Political cross-dressing and the NHS

This election campaign has turned long-standing political perceptions on their head, prompting political commentators to make frequent use of the phrase ‘political cross-dressing’. The Labour party, keen to banish perceptions of profligacy, has emphasised its fiscal rectitude throughout the campaign. The Conservatives, by contrast, have sought to cash in on their handling of the economy by promising seemingly unfunded goodies, made possible by achieving the levels of economic growth that they claim only they can deliver.

This role reversal has been played out at a policy level within the heated topic of the NHS: the Conservatives (and Liberal Democrats) have promised the full £8bn that the NHS has said it needs to break even by 2020 (assuming eye-watering efficiency savings). The Labour party have refused to match this commitment, offering a more modest but allegedly fully funded £2.5bn in the early years of the parliament.

This tension was evident at a major health debate held last week by the Nuffield Trust and five other leading organisations. The purpose of the debate, which featured the Conservative’s Jeremy Hunt, Labour’s Andy Burnham, the Liberal Democrats' Norman Lamb and UKIP’s Dr Julia Reid, was to put the main party spokespeople through their paces.

Expertly chaired by Sarah Montague of the BBC’s Today programme, the 200-strong audience of health and care professionals, patients, policy-makers and journalists witnessed a series of fiery exchanges.

Three big issues dominated: money and which party will give the NHS what it needs to survive and thrive – not just by 2020 but next year too; who has the right prescription for joining up health and social care so the NHS can meet the needs of a growing and ageing population; and who would ensure the NHS has enough doctors, nurses and other professionals, adequately paid, and in the right places to meet this challenge.

Despite moments of intense heat in the debate, there was also a healthy degree of consensus. All parties outlined their desire to prioritise the NHS and all sought to reassure the audience that its budget would grow and continue to be protected. There was also broad agreement for policy areas left out in the cold at previous elections, such as mental health, with each spokesperson clamouring to out-bid the other to ensure parity of esteem between mental and physical health.

While the debate did not offer us any new policy announcements, it did offer some insights into how each party might shape the future of the NHS if elected.

Funding pledges

In a now familiar dance to health policy watchers, Hunt and Lamb attempted to tie Burnham up in knots with their £8bn funding pledge. Burnham bullishly responded that Labour’s £2.5bn Time to Care Fund – paid for by new taxes on ‘mansions’, tobacco companies and hedge funds – was the only fully-costed and funded pledge on offer. An otherwise largely silent Julia Reid said UKIP would commit to investing an additional £3bn a year into the NHS in England by the end of the parliament.

But as my colleague Mark Dayan has outlined in greater detail , there has been much concern and confusion about when the respective pledges would actually kick in, something Sarah Montague pursued with vigour. Hunt wouldn’t commit beyond providing NHS England’s £8bn by the end of the next Parliament, while Burnham said his £2.5bn fund would come on stream in time for the 2016/17 financial year – addressing what he called the immediate ‘financial crisis’ facing the NHS now.

Lamb urged the main parties to agree to be part of a non-partisan commission to review the long-term funding requirements of both health and social care, something that was met with support from much of the assembled audience who wanted the politicians to move beyond their tribal instincts.

Integrated care

There was much consensus on joining up health and social care. Lamb outlined plans for a single pooled local budget for health and social care by 2018; Burnham majored on his ‘whole person care’ policy; and Hunt emphasised the Government’s existing work in this area through the Better Care Fund, the vanguards that are emerging from the Forward View, and the Devo-Manc proposal to devolve powers to Manchester.

But there was discord around the level of local experimentation that each parties’ approach would allow. While Hunt was relaxed about local areas having autonomy to implement the Forward View and other models, Burnham expressed misgivings about Devo-Manc and warned of the fragmentation the plans could bring (this is despite the proposals appearing to be closely aligned with his party’s plans for greater integration).

Staff and pay

There threatened to be an arms race on which party would deliver more staff, with Burnham promising 8,000 new GPs, 20,000 more nurses and 3,000 more midwives; and Reid saying UKIP would deliver a similar return. However, both Hunt and Lamb were more cautious and did not offer similar commitments.

The real debate here came on pay. Burnham accused the government of getting it wrong, saying he would, in all likelihood, commit to no more real term pay cuts under a Labour administration.

Hunt refused to offer such guarantees, saying that while he was in office he faced a difficult decision between holding down pay or losing staff. With £22bn of efficiency savings required up to 2020, there was deep despondency among the audience over the legitimacy of holding down staff pay further during the next Parliament.

Where does this all leave us?

The politicians would have left the impressive British Library chamber with several warnings from the audience: that the £8 billion is the bare minimum required to keep the NHS afloat; that the efficiency savings required cannot be banked on; that political leaders ignore the ‘wicked’ problem of social care funding at their peril; and that any imposed system-wide reorganisation would damage the chances of the NHS achieving its efficiency targets and maintaining quality.

The debate also once again highlighted how few levers national politicians have at their disposal when it comes to reforming the NHS in the post-Lansley world. Since the 2010 election, the locus of power in NHS policy-making has seemingly shifted away from political leaders towards NHS England and the other arms-length bodies.

Through the Five Year Forward View, NHS England has set the weather when it comes to outlining the path to reform. This may reflect a wider ceding of power away from the centre – not something unique to the health service – or it may be down to Simon Stevens’ acumen in corralling the entire leadership of the NHS around his vision, not to mention getting the coalition partners to sign up to the £8bn.

This clearly troubles Andy Burnham who has stopped short of explicitly endorsing the Forward View in Labour’s manifesto. There was more than a whiff of an interventionist and centralising approach to setting policy from Burnham at the debate, while Hunt was seemingly relaxed with a more pluralist model with the prospect of local experimentation and variation.

One would expect a Conservative-led government (coalition or minority-led) to press on with this vision. But it is interesting to ponder whether Labour would seek to reassert the power of national politicians to dictate strategy and extend the command and control approach that was characteristic of the New Labour years.

The answer to this question may end up determining the prospects of the Forward View vanguards as well as Manchester’s plans.