The unifying theme of the debate, if there was one, was the need to deliver better services in an era of tighter budgets. In a room full of doctors, nurses and health professionals – and no doubt with an eye on the votes of their colleagues outside the room – all the spokespeople spoke the language of efficiency and productivity, rather than cuts. All three pledged to protect frontline jobs, claiming that only managers and bureaucrats would be sacrificed. With Peter Carter, General Secretary of the RCN, reminding the audience how many jobs were lost during the NHS deficit crisis a few years ago, and others pointing to redundancies already being made, many remained sceptical about these assurances.
The first sign of division came early on in the debate in response to concerns from the audience about the use of independent providers. While Andy Burnham stressed that, under Labour, the NHS would get the first opportunity to deliver the services needed to address the challenges of the future, Andrew Lansley called for a level playing field, with decisions being made on the grounds of price and quality alone, an argument supported by Norman Lamb.
On public health, the dividing line was between the Liberal Democrats and the other two parties, with Norman Lamb calling for minimum prices for alcohol. Lansley and Burnham resisted this, prompting accusations from the audience that they were beholden to business interests. While Andrew Lansley pointed to evidence – disputed from the floor – that minimum pricing would have a disproportionate impact on people on low incomes, Andy Burnham did concede that it may be something to look at over the long term if he remained as Health Secretary.
The debate really livened up when the discussion turned to local service changes. Andy Burnham, clearly smarting from his Tory counterpart campaigning in his Manchester backyard earlier in the week, accused him of 'saying what people want to hear' by pledging to stop the 'forced closures' of local A&E and maternity units. This led to heated exchanges, with Andrew Lansley denying that he is opposed to local service changes where they are supported by clinicians and patients. Norman Lamb stressed that the key is to ensure local accountability – something that he argued the Lib Dem proposal for locally elected health boards would deliver. With arguments about local service closures playing out strongly on the doorstep, this issue may yet be the catalyst to kick start a national health debate before polling day.
But the biggest differences emerged during the debate on social care reform. The exchanges revealed significant philosophical differences between the Labour and Conservative approaches. Andy Burnham's proposal to share the costs of social care – as he put it 'currently the only part of the welfare state where we don't come together as a society' – by developing a National Care Service contrasted sharply with Andrew Lansley's voluntary approach to insuring against the costs of residential care. Lansley argued that a compulsory levy would undermine the incentive for people to undertake the informal care on which the system depends. Meanwhile, Norman Lamb condemned the Tories' voluntary insurance scheme as unworkable and criticised Labour for putting back comprehensive reform until 2016. He said he favoured a partnership model, as The King's Fund has previously proposed.
On yesterday's evidence, the consensus on social care called for last week by all three party leaders seems as far away as ever.