austerity has squeezed NHS finances to unprecedented levels. Coupled to a far-reaching top-down reorganisation implemented as part of the Health and Social Care Act 2012 in England, the NHS is facing a financial crisis that risks compromising the quality of services provided.
Since healthcare is devolved to smaller nations, each of the largest parties’ manifestos are England-centric. All three place importance on the integration of health and social care, parity for mental health and improved patient access to care.
And these are all commendable objectives, but in its analysis of the manifestos, the Nuffield Trust says the extra money promised for the NHS would not be enough to achieve the long list of proposals and that it is unclear how they could be afforded even if the economic upturn continues. Each of the parties set out “what” needs to change within the NHS. But the “big gap” is how this change will be achieved, the independent research organisation says.
Agree to disagree
The Conservatives have thrown their support behind NHS England’s strategy, the Five Year Forward View, and the Liberal Democrats allude to it in their funding proposals — while Labour does not mention it at all. The Nuffield Trust calls the lack of explicit reference in the Labour and Liberal Democrat manifestos “worrying”. The importance of stability is emphasised in the Nuffield Trust analysis, which explains that “change has to work with the grain of existing policies and should not undermine the efforts of staff who are already attempting to deliver very challenging efficiencies in both NHS and social care”.
According to the King’s Fund, shadow health secretary Andy Burnham says the reason Labour is not explicitly supporting the Five Year Forward View is because the party is planning “fundamental” changes that could alter the assumptions on which the view is based. Part of this change includes repealing the Health and Social Care Act 2012, with particular emphasis on scrapping the competition rules and making the NHS the preferred provider of care. But this Labour policy raises the spectre of another top-down reorganisation of the NHS. The King’s Fund says “it is hard to see how Labour’s plans to dismantle the Health and Social Care Act could be achieved without disruptive structural changes to the NHS”.
In a health debate organised by the NHS Confederation — which calls itself the voice of NHS leadership — on 21 April 2015 in London, Burnham said that his aim was to achieve better “integration” of services by incentivising care for patients in their homes but that this would not amount to a reorganisation. The Liberal Democrats would also repeal parts of the Act that make the NHS vulnerable to “forced privatisation” and they plan on pooling health and social care budgets. However, the Nuffield Trust warns that even if there is no structural reorganisation, “policy reorganisation can be just as disruptive for managers and clinicians”.
Where the parties do agree is that the NHS needs more money, although Labour’s plan departs from the Conservatives’ and Liberal Democrats’ proposals.
After years of limiting increases in NHS spending and pushing for efficiency-savings, it has been recognised that the NHS will need real-terms increases in its budget over the course of the next parliament. It is projected that there will be a £30bn shortfall in funding by 2020. According to the Five Year Forward View, further efficiency savings could close this gap by £22bn — if there is increased investment in infrastructure and operations. The Conservatives and Liberal Democrats have promised to tackle the problem with a real-terms funding increase of £8bn per year by 2020, while Labour has promised £2.5bn.
However, the Conservatives do not specify when the budget increases will kick in. “If they are following the letter of the Five Year Forward View, one would assume that it would be a steady increase from 2016–2017,” says the Nuffield Trust, in its analysis of the manifestos. At the NHS Confederation health debate, health secretary Jeremy Hunt spoke of how the Conservatives’ funding plan would follow the NHS Five Year Forward View, which he said requires £1.7bn additional spending next year. But Hunt pointed out that the Conservatives are increasing the amount to £2bn, with the money coming from a “strong economy”, which was announced as a policy by the chancellor in November 2014.
The Liberal Democrat manifesto says that its funding increases will kick-in only once they have “balanced the books” in 2017–2018, but that there will be a £1bn boost on spending in the meantime. Thereafter, funding will be linked to economic growth, which they say will mean at least an extra £8bn per year by 2020. But the King’s Fund warns that holding back most of the £8bn funding increase until 2017–2018 will place an unsustainable strain on acute services and do nothing to address the immediate financial pressures facing the NHS. Yet, speaking at the NHS Confederation debate, Norman Lamb, minister for care and support (Liberal Democrat), said that the case for extra investment was overwhelming and “must happen this year”.
Labour’s promise of £2.5bn signifies a different approach to financing the NHS. The King’s Fund points out that Labour is the only main party not to have pledged to find the £8bn a year in additional funding called for in the NHS Five Year Forward View. But exact funding levels remain unclear. The Labour manifesto promises to spend £2.5bn a year more than the Conservatives, but this was published before the Conservatives promised an extra £8bn. What is clear, however, is where Labour intends to get the money from. Revenue will be generated from a ‘mansion tax’ on properties worth over £2m, a levy on big tobacco and tackling tax avoidance.
