General election 2019: taking the pulse on health and care

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  • Posted:Friday 29 November 2019

A podcast about big ideas in health and care. We talk with experts from The King’s Fund and beyond about the NHS, social care, and all things health policy and leadership. New episodes monthly.

What are the main parties saying about health and social care in the general election debate? What comes next in delivering their manifesto pledges? Helen McKenna sits down with Sally Warren, Siva Anandaciva and Dave Buck from The King’s Fund.

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HM: Helen McKenna
SA: Siva Anandaciva
DB: David Buck
SW: Sally Warren

HM:  Hello, and welcome to The King’s Fund Podcast where we talk about the big issues and ideas in health and care. I’m Helen McKenna, I’m a Senior Fellow here at the Fund and I am your host for this episode. I’m super excited, because today’s episode is an election special. We are going to be looking at to what extent health and social care have featured throughout the election campaign, and then we will look at some of the main themes in the manifestos as they relate to health and care. And we are going to end by discussing what comes next in terms of the reality in implementing those manifestos for whoever is lucky enough to step into Number 10 come the 13th December. To help us unpack all of this I’m joined by three wonderful colleagues. We’ve got Sally, Siva, and Dave, so thank you for joining us. Can you tell us who you are and what you do here at the Fund? Siva Anandaciva, do you want to start?

SA:  Hi, I’m Siva Anandaciva, I am the Chief Analyst here at The King’s Fund and mainly work on money, workforce, digital, and performance.

HM:  Fantastic, and Dave Buck.

DB:  Hello, I’m David Buck and I lead a lot of our work here at the Fund on public health and health inequalities.

HM:  Lovely, and Sally.

SW:  Hi, I’m Sally Warren, I’m the Director of Policy here at the Fund, so that means I take an interest in all of the policy work we do, but probably my specialist subjects are around social care, population health, and mental health.

HM:  Great. So, let’s start by thinking about the general tone of this election, and the extent to which health and social care have featured. Siva, thinking about health and the NHS specifically, so they have been some of the main talking points of this election, so we have had the Prime Minister Boris Johnson talking about the NHS as one of the people’s priorities, alongside schools and police. And then we have had Jeremy Corbyn for Labour at various points describing this election as the NHS election. But perhaps because of all of this we have heard criticism from some quarters that the NHS is being overly politicised and is being treated like a political football. What do you reckon is going on there? Do you think that is a fair accusation?

SA:  I’ve got to admit I have quite a simple view on this. When you are spending £130 billion of public money on your Health Service, I just can't see how it wouldn’t be a political issue for any government. So, that is one thing. The second thing I would say is, to be honest the NHS has done pretty well out of being a political football. No doubt some of the extra money it gets is because parties are looking at demands on the service in the future, but some of that extra money comes because the parties want to outspend each other. So, there are benefits of being a political football. But I think underpinning all of it is, there is this sense of unhelpfulness that the NHS isn’t given a stable platform to plan its services over the next five to ten years. So, I think there are some examples from other countries, so like Mexico, where they haven’t done it for the whole Health Service, but they have done it for certain things like public health, where they have said, “Whatever party is in government, let’s form some cross-party consensus on what the strategy is for the next five to ten years and let’s stick to that.” So, you do politicise some elements of health spending, without trying to de-politicise the whole thing.

HM:  And during this campaign we have not really seen cross-party consensus in that way on the NHS, it has been sort of fighting for territory?

SA:  I think it has been fighting for territory. If you look at the manifestos, particularly around social care, there is talk of how we can build a cross-party consensus but, sorry I am looking at Sally who is shooting the evils because I am probably on her turf, or she is eating something very odd (laughter). So, they talk about a cross-party consensus, which is great in theory, in practice you do worry whether we have got the right atmosphere to deliver anything on a cross-party basis. I think that is in a highly risky box for me.

HM:  And you know, you brought us onto social care very helpfully. So, I notice Sally, although all the parties have included something on social care in their manifestos, it has just not been as say, omnipresent as the NHS. What is that about in your opinion? Is it that social care is just not a sexy enough topic when it comes to selling content to the electorate?

