Election manifestos are not the place to find detailed health policies, but they do give an insight into how the parties are responding to calls for credible plans to solve the crisis in our health service. Here is a quick round-up on where the three major parties, plus the Green Party, stand on some of the central issues of concern for the NHS and social care.
Funding
The general consensus of opinion (think-tanks, BMA, IFS etc.) is that the NHS needs at least 4% per year over the next five years to maintain the current level of service, but to make any meaningful progress on its major problems, including staff shortages, mental health provisions and waiting times, the NHS will need funding growth of around 5% a year over that same period.
The Labour Party has pledged to increase expenditure across the health sector by an average 4.3% a year, the Green Party has pledged 4.5%, the Liberal Democrats have pledged 3.8%, and the Conservatives have pledged around 3.1%. The figure for the Conservatives spend has been calculated by The Health Foundation as no total health budget was published by the Conservatives.
The Green Party pledge most, but an analysis by The Health Foundation of the three main parties, concludes that only the Labour funding promise will enable improvements in care to take place, whilst the Liberal Democrats pledge will maintain current levels of care. Planned funding under the Conservatives, however, is not enough to maintain the current levels of care.
Staffing
The NHS has a staffing crisis with an estimated 100,000 vacancies. The policies of the last Conservative Government, including the axing of the nursing bursary and Brexit, have fueled this problem.
All four parties aim to reinstate the bursary in some form, although only the Labour Party promises to reinstate bursaries for nurses and other allied health professionals. The Conservatives and the Liberal Democrats only plan to fund bursaries for nurses doing training in areas with staff shortages and in certain regions. The Green’s pledge is not specific.
One of the key promises of the Conservative manifesto is the pledge to deliver 50,000 more nurses, although the manifesto is unclear as to the timescale for delivery. The figure of 50,000 nurses includes retaining 18,500 nurses who might otherwise have left, so the actual figure for additional nurses is 31,500. The recruitment of additional nurses will be 12,500 from overseas and 14,000 through new undergraduate students and 5,000 would be degree apprenticeships.
The viability of recruiting so many overseas nurses given the brutal immigration policies from the Johnson and May governments has been questioned, however. The Conservatives plan to increase the NHS surcharge payable by people from non-EEA countries from £400 to £625 per year and extend it after Brexit to people from EEA countries – another move that will make the UK a less attractive location for healthcare staff. Plus there is the issue of the £30,000 minimum salary for migrants and how this will be applied to healthcare staff.
In contrast, both Labour and the Liberal Democrats promise to develop ethical recruitment policies for overseas staff. In addition, the Lib Dems note that they will also maintain freedom of movement.
Recruitment and training of staff is expensive and Full Fact has raised doubts over the minimal £879 million allocated by the Conservatives to funding the extra nursing staff and reinstating the bursary for student nurses — with a minimum of £5,000 per year.
Full Fact argues that the full cost of employing 50,000 Band 5 nurses could be as high as £2.6 billion per year, far more than the almost £900 million allocated.
The Conservatives promise of 6,000 extra GPs also grabbed attention, with the related promise of 50 million more appointments each year. The promise had already been made by Matt Hancock – and exposed by Pulse magazine as another misleading claim, including 3,000 trainees along with 3,000 qualified GPs in the total.
Labour has a number of policies in its manifesto to target the staffing crisis. As well as the restoration of bursaries, there is also a plan to increase the number of health visitors and school nurses and expand the number of GP training places by 5,000 per year.
Labour promises NHS staff a 5% rise in pay in 2020 followed by year-on-year above inflation pay rises. The party says it will enshrine safe staffing levels into law; Wales and Sotland have already done this.
The Liberal Democrats pledges include action on the pensions crisis, GP numbers and a workforce strategy. The Health Foundation notes, however that “the manifesto acknowledges that [the workforce crisis ] will require investment in recruitment, retention and making the NHS an attractive place to work. Yet the funding promised [by the Liberal Democrats] falls short of the amount needed for workforce training, despite chronic staffing shortages.”