None of the parties directly addresses the implications (and feasibility) of the extremely ambitious efficiency assumptions that lie behind the £22bn of savings
Despite all parties vowing to increase NHS funding in one way or another, the Nuffield Trust says there has been a failure to recognise the scale of the NHS’s financial problems. “None of the parties directly addresses the implications (and feasibility) of the extremely ambitious efficiency assumptions that lie behind the £22bn of savings identified by NHS England, or the degree of financial distress already being felt in the system, particularly the acute hospital sector.”
Yet despite the scale of the problems facing the NHS, each party has ambitious goals for the health service. The Conservatives are committing to seven-days-a-week access to care and a guarantee that anyone aged over 75 years will get a same-day appointment with their GP. “Significant challenges will need to be overcome to ensure sufficient hospital consultants and other staff are available at weekends, and it will cost money,” warns the King’s Fund. “A seven-day NHS is the right ambition but delivering it by 2020 will be a tall order.” Labour also makes commitments on access to care; the party is guaranteeing a GP appointment within 48 hours and urgent tests for cancer within one week.
The Nuffield Trust says that improving access to GPs is a “well-worn policy path” and that there is a danger of “over-specification and the perverse consequences of aggressive performance management of access targets”. Increasing access to care will require more staff and Labour has made specific commitments to increase the number of NHS workers, promising that there will be 8,000 more GPs, 20,000 more nurses and 3,000 more midwives. The Conservatives have previously addressed staffing levels with a promise to “train and retain” 5,000 extra GPs, but this plan is not in their manifesto.
Any promise to increase staff will need to be backed by an appropriate increase in funding for the health service
The NHS Confederation is critical of “arbitrary” targets for recruiting certain numbers of staff. Indeed, Labour has not explained how it plans to recruit these numbers of doctors and nurses. During the NHS Confederation health debate Burnham said that general practice could be turned around by giving young doctors new care models to work with in a bid to retain existing GPs and attract others back to practice. Hunt and Lamb made similar statements, pinning increases in GPs on the profession becoming “attractive” and “exciting”.
But the NHS Confederation is not convinced; instead of setting staffing targets, the next government should facilitate sustainable long-term workforce planning. “Any promise to increase staff will need to be backed by an appropriate increase in funding for the health service,” it says.
The Liberal Democrats are most specific when outlining their plans for mental healthcare, which is a big focus of the NHS portion of their manifesto. This emphasis is described as “striking” by the Nuffield Trust, and the King’s Fund says “the Liberal Democrats have led the way in pushing mental health up the agenda”. The party promises to increase funding for mental health in England by £500m by 2016–2017, half of which will be introduced in the current financial year. The Liberal Democrats propose waiting time limits for treatment, specifically a six-week limit for therapy for depression or anxiety and a two-week limit for young people experiencing a first episode of psychosis.
Likewise, the Conservatives and Labour both say they will increase access to talking therapies and emphasise the need to better address the mental health of children and young people. But the Nuffield Trust says the challenge is to turn manifesto pledges into reality. “This might be an area where the blunt instrument of high-profile targets could be effective,” it says.
Joining up health and social care is emphasised in all three manifestos. Labour proposes a system that joins up services “from hospital to home” by bringing together commissioning and budgets at a local level and by incentivising service providers to help people stay healthy and out of hospital. The Liberal Democrats propose pooling the budgets for health and social care. Meanwhile, the Conservatives point to the use of the £5.3bn Better Care Fund as a means to integrate health and social care systems and also support using pilots such as one in Manchester, which has pooled around £6bn of health and social care funding.
None of them contains a plausible explanation for how the immediate short-term financial challenges facing this heavily squeezed sector will be met
But, other than the mission statement to integrate services, there is very little detail about plans for social care itself, which is described as a “glaring omission” by the Nuffield Trust. The sector has been heavily squeezed, with a 16% cut in its budget over the past five years. The King’s Fund, Nuffield Trust and NHS Confederation all criticise the lack of clarity from the Conservatives, Labour and Liberal Democrats. “None of them contains a plausible explanation for how the immediate short-term financial challenges facing this heavily squeezed sector will be met,” says the Nuffield Trust.
The story is similar for already cash-strapped health services, such as A&E, mental health services and primary care. “The manifestos are all silent on how more immediate pressures facing NHS providers across sectors will be met,” it adds. So, which party can be trusted with the nation’s most precious resource? The answer is unlikely to be gleaned from their manifestos. As Sir Alan Budd, former chairman of the Office for Budget Responsibility, told Radio 4 listeners on 27 April: “Unfortunately, none of the manifestos are specific enough to be judged, to know whether plans set out are consistent with the overall objectives that the parties are claiming — there’s not nearly enough detail.”