SW:  Yes, so I think social care suffers on a couple of fronts in terms of being an election issue. The first is the public’s complete passion for the NHS means that the focus on health does tend to be the focus on the NHS rather than our health and care system as a whole. So, the fact that the public don’t really understand that social care is separate, means that political leaders don’t feel the need to be talking about social care a lot. But I think particularly for this election as well there is clearly a shadow from previous elections falling onto the political parties. So, 2017 and the Conservative’s proposals that very quickly were labelled a dementia tax, has meant that a number of parties are very nervous about putting detailed proposals about reform on the table, so they are tending to step away from that detail.

HM:  And Dave, what about wider health and wellbeing? We will come onto the manifesto commitments in a bit, but has the focus on the NHS and then to a lesser extent social care meant that those others areas in the wider health and wellbeing space, particularly public health and inequalities, they have had less attention during this campaign? Or is it in all campaigns we see that?

DB:  I think the answer is yes and yes. So, it is interesting that today we are actually recording this, as there was a debate already at the annual conference about the shadow that the NHS, and social care to a lesser extent, cast over public health, and whether public health has a brand problem, and lots of debate about that. So, it’s good that we are having that debate here at The King’s Fund, but that debate is not happening out there in the conversation about the election. I think to some extent it was ever thus, and therefore there is an issue about that, about how we help politicians speak about the broader things that impact on the public’s health beyond the NHS and social care. So, that is not a surprise, it is a shame, but it is not a surprise. Although when we do come on to speak about some specifics in the manifestos there is actually quite a lot in some of the manifestos, in the health bits of the manifestos it is per se on public health, but also more broadly across the manifestos I think one issue is actually a lot of things that will impact on health are not seen as health issues. So, they are there, they are just not being discussed through a health lens.

HM:  That’s really interesting. So, you mean sort of the wider determinants of health, such as housing and education?

DB:  Absolutely, and policies towards poverty etc.

HM:  Fantastic, thank you. So, before we continue, just for the benefit of our listeners I’d like to signpost you all to the election page of our website where we have set out some of the main pledges from each of the parties in a very handy manifesto grid, and I think there is a link to that in the show notes, and then there is also a lot of other election content. So, just to refer you all to that, if you want more detail. Thinking about the polices themselves, Sally let’s start with you. At the start of the election campaign you set out the five things that you would be hoping to see in the manifestos from a health and care perspective. Can you briefly run us through what… I guess they are The King’s Fund’s priorities. What are they?

SW:  Yes, of course. So, right at the start of the campaign I set out really a plea to say that health is much more than the NHS, so sort of anticipating that the NHS may well get a lot of political attention, but trying to say, “Actually, we need a much broader debate for our political parties.” And we set out as you say, five priorities. The first was public health, where we wanted political parties to recognise that there was much more we could do upstream to help people be healthy. The second was social care, where we needed to both think about how the current system can be supported having had many years of really tight funding positions, but also think about long term reform, so how to change the system to be fairer in the future.

We then talked about mental health, which is an area that has become increasingly important over the last few years and talked about much more now than it ever has been before, but for there a focus on helping children and young people with emerging mental health problems and also a real focus on the quality of specialist mental care services. Our fourth priority was workforce, because really we don’t have a health and care system unless we have a trained and retained workforce, so a real challenge around how do we retain enough people to be able to deliver high quality care? And then finally we wanted a transparent and clear funding position from all three parties, for health and care as a whole, rather than just for some specific parts of NHS budgets.

HM:  Great. that’s really helpful, and that sets the thematic approach we are going to take for the rest of this discussion. So Siva, Dave, Sally, no need to run through each of the commitments in the manifestos, because that would take us a long time and we have got lots on the website on that. But taking each of the themes that Sally set out in turn, Siva on funding, NHS funding, what is your take on the manifestos?

SA:  So, on NHS funding my take is two things. I think the first is that, if you look at the parties’ overall plans for public spending they are clearly in vastly different places. But if you look at their plans for health spending they are actually closer than you might think. So, everyone wants to grow health spending, they want to grow it by varying amounts. The Labour Party looks like it has got the most generous proposals on the table, a 4.3% growth each year over the next five years. The Liberal Democrats coming in just behind at about 3.8%, and then you have got the Conservatives at 3.1%. That may not sound like a lot, but it is a lot, that difference, when you are talking about £130 billion. But I think all of them are broadly in that middle territory of giving the NHS enough funding to keep the show on the road. It is not a bonanza of the Blair/Brown years, it is not the austerity we saw under the coalition government where funding was rising at about 1%.