Infrastructure
The NHS’s infrastructure is crumbling and disintegrating – 50% of GP surgeries are not fit for their current purpose, according to the BMA, and recent data shows that £6.5 billion is needed to complete the backlog of maintenance needed in hospitals and clinics.
Back in 2017, the Naylor report estimated that £10 billion would be needed to make the NHS fit for purpose and deliver the plans that had been drawn up around England to improve the NHS. The plan was for the NHS to raise at least £6 billion of this itself from land and property sales.
What do the main parties promise for our crumbling infrastructure? Well the Conservatives highly publicised promise of 40 new hospitals, was almost immediately exposed as a sham. We now know that the promise is just £2.7 billion for six upgrades to currently existing hospitals. The funding for the remaining ‘34 hospitals’ only consists of £100 million to develop business proposals.
Furthermore, as the bill for backlog maintenance of NHS infrastructure is around £6.5 billion, the £2.7 billion for six projects just scrapes the surface of the problem.
Since the Naylor report in 2017 hospital trusts have been ramping up their sale of land and assets, but as the maintenance bill keeps rising, this approach appears to be having little impact on spending on infrastructure.
Labour promises to invest £15 billion in infrastructure to bring capital spending up to the international average and to halt the sale of NHS land and assets driven by the Naylor review.
The Liberal Democrats have promised to spend £10 billion and the Greens will focus funding on the construction of new community health centres, bringing health services closer to people’s homes.
Social Care
Social care is in crisis with demand rising and real problems with attracting and retaining staff. Years of austerity has led to major cuts in services and serious problems in access to care. This has also had a knock–on effect on the NHS as patients well enough to leave hospital can not due to a lack of care packages.
The three main parties have all pledged more money for social care. But an analysis by The Health Foundation, found that none have pledged enough to meet the growing demand or improve pay for social care staff. The estimate is that an additional £12.8 billion is needed for social care to bring it back to levels of access seen in 2010/11.
Out of the three main parties, only Labour has set out any concrete proposals for reform, with a headline pledge of free personal care for the over-65s. The plans also include building a ‘national care service’ and a life-time cap on social care costs. They will plow in an additional £11.1 billion for social care by 2023/24, according to the Health Foundation analysis.
The Liberal Democrat plans, which according to the analysis by The Health Foundation amount to £2.9 billion in additional spend by 2023/4, include establishing a cross-party convention to agree a long-term funding model for health and social care and introduce a cap on the cost of care.
The Conservative manifesto says the least of any of the parties opting just to say they plan to “build a cross-party consensus on long-term social care funding.” Their additional spend is just £1.1 billion.
Several Conservative policies, including Brexit and the minimum salary level of £30,000 for migrant workers, will actively exacerbate the problems in social care. These policies will block new recruits to care work and leave nursing homes and domiciliary care companies struggling to keep services running.
Privatisation and restructuring reform
The NHS has been in a state of reorganisation for many years now – the Health and Social Care Act 2012 ushered in competition, privatisation and major changes to the way the NHS is organised.
The failings of the tendering system and the forced competition between NHS organisations have made it unpopular throughout the NHS. It has disrupted the planning of healthcare and wasted precious resources.
The Labour Party and the Green Party pledge to repeal the H&SC Act and so end competitive tendering and privatisation across the NHS. Labour promises that all integration of care will be delivered via public bodies.
In contrast, the Conservatives and Liberal Democrats only promise to make changes to the legislation in the 2012 Act that will end compulsory tendering and competition between NHS organisations. These are the changes that NHS England proposed in the January 2019 Long-Term Plan.
