This campaign will leave an uncertain dawn for the NHS

With the general election now upon us, it’s been perhaps surprising over the past six weeks how little we have heard on the NHS and social care, despite how important they are to the public. Mark Dayan, Leonora Merry and Matthew Jones review what has (and hasn’t) been said and promised by the main political parties in England on the key issues facing health and care, and emphasise how important it will be for the new government that people’s experiences of these vital services are improved.

Long read

Published: 03/07/2024

The NHS and social care are issues of burning importance for the public, who are dismayed by the current state of both. Yet after six weeks of hard campaigning, we have heard those who want to run the country say far less about them than might be expected.

At the Nuffield Trust we have tracked the manifesto pledges of five of the leading political parties in England – Labour, the Conservatives, the Liberal Democrats, the Green Party and Reform – against a set of criteria we have developed to assess policy on NHS workforce, social care, general practice and dentistry, and waiting times. We have also continued to track their financial pledges, and the current financial state of the NHS, though our finance tracker.

Across the board, we have seen important pledges and promises, which mean the public will expect some serious improvements. What there is much less of is detail on the toughest choices ahead. Britain’s political parties have felt either too electorally strong to need to spell these out, too weak to dare to, or too far from government to confront real trade-offs. As a new government is appointed, the celebrations will not last long before a very sobering look at the inbox for the incoming Prime Minister and Secretary of State.

NHS staffing

The 1.7 million-strong NHS workforce is consistently a top public priority for health policy. Following a time of strikes, reliance on huge international migration for key workers, and too many staff dropping out near the start of their career, it should be a top priority for the next government. Yet it has received remarkably little detailed attention during the election campaign.

In the first of our series of election briefings produced with funding from the Nuffield Foundation, we concluded that effective policy would involve reforming the pay review process, improving domestic training, making sure different professional groups are deployed effectively and safely, eliminating the staffing postcode lottery, and focused work on retention.

Labour and the Conservatives did both commit to the Long Term Workforce Plan, with its huge increases in training and plans for workforce numbers over 15 years. But both were tight-lipped on how all those additional salaries would be paid for.

The gap for both main parties is in concrete proposals to support and secure the staff who already exist, given the level of dissatisfaction we see through staff taking strike action over the last year and a half, and the rate at which trained workers are dropping out before they join the NHS or just afterwards.

The Lib Dems’ pledge to establish a “properly independent” pay review body, commitment to a 10-year retention plan, and proposals to expand access to childcare for NHS staff are the most substantive effort to address the problem. Reform, meanwhile, backed our proposals for student loans forgiveness – an effective way of targeting people at the start of their careers where attrition is such a worry. The Greens offered pay restoration for junior doctors, which could mean anything from 35% to much less depending on how it is counted. It is unclear whether this commitment applies to other staff as well: if it does, the costs based on more expansive definitions could be enormous, but if it does not there will be a disparity.

Given that NHS staffing is among the most crucial issues to the functioning of the health service, and that the public are so concerned, it is surprising that these issues have not featured more prominently either in the manifestos themselves or the wider campaign. None of the manifestos have set out how a new government would tackle the postcode lottery that leaves some areas with fewer staff than others, regardless of local need. One of the biggest shifts needing difficult choices is the rapid rollout of new roles, like physician associates, taking on tasks previously done by doctors. Medical unions are up in arms, there are disputes over whether some ways of working are safe or not, and tens of thousands of staff are left with an uncertain future. Yet this very difficult issue is not addressed by any of the campaigning parties, at all.

Social care

Our briefing on social care, the most neglected policy area, outlined what it would take to make measurable progress towards a thriving service which a government could show as a proud political success. The next government, at least gradually, must undertake reform across the board. It is no use fixing inconsistent standards for who gets care without the money to cover it. It will not be possible to raise wages without stabilising the providers who employ staff so that they can afford to pay more. And it will not be possible to reduce the appalling number of people in need of support who get none without making working in the sector a better career which attracts more staff.