So, I think the first take-home is that everyone is broadly in the same place. But on funding, I think the second thing is, what do you think you will gain from the money? And that is perhaps slightly more worrying, because everyone talks in slightly coded terms in their manifestos about improving performance, changing performance, restoring performance. And given the workforce issues Sally has already set out, I think you are on quite shaky ground if you think for the level of money you are going to be pouring in, whether A&E waiting times, hospital waiting times, are really radically going to get better over the next five years.

HM:  And you are saying in part because there simply isn’t a workforce, and you can't magic that up quickly with money?

SA:  Yeah, absolutely. I think if this was fifteen years ago you could have poured more money into the system and you could have found the staff, you could have asked the existing staff to do extra sessions. Now I think you have not got enough people, because you have got 100,000 vacancies. Even if you were to press go on training new people now, it would take three to five years, so you are already at the end of the parliament before you start to see new people coming in. And with your existing workforce staff, good luck trying to get a surgeon to work an evening or on a weekend, given the potential likely impact on their pension. So, I think you are quite boxed in on what this money can buy you, welcome as it is.

HM:  Great. And Sally, with social care you said as you were articulating the kind of priorities that we have, that we were looking for both immediate investment to stabilise the system, but also then proposals for a new funding system in the longer term. Where do the manifestos leave us in relation to those things?

SW:  So, we are seeing quite a difference between the three parties in social care actually, and some of the manifestos are quite disappointing when it comes to social care. So, the Conservatives have committed to a billion pounds for social care, a really important caveat there, that is shared between children’s and adult’s services, so more likely to be £500 million pounds, and it doesn’t increase over the course of parliament, so it is not going to keep up with demography and inflation. So, that isn’t enough money to really prop up the existing system. And for long-term reform the Conservatives have said they want a move towards a cross-party consensus with their red line being, ‘Nobody should have to sell their house to pay for care.’ That is disappointing on a number of levels. One is around how narrow that framing is, that social care is much more than about people having to sell their house. But also, we have been promised a Green Paper by this government for two and a half years, so there is a sense of how long do we need to wait to see some proposals from them?

The Liberal Democrats, I think kind of sit in the middle here in the manifestos on social care. So, they have committed to significantly more funding for the adult social care system, in particular using some of the £7 billion that they will raise through the 1p on income tax to support the system, so we think that is a reasonable amount of money to keep the current system going. But again, their long-term reform is a bit disappointing. It is seeking a convention to drive to cross-party consensus with their starting point being a good policy which is a cap on social care, but again we would have liked to have seen more urgency and pace in their proposals.

It is clear to me that the Labour Party has the most comprehensive package for adult social care. So, that is a large amount of money for the current system, the most generous of the three, to enable it to keep pace with demographic change and inflation, and then a really firm set of proposals about what their long-term reform option will be, which is introducing free personal care for people over 65 and considering the evidence about introducing that for working age adults as well, combined with a cap on the costs of social care which aren’t free personal care. So, I think for me there is something really important about the Labour Party, that despite social care quite often being a real challenge in elections, they have gone as far as putting a firm proposal on the table, which I think is really welcome.

HM:  So, in terms of where those proposals leave us, it is not the first time that we have heard plans or proposals for finding a long-term funding solution. Should we feel optimistic regardless of who gets into government?

SW:  To be honest, I don’t think we should feel optimistic. I think there is a real risk that the kind of commitments to cross-party consensus, particularly when you look at the type of politics we have at the moment in the last few years, don’t particularly feel to me to be the kind of environment in which you are likely to get party consensus. So, I think the risk is that there is further delay and maybe debate, but actually that we don’t move forward to a solution. And the really important thing here is we can quite often talk in kind of quite abstract ways about cross-party solutions and Green Papers, but we have got to remember right now there is 1.4 million older people with unmet needs because the social care system is not fit for purpose. There are 600 people a day who leave their jobs to become an informal carer, partly because they cannot rely on the formal care system. There is real cost every single day of our failing social care system. So, when we say we are frustrated by delay, it is not because we are policy geeks frustrated that there isn’t a White Paper that we can kind of really delve into, it is because we see and hear the consequence of the failure to reform, on a daily basis.

