The NHS was not a major issue during the 2010 election, so what should we expect in 2015?

The government’s record on the NHS will be at the heart of the election debate. The good news for the coalition is that the unprecedented slowdown in NHS funding since 2010 has not yet had a serious, adverse impact on patient care.

Today we publish the health questions from NatCen's British Social Attitudes Survey 2013, which show that public satisfaction with the NHS remains high. The bad news is that a significant amount of  capital was expended on the reforms enshrined in the Health and Social Care Act 2012, at a time when the last thing the NHS needed was a destabilising, top-down reorganisation.

As we argued at the time, Andrew Lansley’s reforms led to precious time and resources being wasted on changes that could have been made gradually, working with the grain of what was already happening rather than turning everything upside down. It is hoped that this lesson is not lost on those writing election manifestos. The policy review led by Sir John Oldham for the Labour party has certainly taken this message on board, making the case for whole-person care while urging that this should be done through evolution not revolution.

Debate about the role of competition and the private sector is certain to loom large in the campaign. Labour spokespersons have argued that Part 3 of the 2012 Act should be repealed to limit the role of competition regulators and reduce the threat of legal action if commissioners decide to place contracts with NHS providers instead of testing the market. For its part, the coalition has maintained that the provisions of the Act reflect EU law that would apply whether or not Part 3 remains on the statute book, although Norman Lamb broke ranks when he called for the role of the Office of Fair Trading in NHS mergers to be scrapped. The involvement of the National Health Action Party in a general election for the first time will also add spice to this debate.

In the Fund's view, the principal challenge for politicians is to be honest about the pressures facing health and social care, and be willing to argue for additional resources notwithstanding continuing pressures on the public finances. Our recent analysis of progress in improving NHS productivity supported by our quarterly reports on performance paint a picture of a service experiencing growing financial distress. This has already been felt in the difficulty in meeting the four-hour A&E waiting time target and is beginning to manifest itself in lengthening waiting lists for hospital treatment.

It is not an exaggeration to suggest that a major crisis will occur if the NHS is not given more time, more support and more funding to deal with these pressures. It is for this reason that we have argued for the creation of a transformation fund to invest in the new models of care needed to meet the challenges facing the NHS. Every health economy should have access to the fund and its use should be conditional on demonstrating that the investments it supports will release cash from existing services. Additional financial support will also be needed to keep necessary services going while new models of care are developed.

We have also challenged politicians to face up to the need for a new health and social care settlement building on the work of the Commission on the Future of Health and Social Care in England, whose interim report made the case for a single ring-fenced budget for health and social care in which entitlements to care are more closely aligned. Hard choices on how to fund health and social care must be confronted in working towards a new settlement, including what should be paid for by the state and what by individuals. The complexity of the issues involved means that debate should start before the election rather than after. The final report of the commission will be published in September to stimulate discussion at the party conferences.

Sadly, the prospect of a serious and informed discussion about these issues seems unlikely when the leaders of all the main political parties seem focused on a narrow agenda centred on the economy and public finances. The unwillingness of politicians to engage in a fundamental debate about the future of health and social care is a sign of the failure of a political process in which argument and dispute are the oxygen of life. Collective denial in the political class not only risks undermining the NHS, which is often cited as  an example of what makes people feel proud to be British but also misses an opportunity to attract support in what promises to be a closely fought campaign.

This blog also features on the Society Central website

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Comments

#42042 Gabriel Scally

Your last paragraph seems rather peculiar given the high level committment that the Labour Party has given to the NHS as a key election issue for 2015. I detect no unwillingness of Labour politicians to engage in 'a fundamental debate about the future of health and social care'. Indeed, it was at the King's Fund that Andy Burnham spelt out Labour's committment to health and social care integration. What they are not prepared to do is to move away from a NHS funded out of taxation.

#42044 HampsteadOwl

I am surprised that neither in this blog, nor more generally, has there been comment about Simon Stevens' announced intention to conduct a review about putting NHS finances on a sustainable footing. He told the health select committee last week that we would spend the next 180 days (very specific on the timing here) looking into the yawning and growing funding gap, and would publish an independent report in the Autumn. If you subscribe to the "low hanging fruit already plucked" theory, then that would seem to commit him to putting forward some radical thoughts.