All parties recognise the status quo cannot continue. Labour commits to a 10-year programme to establish a ‘national care service’: the details of what this would involve are extremely light, but it shows an intention to reform and could be a useful framing. The Conservatives recommitted to the cap on social care costs, already delayed for over 10 years for lack of funding. Neither identified a particular pot of money, and lack of money is exactly what caused each previous delay to the cap and other reforms. Labour’s commitment to wage bargaining and fairer conditions engages with one of the sector’s biggest problems, but does not answer how employers could stay afloat to pay those wages. The Conservatives mentioned help for unpaid carers, but no specific proposals after a decade of support worsening.

None of the smaller parties has a comprehensive offer, but they sporadically show some ambitious ideas. The Reform Party’s offers of tax breaks could attract staff, although no adequate source of funding is visible. They also propose to address the financially irresponsible behaviour and opaque ownership of some large provider companies, although this appears to be limited to those who file overseas.

The Liberal Democrats and Greens pledge new funding to provide “free personal care”. This shows a much higher level of ambition. However, free personal care represents a much narrower offer than is often assumed, leaving out forms of support that range from laundry and shopping, to one-to-one dementia care. The Liberal Democrats’ choice to make social care and unpaid carers a visibly central theme to their campaign, and to talk about leader Ed Davey’s personal experiences, is a good example of how actually improving social care could make the issue something politicians are proud of rather than ashamed of. The Greens have the most comprehensive pledge to build up social care as a career – but with a massive £20 billion a year in funding, could have promised a more comprehensive reform programme.

General practice and dentistry

Our third briefing looked at general practice. Published during the short campaign itself, we set out six specific tests for any new government to tackle the crisis in general practice: restoring the ability of patients to access their own doctor; tackling patients’ poor experience of accessing general practice; improved use of digital technology; addressing the problem of declining GP numbers; ensuring new roles are deployed safely, fairly and efficiently; and avoiding a structural reorganisation of general practice.

Both the Labour party and the Liberal Democrats offered clear pledges around people seeing their own doctor over time, where there is strong evidence to support the benefits in terms of patient satisfaction and managing risk without onward hospital referrals. Labour pledged to “bring back the family doctor” by incentivising GPs to provide continuity. The Lib Dems proposed continuity for the over-70s or people with a long-term health condition.

But there was little information across the manifestos about how the different parties would tackle the ongoing decline in GP numbers. The Labour manifesto contained promising sentiment about training more GPs and reforming the system, but little detail on how. Both the Liberal Democrats and the Greens fell into the trap of promising rapid access within set timeframes, something we have argued can be counterproductive. Labour’s pledge to guarantee face-to-face appointments brings real problems: while patient choice is important, so is keeping aside enough availability for people who have a serious clinical need for a GP in the context of great pressure in some practices. Both Reform and the Conservatives put a lot of faith in Pharmacy First to solve access problems.

All the parties except Reform pledged to overhaul the contract for NHS dentistry. Given the disaster that this has been through successive governments since 2006 – essentially losing NHS dental coverage for most adults in England – this is the basic requirement of a serious policy.

But while Labour and the Conservatives do pledge some extra money for more care, they do not level with the public about the bitter truth: that without billions more, each year, universal NHS dentistry is not coming back. Only the Liberal Democrats seem to acknowledge what this might mean by focusing on restoring free care specifically for the most vulnerable: children, new mothers and pregnant women, and those on low incomes.

Interestingly, the sentiment that all who need it should be able to access an NHS dentist has been quietly dropped from both the Conservative and Labour platforms, perhaps indicating that this is no longer a realistic aspiration, given how far gone NHS dentistry really is.

Waiting times

Our briefing on waiting times pulled together a series of lessons about how to improve access to care from the UK’s recent history, from data and from international evidence.

The most obvious, and controversial, is that targets and promises only work if there is enough money to pay for the care they provide, given the level of productivity the NHS can deliver. We have had over a decade of promises to deliver waiting times unrooted from the reality of funding and supported by hopes of radical efficiency improvements which never materialised. It has not worked: the NHS is missing nine out of the 11 targets set out in its Constitution.