HM:  So, a real impact on real people?

SW:  Absolutely.

HM:  And Dave, you’re our resident public health and health and equalities expert, to what extent are you satisfied that the manifestos recognise the importance of health beyond the NHS?

DB:  Again, like Sally, I think there is quite a lot of difference here between the manifestos. So, I will start with bad stuff, but then there is some good stuff. So, we have called for a health and equality strategy across government because it is so critical. Talking about figures, we know that in certain parts of the country people live 7 to 8 years fewer length of life in terms of age, and 20 years less in good health. That is absolutely scandalous. And in order to really deliver on doing something about that, our view is actually you need a cross-government health and equality strategy, because it is in the hands of all of government supporting local areas, local communities and the local system. So, that is not in any of the manifestos. However, both the Liberal Democrats and the Labour manifestos include some things which we would want in a health and equality strategy, in particular the Labour manifesto is talking about possibly a version in England of the Welsh Future Generations Act, which is a legislative approach but is thought to be quite a good approach.

The Liberal Democrat manifesto is talking about wellbeing in all policies. So, more for those that know the New Zealand Treasury have taken a lead on ensuring that all spend, or at least all new spend, has a focus on wellbeing wherever it comes from across government. And both of them commit separately, although clearly linked to both of these sort of mechanisms, to a health in all policies approach across government. So, if that becomes true, then that could be really significant. Of course, the issue is, what does that really mean and how do you make it true? But both parties have committed. In contrast, the Conservative manifesto is very silent on this sort of stuff, doesn’t talk about it, however they have their prevention consultation out at the moment and there is a phrase saying, “We will create a long-term strategy to empower people with lifestyle related conditions to live healthier lives”, although as you will notice by the phrasing, that is very much by individual responsibility as opposed to the wider role of government policy and everything else in society.

And then finally, both Labour and the Liberal Democrats have committed, so what Siva was saying about keeping the show on the road, the car has veered off the road in terms of public health spending, we are actually spending a lot less in real terms and in cash terms than we were in 2013/14, but both the Liberal Democrats and the Labour Party are committed to put that money back into the system, which is something that we jointly called for with the Health Foundation and alongside other charities. So, that’s at least around a billion pounds annually to the public health grant. And finally, separately to that, local government as a whole has had a huge reduction in its spending power, I think about 30% in its overall spending power, has managed to actually put a lot of the money it has had into social care, keeping that going, but not enough. But it is the rest of local government spending that has really suffered, and Labour says that they will take that back to the 2010 real spend, although hasn’t really given many details. I haven’t seen a specific costing.

So, there is stuff in the manifestos, and as I have said before, there is a lot of stuff around … so, for your pains, if you want to see the big picture you will probably have to read the whole lot, which is not fun, I can testify (laughter), but if those particular Future Generations Act, health in all policies, and a focus on wellbeing, if that really comes to fruition under either Labour or Liberal Democrats, then there is real opportunity here.

HM:  Okay, so you sound more positive about the Labour and Lib Dem manifestos in regard to inequalities and public health prevention strategies?

DB:  I think potentially, because we don’t know the real detail, what does that really mean? But there are mechanisms there that you can see, “Ah-ha, this might…” I’m like Alan Partridge there, apologies, but there are ways into tackling public and populational issues and particularly health and inequality. It was a real disappointment that they haven’t really committed to a national health and inequality strategy.

SA:  All parties?

DB:  No parties. Although Labour has a section on health and inequality, it talks about what we have just talked about, the Future Generations Act, and a child health strategy, which is again not a bad thing. But it doesn’t really bite the bullet.

SW:  But I think we get quite a good flavour though the manifestos about what the health in all policies may well mean, that sits behind Labour and Liberal Democrat thinking. So, there is a very long list of commitments in Labour and Lib Dems about a whole host of things which is about recognising that this isn’t individual choice. Children are not choosing to be obese, parents are not choosing for their children to be obese, there is a whole set of things about the environment they live in and the choices that are legitimately available to them. And I think we are seeing a number of commitments, whether that is around advertising food, whether it is around active travel, whether it is around fast food near schools, where we are seeing quite an all-encompassing approach to not leaving it to the individual, but recognising the kind of economy and society aspect of it. In that sense I think that is an encouraging window into some of the thinking about what would health in all policies really mean?