The years of top-down restructuring of the NHS that began with the 2012 Act will carry on, according to the Conservative manifesto, as it pledges to continue with the restructuring set out in the Long-Term Plan. Organisations put in place under the 2012 act, such as the CCGs, are now being merged and integrated under plans for Integrated Care Systems (ICS). It is likely that NHS outsourcing will continue due to pressure on capacity and the structure of the proposed integrated care provider contract. These plans confirm a U turn on key elements of the Lansley reforms (H&SC Act 2012) but do not block the possibility of further NHS privatisation.
Labour too would introduce new NHS legislation, but to reinstate the duty of the health secretary to provide care to all citizens, which was removed under the Coalition’s reforms in 2012.
Public Health
Under the last Conservative government, the responsibility for public health was transferred to local councils and funding was cut. By 2020/21 funding for public health will have been cut in real–terms by 25% on 2015/16 levels or around £1 billion. This has had a major impact on service levels, particularly in more deprived areas.
Labour promises to address the shortfall in funding with an increase of £1 billion in spending on public health. The Liberal Democrats also promise to make good the shortfall but without mentioning a figure. Both these parties appear to appreciate the importance of public health services to our society and people’s well-being.
They both outline a number of pledges, many focused on food and drink, including minimum unit pricing for alcohol, extending the Soft Drinks Industry Levy to juice and milk-based drinks and approaches to regulate junk food advertising and sales.
The Conservative manifesto, on the other hand, does not address this issue in much detail, instead it says they will “invest in preventing diseases as well as curing them” and try to “empower people with lifestyle related conditions to live healthier lives.”
Waiting times
In November this year, data from the NHS showed that key targets for cancer, hospital care and A&E have been missed for over three years. The delays for hospital care and in A&E hit their highest levels since both targets were introduced.
Less than 75% of people who went to A&Es in England in October were treated and then discharged, admitted or transferred within four hours – the smallest proportion since the target was introduced in 2004. In September 2019, 4.42 million patients were on the waiting list, the highest number ever and 76.9% of cancer patients starting treatment within 62 days – below the 85% target.
All these problems can not be addressed in isolation and are inextricably linked to funding of both the NHS and social care. As already outlined, the Conservatives funding plan does not provide enough money and no plans have been put forward to solve the problems of social care. So although the manifesto lists pledges for waiting time reductions, in reality there will not be sufficient funding to have any impact.
Mental health services are in crisis at present due to lack of staff and funding, with high waiting times and a lack of sufficient infrastructure and beds. Children and adolescent services are particularly badly hit.
Mental health is discussed in all four manifestos, with all four parties, Labour, Green, Liberal Democrat and Conservative, pledging to treat mental health and physical health with the same urgency, however as already discussed this will only happen if funding is sufficient.
Other pledges
All the parties have a number of other pledges relating to healthcare.
Labour plans to introduce free prescriptions and annual dental check-ups for all, and to not let NHS data be exploited by international technology and pharmaceutical corporations.
Following the considerable media coverage of possible drug price rises under any post-Brexit trade deal with the US, it is interesting that Labour plans to establish a government generic drug company, so if fair prices are rejected for patented drugs, the provisions of the Patents Act, compulsory licences and research exemptions can be used to secure access to generic versions. Labour also plans to plant an ‘NHS forest’ to ensure the organisation can become carbon neutral.
Both Labour and the Liberal Democrats have pledged to make PReP for HIV prevention available on the NHS.
The Conservatives announced an extension of the Cancer Drugs Fund into the ‘Innovative Medicines Fund’ and a doubling of investment in dementia research and speeded up trials. However, Brexit has already led to a significant ‘brain drain’ of academics and researchers from UK universities. The charity Alzheimer’s Research UK has already warned about the negative effect of Brexit on research into dementia, with a loss in funding – dementia research in the UK has benefitted hugely from EU funding over recent years – and the loss of researchers and collaborations with European researchers.
And finally the regular battle over car parking fees should get a mention – Labour will scrap them for all and the Conservatives will end hospital car parking charges only for those in “the greatest need” plus staff working night shifts.