Labour and the Conservatives are both promising to return to meeting the main hospital care targets within five years, which would require an explosion in the amount of care provided, alongside funding pledges consistent with the tightest budgets since the 1980s and with realistically modest or non-existent assumptions about efficiency.

The Green Party’s proposals present the opposite problem. Their very large spending pledge, rising to £28 billion, is paired only with a very cautious commitment for waiting times to fall year on year from where they are now. The Liberal Democrats leave it unclear whether they are committed to returning to delivering on headline targets.

Equally important is how the money is spent. The NHS has repeatedly received panicked last-minute bailouts and funding deals, costing the taxpayer billions and enraging the Treasury. Yet these usually go into the bottom line of hospitals. They do little to shore up everything else that makes it possible to treat patients quickly: strong services in general practice and rehabilitation, good buildings and equipment, or functional IT.

Neither Labour nor the Conservatives note in their manifestos the need to maintain investment in capital at a level that the best European health systems would recognise. Labour’s focus on scanners is well founded, as this is an area of particularly scarce provision in the UK compared to elsewhere in western Europe. The party has also pledged to move resources to primary and community care. They would need to learn from the past four years where the same policy has notionally been in place, and yet community spending has fallen per age-adjusted person. The obvious place to learn from is the example of mental health, where a tightly defined and enforced requirement has raised spending hugely.

There are several improvements which would cost relatively little money at all and would make a significant difference to patients’ ability to get the care they need, and yet feature nowhere in the manifestos of any party. The same short-termism is visible in the way the NHS has often tried to improve care and access recently. Successful waiting times drives have been long term, strategic and staged. Small pots of money each winter deliver limited results, because hiring staff, arranging buildings and changing the way people work takes time and coordination.

Our analysis underlined that planned care is unfairly distributed, with people in poorer neighbourhoods receiving 20% fewer hip replacements than people in areas of average deprivation. Sadly, there has been little recent improvement. Making sure that, as waits become shorter, this reaches everybody evenly would help match care to the need for it.

Meanwhile, efforts to deliver more efficiency and better care have been repeatedly muddied by gaps in the data the NHS collects and the way it is connected. This often means that even after trying high-profile new initiatives for years, it remains a matter of speculation whether or not they actually work. When the noise of the campaign settles, these are the complex but quiet issues that will determine whether or not a new government can gradually begin to pull the NHS back to being what patients and the public expect and demand.

The sound of silence

As instructive as what is in the manifestos is what’s missing from them. No party explores the role the health system can and should play in the explosion in referrals or demand for autism or ADHD or how social care can meet growing and complex demand – not just from the ageing population but increasingly from younger people with severe and intense care needs. No party offers any response to the growing problem of medicines shortages, a Europe-wide problem we face alone following Brexit. And, as we and the IFS have pointed out, pledges on health and social care are not clearly costed against a suitably ambitious and long-term answer to how they will be funded.

These areas of silence are at the heart of some of the most profound challenges awaiting whoever gets the keys to Number 10 Downing Street on Friday morning: how to extract more for less in public services; how the state should adapt to changing patterns of demand for care; what our future relationship with trading partners and global markets means for health care; and how to fund health and care in the context of low economic growth and wage stagnation.

Ultimately, the success of the next government will depend on whether it meets these challenges with proposals and ideas that improve people’s experiences of health and care. This campaign has shown that there is remarkable consensus among both the parties and the public in where the NHS and social care needs to end up. The big challenge for the next Prime Minister and Secretary of State is tackling the difficult choices required to get there. 

*The Nuffield Foundation is an independent charitable trust with a mission to advance social well-being. It funds research that informs social policy, primarily in Education, Welfare, and Justice. The Nuffield Foundation is the founder and co-funder of the Nuffield Council on Bioethics, the Ada Lovelace Institute and the Nuffield Family Justice Observatory. 

The Foundation has funded the election briefings referred to in this long read, but the views expressed are those of the authors and not necessarily the Foundation.; @NuffieldFound