HM:  And just on the £1 billion public health grant to local authorities, so you mentioned obviously the cuts to local authority budgets, and we have seen them have an impact in terms of cuts to services, public health services that are provided by local authorities or arranged by local authorities. Given the level of cuts and the time during which that has happened, would the £1 billion be enough to get those services back?

DB:  That’s a great question, and I think it is very hard to tell whether it would be enough, and also how quickly can you spend it? That is the other question. The same with all spending, you don’t want to just flood the system with cash and then not spend it properly, so there is a timing issue here. But it would certainly make a big difference. We do know from work from the Centre for Health Economics at the University of York that the bunch of services in the public health grant, if you are really interested in improving health, are three to four times as cost effective if you stuck that same money into the NHS baseline spend, let’s say the average spend in the NHS. So, as a means to improving health of the population, the public health grant is a really good buy, as are many other things that aren’t in the public health grant.

HM:  So, a bargain?

DB:  So, it’s a bargain. It’s peanuts in whole spend terms. So, I agree there is something, but how do we make that case more persuasively to politicians?

HM:  And Siva, you mentioned workforce briefly earlier, but obviously the health and care workforce are under enormous pressure right now. Now that we have seen the manifestos, tell us, are you optimistic that the word crisis will soon become a thing of the past in terms of how we refer to the workforce, and the situation with the health and care workforce?

SA:  So, you know me, and I am not optimistic about anything, but I am marginally more optimistic having read the manifestos. Every one of the major political parties is promising more, more nurses, more physiotherapists, more general practitioners, and they hope to get there in different ways. So, Labour is proposing bringing back some of the bursaries for NHS nurses for example. The Lib Dems don’t go quite as far, they are promising more targeted bringing back of financial support so that you train as a nurse. But there is clearly some thought that has gone on here to say, “We are in a hole, we need more staff, and we need to pull as many levers as we can.” I think what is disappointing is firstly the level of expectation that you are going to get 50,000/24,000 more nurses, I think is vastly optimistic, so as an ambition, great, but what is the actual plan for the service given you are not going to get those nurses in time, what does it mean for the quality of services, how do you manage in the interim? The second thing is, there is relatively little said about how you use your existing staff. So, at the moment if you wander around the NHS everyone is talking about how in primary care you can bring different groups of professionals together to deliver better, more co-ordinated services around patients, and the manifestos seem to be more in the case of, can we just get more staff in to deliver the existing business model?

But the bit that gives me optimism is, I never thought I would see a manifesto where support for care workers, support for the people in that part of the sector was given such prominence, and some of these manifestos, which is one sign to me that they are starting to think a little bit more about health and care as a joined up sector, rather than, “Let’s just get more nurses on hospital wards, and that will solve all the problems we have.”

HM:  Okay Sally, coming on to mental health and wellbeing, so that was another one of our priority areas. What are the manifestos offering here?

SW:  So, there is some commonality across all three manifestos, and then we start to see some difference. So, I think the first thing I would say is that actually it is really positive that all three manifestos talk about mental health. This is not something that I think if we looked back ten or fifteen years would have been a common feature in manifestos. So, I think that is a really good sign of how attitudes towards mental health have really shifted in our political leaders and also in society as a whole. When we look at what is common across all three, all three commit to parity of esteem between mental health and physical health, that phrase that we have heard for quite a long time now. They all commit to some form of legislation broadly based on accepting the reviews of the Mental Health Act, which is all positive. And all three in some way commit to tackling what has been a real scandal in learning disabilities and autism services where far too many young people are being kept in inappropriate settings, quite often far away from home where the quality has not been good enough. So, commitments to support those individuals to move back to their communities and be supported there. So, that is all very positive.

