As the snap election campaign ends in yet another burst of political chaos, like many people across the UK I have spent the weekend asking what it all means. For the NHS it is, in one sense, business as usual, with Jeremy Hunt resuming the role of Health Secretary for a fourth time. The uncertainty that follows from a minority Conservative Government, an emboldened Labour Opposition and an increasingly confused political landscape make long-term predictions hazardous. But here are five points that do seem clear already.
1. The parties didn’t grasp the NHS nettle, but the voters might
As a policy issue, the NHS featured surprisingly little during the election campaign. While chunks of the parties’ manifestos did contain proposals on health care, the campaign largely focused elsewhere. Proposals to deal with the financial sustainability of a service creaking at the seams fell short of the mark.
But voters themselves are very worried about the NHS. Ipsos MORI’s most recent Issues Index showed the NHS as the single top issue, above even Brexit. And Lord Ashcroft’s Election Day poll revealed that, while Brexit was a top concern for voters overall, it was the NHS that was the most important electoral issue for voters in the 18-24 and 25-34 age groups – who, it is believed, turned out in large numbers to vote.
There is a danger that leaders in Government and NHS England will now respond with an ever more desperate push to meet targets. But without long-term financial questions answered, it is not clear that this is possible. Is there an opportunity to be honest with a concerned public about the sort of tax and spend decisions that would be needed to put the service on a steady footing?
2. Local hospital changes may now be even more difficult to achieve
The NHS is in the early stages of a major change programme that could see some hospital services closed or downgraded. But parliamentary arithmetic may have real implications for these changes. If the Conservatives manage to scrape a majority backed by the DUP, it will require just four Conservative MPs to vote against or even abstain for the Government to lose this effective majority. Yet several MPs have run explicitly against changes in areas such as North Oxfordshire and West Devon, where the winning Conservative candidate has vowed to leave his party if the local A&E is closed.
Meanwhile, the Labour party’s proposals to halt the Sustainability and Transformation Plans (STPs) and oppose hospital closures seemed to resonate with public concerns and may well have been behind some high-profile swings to Labour, such as the dramatic result in Canterbury.
3. There will be continued uncertainty for arm’s-length bodies
The snap election and seven weeks of purdah have had implications for the ability of arm’s-length bodies to move forward with new policies and settle unresolved issues. The uncertainty that rages today will not help.
In particular, NHS Improvement may find it difficult to get a new chair approved after the departure of Ed Smith before parliamentary recess in July. The appointment requires a pre-appointment hearing by the whole of the Health Select Committee. But there is no saying how long that will take. And a new chief executive to replace Jim Mackey is unlikely to be appointed until a chair is in place. What’s more, this uncertainty could be made worse if there continues to be speculation about further elections.
4. The role Brexit will play in the NHS’s future is unlikely to change much
While the outcome of the election has raised many questions about Brexit, from an NHS perspective it is unlikely the result will change things. The Conservatives are committed to ending free movement of labour – which Labour also supports. The DUP manifesto does not specifically oppose this, meaning we can expect it to remain part of Britain’s negotiating position when talks begin next week.
The economic reality is that health and social care need migrants. Unless there is a dramatic and expensive increase in domestic labour, opt outs will be needed to allow nurses and social care workers to continue to migrate. The Conservatives are both the party of the free market and the party of Brexit. They may have to choose between which of these ideas is paramount. The prospect of elderly people without carers, more expensive hospital cleaners, and safe staffing ratios of nurses growing ever more distant could start to make free movement look more appealing.
Both the Conservatives and the DUP also specifically pledge to withdraw from the European Court of Justice. This is likely to mean reworking a wide range of complex key regulations and a significant opportunity for conflict. Whether there is the time for a proper debate on these in the development of the ‘great repeal bill’ remains to be seen. There are dangers here in the NHS losing access to the European medicines market. Some might welcome the opportunity to end rules on working time and procurement. But these too require complicated and contentious deals to be struck, and future potential trading partners might want to restore or increase the use of competitive procurement.
5. Finding the cash to invest in the NHS will be even harder
The polling evidence suggests that the general public would like to see more money spent on the NHS, and during the election campaign we became increasingly concerned that none of the parties’ pledges were likely to meet the scale of rising need. But getting more money from taxation or cuts elsewhere could now be more difficult.
Many Conservative MPs were ready to rebel over the attempt to increase national insurance contributions earlier this year. The DUP manifesto opposes any cuts to the winter fuel allowance, and supports the triple lock on state pensions. And there is wide speculation that the DUP may also ask for more funding for projects in Northern Ireland, reducing still further any wiggle room available to the Treasury (and, incidentally, further delaying the long overdue reshaping of the hospital system in Northern Ireland).
If running a Government with no overall majority were not difficult enough, the prize for being the largest party in this election is being in power at the point that the health and social care system has run out of financial road.
With speculation that the Prime Minister may not even last the week, widespread discussion over a future election and Brexit talks about to begin, it is hard to say much at all with any certainty. There will undoubtedly be many more consequences of this situation on the NHS that we have not yet anticipated – and what this all means for social care would take an entirely new blog.
But one thing is clear: with attention diluted by the sheer difficulty of governing as a minority, as well as by Brexit, any politically-led solutions now seem further off than ever. While the situation unfolds, our priority will remain supporting the health service to work together on developing solutions, sharing ideas, providing mutual support and preparing for further years of austerity.
Edwards, N (2017) 'Five thoughts on what the election result means for the NHS'. Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/five-thoughts-on-what-the-election-result-means-for-the-nhs