NHS and social care funding: speaking truth to piety

As the noise generated by last week’s local and European elections fades, political energy will now be directed towards defining the policy battlegrounds on which next year’s General Election will be fought, which will have to be much wider than immigration and the European Union.

Even though the NHS is so central to politics in the United Kingdom, predicting how noisy an issue it will be in the run up to next year’s General Election is difficult. This is partly because of its peculiar status, at least in the minds of politicians, who believe that the voting public has an essentially irrational relationship with the NHS as an institution: the NHS is often simultaneously venerated, when things go right, and reviled when things go wrong.

This was perhaps the idea behind Nigel Lawson’s much quoted observation that the NHS was the closest thing the English had to a national religion. Like religion, people’s personal experiences of the NHS are private territory.

Election campaigns can often be dull because political parties tend to play it safe and offer bland pieties back to the electorate about their plans for NHS, often ducking controversial issues which might be considered heretical

Even though there is now good data on patients’ experiences of different parts of the NHS and public attitudes to the NHS as a whole, the campaign trail can bring politicians into direct confrontations with voters who have had intensely and undeniably bad experiences with individual NHS services, for whom no amount of patient experience data or other statistics about NHS performance can mollify. Politicians cannot know whether the balance of all these millions of individual interactions results in a desire for reform or preservation.

As a result, election campaigns can often be dull because political parties tend to play it safe and offer bland pieties back to the electorate about their plans for NHS, often ducking controversial issues which might be considered heretical (or in the case of the Conservatives in 2010, bury radical plans behind innocent looking language).

It is often difficult to find much difference between each parties’ NHS policies, beyond them all claiming to be the best placed to preserve the NHS and a few catchy ideas to improve access to GPs, new drugs or screening programmes.

Next year’s election could well be different, if the electorate starts to notice the effects of the huge financial crisis unfolding within the NHS and social care services. New pieties are emerging this time from the political parties, which reflect but do not solve the funding problem: that spending money on ‘integration’ and social care will reduce pressure on hospitals and save money, and that there is still scope for more war on ‘bureaucracy’ and administration to free up savings.

It’s not impossible that some clear differences might emerge between Labour and the Conservatives over the role of competition in the NHS, but Labour are on sticky ground here as architects of competition between hospitals for elective surgery and the extension of competition into community services in the form of Any Qualified Provider.

The Conservatives meanwhile are unlikely to be able to marshal any convincing evidence that increased competition in the NHS as a whole has improved quality and reduced costs or will do so in the future.

Labour may be tempted to attribute the financial problems in the NHS to the reorganisation following the Health and Social Care Act and promise salvation by repealing parts of the Act. But the words ‘CCGs,’ ‘NHS England,’ ‘expanded role for Monitor’’ Health and Wellbeing Boards’ are not being bandied around in conversations between voters about the NHS on the bus or in the pub.

What people notice are stressed out staff and anxious waiting times in hospitals and ambulances and (perhaps) in their GP surgeries.

The Liberal Democrats may want to take ownership of the reforms to social care contained in the recently passed Care Act. But however much they talk up the benefits of the social care reforms (the Act will simplify a tangled care system, and the cap will extend some state protection to some people), they can’t pretend that publicly funded social care will still be anything other than brutally rationed even with the Care Act in place.

The challenge for the coalition parties will be deciding whether or not to stick to their claims that nominally protecting spending on the NHS has been successful (inflation and the Better Care Fund notwithstanding) and whether it will be enough to reiterate this as their central manifesto commitment.

The growing number of hospitals forecasting deficits is likely to filter through to public consciousness in the next 12 months, and a difficult winter could exacerbate a sense of the ‘NHS in crisis’ even if performance against the main waiting times targets holds up. ‘Protecting NHS spending’ could well look a bit threadbare as a strategy from the perspective of the electorate.

Which brings us to the central dilemma facing all parties: should they tough out the funding gap with vague promises about integration and efficiencies or do they dare suggest that spending on the NHS should be increased, and if so how, and by how much?

The parties of the governing coalition may well be too tangled up in their reputation as the government of fiscal discipline to risk anything that resembles a commitment to raise taxes and/or increase spending in one area of the public sector and not another (what about social care?). While the Conservatives may, for now, tolerate some heretical thinking about other, novel ways to raise money, like user charges (perhaps directed at ‘non-deserving migrants’), these are likely to be reined in by the party leadership that is all too aware of the toxic potential of policies that suggest they don’t uphold core NHS values, a service ‘free at the point of use’.

This leaves Labour with a dilemma of whether or not to risk broaching the funding question in the run up to the election. They will have to decide if the public’s affection for the NHS will tolerate paying more for it through increased taxation or national insurance contributions and fend off the inevitable accusations that they are playing fast and loose with public spending once more, and can use the extra cash wisely without breaking their promise to avoid further reorganisation.

It’s possible that none of the parties will want to mention funding. Whether it emerges as a potent election issue is probably outside their control. It may hinge on factors like the weather and the extent to which the huge financial pressures become evident in the millions of individual, private contacts between patients and NHS professionals over the next 11 months.

The Nuffield Trust will be following the progress of the political debate in the run up to the 2015 General Election, with the help of our regular surveys from our panel of health and social care leaders, who will be reflecting the mood and temperature from the frontline.

With our regular analyses of performance on NHS quality and finances in QualityWatch and other publications over the next year, we will be attempting to speak some truth to piety in what could otherwise be a very distorted debate.