But that is then where the commonality stops, we then don’t have any more detail really from the Conservatives about what more they would do to really bring to life the reality of the parity of esteem claim. But we do then have a number of commitments from Labour and the Lib Dems. From Labour, some of this is about increasing spending on CAMHS services, having a 24/7 crisis service for talking therapies, and also some specific commitments on some specialist areas, so eating disorder services for example. So, a kind of wide range of action to support mental health across the piece. The Liberal Democrats again have commitments to improve access to talking therapies, some of that particularly looking at areas of our society that might have struggled to be able to access services, commitment to invest in the physical infrastructure of our mental health services, which is absolutely critical because we do have some absolutely shocking physical facilities.

But I think one of the really interesting things about the Lib Dem proposals on mental health which does stand out from the others, is that they are also saying that they want to make sure a fair proportion of health research spending is spent on mental health rather than physical health, and I think that is a really important side as well, because actually if we are constantly spending our research money on physical health issues we are never going to have the kind of evidence base to understand how we can better support people with mental health issues.

HM:  So, some reason to be overall optimistic, because of the fact that mental health is present in all of the manifestos, and that is something that is relatively new?

SW:  Yeah, I think so.

HM:  And actually you mentioned infrastructure, which reminds me Siva, a question for you, we talked about funding, NHS funding, but is there anything you want to add in terms of improving the NHS estate and what resources have been committed to there in the manifestos?

SA:  Well, everyone wants to do it. Everyone wants to improve the NHS estate. The Liberal Democrats have proposed £10 billion of extra spending over the next parliament. Labour top that and say £15 billion. The Conservative Party has recommitted to build those six new hospital facilities with the potential for a further 34, and you know I think again capital funding for buildings and equipment is not something that would be writ large in a manifesto, so I think it is welcome recognition that the NHS has some absolutely knackered estate, £6 billion backlogs that you would need to invest huge sums of money just to make the premises safe for staff and patients, which is a bad place to be in. So I think, again there is some variation across the parties, but they are broadly in the same place of recognising you need to invest more.

HM:  Great, thank you. So, we are now going to have a quickfire round. This is just a little bit of fun.

SA:  So you say (laughter).

HM:  Fun for me. One question to each of you on some of the interesting issues that have come up during the election. Dave, I would like to start with you. So, is it time to bring drug policy under the responsibility of the Department of Health and Social Care, as the Lib Dems have proposed?

DB:  That’s a great question. Not a quickfire response, but I’ll do my best. So, I think more broadly this is a sign of a more mature approach across quite a lot of really tricky issues which are sometimes not seen as health issues, but they clearly are health issues, to move towards a harm reduction approach as opposed to possibly prohibition. So, we have seen some of that already in the tobacco control policy, so the introduction of e-cigarettes. I know that is really controversial and there are different views on that, but one way to see that is as harm reduction as opposed to prohibition or cessation. All the manifestos talk about gambling in this way, which is really interesting, a public health approach to gambling, which means move upstream and look at prevention, look at the risks, as well as focusing on the consequences. And variously, particularly Labour and the Liberal Democrats looking at various points of addiction and also violence, a public health approach to violence. So, having said that, I think there is a case for it, but it is clearly a really tricky issue and we don’t have a particular position on this at the Fund at the moment, but there is definitely a case for it if you are thinking harm reduction is the key issue.

HM:  Fantastic, thank you. Siva, privatisation, the big P word, it has come up a lot, you know Labour have talked a lot about it. Is it happening? Might it happen? What is going on?

SA:  This is quickfire?

HM:  Yeah.

SA:  So, the quickfire response is, yes privatisation exists in the NHS, it has existed since the 50s, so is not new. I think underlying this is, is there too much privatisation, is it growing out of control? Data is really hard to get on a comparable basis, but from what we do have, I think the answer is no, you haven’t got rampant privatisation of services. I realise this is not going to make me the most popular person in some quarters. But the third thing is, so Labour have been the clearest on what their plans for privatisation are, and you could get worried from the manifesto that it is all a bit confusing against other commitments. So, how do you reduce waiting times? How do you do all these other reforms you want at the same time as asking the NHS to bring back a lot of these services inhouse? Are you going to nationalise QPs? I think if you look at the communication around the manifesto, there is a lot more pragmatism on show of that, what rowing back on privatisation would mean in practice, things like reducing competitive tendering. So, that again was a long answer. But is there privatisation? Yes. Is it radically out of control? Probably not.