Potentially explosive stuff this - and it will be interesting to see what "leadership" the politicians display over such a report coming out months before an election and from someone who is not just the current chief exec, but a former Labour government adviser.

#42046 Chris Ham

Gabriel

I was seeking to highlight the curious spectacle of politicians from different parties who appear to be unwilling to have an open debate about future funding of the NHS. The political process ought to be characterised by lively and honest disagreement on issues like the level of funding the NHS needs now and in the future. What's remarkable is that there seems to be no disagreement. More worryingly, I see no evidence that any of the main parties is willing to acknowledge that the growing financial and service pressures facing health and social care will require additional funding very soon if a crisis is to be avoided. Consensus is all very well but not when it signals collective denial on issues of the greatest importance to the public and the services on which they rely.

I am more than happy to stand corrected if you can point me to evidence that the Labour Party has offered to fund the NHS more generously - or even less generously - than the Coalition partners.

Chris

#42048 SW

Is more funding the answer?

If the NHS is underfunded it is. However, the NHS compares favourably with other economies on per capita funding. Its above the OECD average. It's also 9-10% of GDP, also favourable. If the NHS is however not underfunded, then would that not signal a problem with the system, either with its skeleton (structure) or distribution and management of resources - i.e. allocation/processes/etc?

I agree that the restructure was poorly timed. I also think that it was not a restructure but another rearrangement of roles. For the past two decades the commissioning hat has been passed around various owners - if Labour get in then possibly soon the Councils will have their turn. But ever has there been a commissioner and a provider.

What if there were only Local Health Economies that received a budget with a board to manage it consisting of provider representatives? What if it were no longer activity based, but funding with population health targets attached?

I think the weakness of the NHS is not for want of funding, but for want of a simple structure with clear goals. Right now its a bunch of siloed organisations vying for their piece of the pie. If we're going to save money, and do what's best for patients, we need to remove these artificial barriers that legislate publicly funded providers to act as if they were private competitors and effectively attempt to profit on taxpayer monies. More money won't solve what ails the NHS, imho.

#42049 Stephen Hewitt

Perhaps we should be expecting or demanding that health and wellbeing, not the NHS, is the major issue in 2015.

It would be more interesting and useful is if we could provoke a national political debate about the nation’s health and wellbeing, rather than the future of the NHS (and its funding) – which are of course different.

We should be framing a debate about how we ‘nudge’, manage or regulate the major food and drink manufacturers and processors, fast-food chains, supermarkets, car producers, energy companies, house builders, culture and media industries to help create a healthier and more sustainable Britain. If we can achieve that, we will be happier, and need the NHS less.

#42050 SarahTS
GP
NHS

I agree with Chris about the need for honesty on what our current NHS funding can provide and the demographic challenges for the future. Clinical commissioning will bring rationing to the Gp consultation which is complex, demotivating and hard to do in 10 minutes. Honesty about the future funding gap will allow those who can to start making provision. We don't want our children to be burdened with higher taxes to pay for our hips, knees and cataracts.

#42052 Mervyn Hyde

With the shrinking of the NHS, closure of cottage hospitals, ambulance stations and selling off of NHS land and property, it should be obvious that stresses will be built up within the system to the point where A&E are put under excessive strain.

Due of course to the extra demand created by the closure programme and insufficient staffing levels to compensate.

For those of us that are long standing users of the NHS we observe the deliberate neglect to adequately fund it and that the privatisation programme necessitates the failure of the NHS to deliver it into the hands of the private sector.

Whether cautiously progressed or not the ultimate objective is the same, to transfer as much of the NHS into private hands, a totally unproven course of action which will destroy the NHS and everything it stood for.

The argument of affordability is also specious as the private sector are in every case more expensive. It would also demonstrate a total lack of understanding as to how money is created and the myth surrounding the so called DEFICIT.

We have infinite funds available to meet any public need, what we don't have is the democratic institution to provide them.

If you want to challenge this assumption then I refer you to last quarterly document produced by the Bank of England.

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