HM:  And just very briefly, you talk about rowing back in Labour’s manifesto. Is there any manifesto, is there any political party where you see symptoms or suggestions that there is going to be some vast rowing forward of privatisation?

SA:  No, at least not from the three main parties. Actually, if you look at competitive tendering, again the strangest things are included in the manifestos these days, all of them provide coded references to ending competitive tendering of services, so they all seem to be in the same place on that.

HM:  Thank you. And Sally, you have got re-organisation of the NHS, so legislative change. So, I want to ask you, is it time for wholesale reforms as per the Labour manifesto? I think I know the answer. Or, do you favour an incremental approach as proposed by NHS England and NHS Improvement, and I think supported by the Conservatives in their manifesto?

SW:  So, the quickfire answer is, it is absolutely not the time for wholesale change in the NHS right now. So, just to expand on that a little bit, an incremental approach is absolutely the right thing to do, so the Conservatives and the Liberal Democrats are both, with slightly different language, committed to supporting NHS England and NHS Improvement’s proposals for legislative change. So, we think that is the right first step. The Labour proposals risk being a really quite massive change in the NHS which we know from previous quite massive changes, really distract us from delivering. So, given what the front line needs to deliver to improve quality and improve access, we think that would be a major distraction. But I will just say there is one important thing when we think about legislation and re-organisation, we do at the moment have an NHS system that spends £130 billion worth of tax payers money, and we have a number of planning processes that involve, I am struggling to use the word body, because they do not exist in legislation or in stats, they are kind of make believe gatherings of people –

HM:  Ideas?

SW:  Ideas, gatherings of people around a table that are making decisions about an awful lot of public money. That is not a sustainable position to be in, so we will have to have legislation over the course of this parliament that helps put a stronger statutory framework around the emerging ways that we are working. So, it absolutely… anybody looking outside of the NHS will find it very, very hard to imagine a world where you could spend £130 billion through non-statutory bodies.

HM:  Fantastic, thank you. I think one point to each of you there, that was very good. End of the quickfire round. So, I also just want to spend a bit of time thinking about what happens after the election. I know it feels right now like the election campaign will never end, we are in the thick of it, but obviously looking ahead it will end come December 12th and December 13th there will be a new government in power. So, obviously manifestos are just the first step in terms of governing but delivering on the commitments that they set is a whole other thing. And you have each spent time working in the civil service at different points during your careers, and I assume each of you have been involved to some extent in delivering on manifesto pledges. So, what comes next for civil servants?

SW:  The civil servants will be using the pre-election period to frantically plan for as much as they can for December 13th. So, they will right now have red, blue, and yellow briefs, which is their interpretation of what the manifestos mean. They have been allowed to have opposition party talks, so some of their understanding may well have been enhanced by those confidential discussions. And what they will be doing is trying to interpret what are the real world implications and choices that need to be made in manifestos so they can have really early discussions to agree relative priorities, because there is an awful lot in these manifestos, they cannot all be delivered in the first three months, twelve months, two years. So, it will be trying to get a sense of pace and ambition over the course of the parliament.

They will also be trying to get a sense of how do the different political parties really work, so to the extent of who are some of the key external influences that help inform decisions? They will be thinking about who are the external stakeholders we should be getting in to talk early to a new Secretary of State or a returning Secretary of State to help inform their discussion? And it is also important to say that there will be a long list of things that civil servants need answers to from ministers, because they haven’t had any really active ministers over the pre-election period, that will have nothing to do with the manifesto. It will be core business of a Department of State that will be quite a long list quite often, and that can be a shock to minsters, particularly if they are new to the Department of Health. So, they will be trying to balance all of that with clearly the other aspect that they will be balancing, that if there was a hung parliament outcome, what might the combination of red, yellow and blue mean in terms of likely policy commitment?

HM:  Okay. and Siva.

SA:  So, I remember going through a period where you try and work out what does the new incoming minister, what do they actually really care about? And I remember when Norman Lamb came in and started talking about mental health, there was a period where you thought, “Oh, he is just talking about mental health,” and then it became clear that, “No, he really does care about mental health, this is a priority.” And then you go through another process of, what is actually going to happen? And that partly depends on, do we have a government with a massive majority, a small majority, or are we back in hung parliament territory? Which really did change the energy in the department from one of vim and vigour and, “We have got an agenda to deliver,” to “We have got something to negotiate here, what can you actually get away with?” But the one thing I would say is actually trying to be again more optimistic and positive, all the parties that have promised cross-party talks or proposals on social care reform, you can still do that even if you are not in a party of government. You have identified the need to come together to solve the biggest policy problem of our time, so there is still an opportunity to deliver that regardless of what sort of parliament we get, if you really want to do it.

HM:  And in terms of relationships within the new ministerial team, presumably there is work for civil servants to kind of try to understand who has influence within that team despite their position. Obviously, you have a Secretary of State who has more influence over the team, but then various junior ministers will be potentially vying for position or are in or out of favour?

SW:  Yeah, absolutely. So, you will find Secretaries of State work in very different ways, so in my time in the civil service there were some Secretaries of State who were very much consensus builders around their junior ministerial team, they would meet very regularly, it was very much a team effort. I’ve worked for other Secretaries of State where they basically never spoke to their junior ministers, they were clear about the areas of work that they were prepared to delegate and that was all the junior ministers were doing and all other decisions were concentrated in the Secretary of State.

HM:  Do you want to give names?

SW:  No, I am not going to give names Helen (laughter). Thanks for the offer though. So, I think that kind of style of working can change quite dramatically with individual Secretaries of State and it does change the tempo and the way of working in the department. So, if I do give one specific example, which is about an individual Secretary of State style of behaviour, I remember when Jeremy Hunt came into the Department of Health, he had come from DCMS and he said, “I have got five priorities. I am going to have a meeting every Monday on each of my five priorities.” And all of us in the Department of Health went, “Yeah, yeah, lovely, that sounds great Jeremy, and then the reality of your being the Health Secretary will kick in and you will realise there is far too much to do. You won’t be able to do it.” When he left six years later, he had held meetings on a Monday on every single one of his priorities for the entire six years. So, he absolutely stuck to his way of working, and it had a huge consequence for the way of working in the department as a whole.

HM:  Okay, so final question from me. Is there any policy or idea that you hope we are not still talking about come the next election? So, one from each of you please, beginning with Siva.

SA:  So, for me it is hospital car parking. Not because it isn’t an important issue, I think it genuinely is an important issue, but I am still naive enough to believe the manifestos should be your grand vision to where the country is going, where the Health Service is going, and hospital car parking is something any government of the day can decide to solve in a year if it wants to, so I hope we’re not sat here in five years time talking about car parking, or one years time, whenever the next election is.

HM:  That’s a good example, thank you. Dave.

DB:  I guess one thing we haven’t talked about very much, I mentioned it very briefly, was e-cigarettes. So, I hope that the debate has moved on and that we have a much clearer knowledge base and a much clearer policy towards them, because they are sort of devices that potentially could be really significant, but we haven’t really got a clear policy direction for them. If, as the current government states, that half of health inequality in terms of life expectancy are due to smoking, then I hope we would have moved on, whatever the answer is, we will have moved on, made a decision, and we will have implemented it around tobacco, but particularly e-cigarettes.

HM:  And Sally.

SW:  Unsurprisingly, it is going to be social care. So, I very much hope at whatever point the next election is, we are no longer debating what the right structure of a new social care system is, that we have got a consensus around the right funding model, and that would then allow us to talk about social care in manifestos and elections in a way much more akin to how we talk about the NHS, so we can talk about quality, how we can support our workforce, what we want to do to improve access, how we can really support independent living in the community for older people and working age adults. So, I really hope it is not that we are silent on social care in five years time, but the nature of the conversation has moved on because we have then got a certain funding structure that we don’t have to keep questioning.

HM:  Well, I hope that all your dreams come true come the next election. So, that is it from us, thanks to our guests Sally Warren, Siva Anandaciva and Dave Buck, and also a huge thanks to our podcast producers Ian Ford and Sarah Murphy. You can find more of our work on the election in the show notes, please subscribe, rate and review us on Apple Podcasts, we would love to hear from you, and it helps others find the podcast too. If you have feedback or ideas for topics you would like to hear covered in future episodes, then please get in touch either on Twitter, at The King’s Fund, or my account @helenamacarena. Hope you can join us next time.