What then are we to make of the commitments made by the three main political parties? At first glance, it is striking how much common ground there is on priorities in the next parliament, including the welcome emphasis placed on health and social care integration, mental health and improving patients’ access to care, as well as commitments to increase NHS spending. More worrying is the limited discussion of social care in all of the manifestos, other than in the context of integration, and the shared desire to pool budgets or, as some would see it, to raid NHS funds to avoid even deeper and more damaging cuts in social care.
Debate about how much funding the NHS needs by 2020/21 has obscured the more pressing question of how to deal with the immediate financial pressures. Providers are expected to report deficits of almost £1 billion in 2014/15, and according to Chris Hopson of NHS Providers these could rise to double that figure in the current financial year. This means that the additional funding promised by all three parties needs to be injected sooner rather than later to avoid the black hole in NHS finances becoming even bigger.
Failure to do so will require cuts in spending locally that will likely involve reductions in the amount of money spent on staff. This could involve reduced spend on agency staff as well as cuts in the number of staff employed directly by the NHS. The risk then is that providers will compromise patient safety and fall foul of Care Quality Commission inspectors. To be sure, there are savings to be made in other areas of spending such as procurement, where Lord Carter’s work will be required reading for the new ministerial team, but these are unlikely to be sufficient to restore financial balance across the NHS in the short term.
To avoid compromising patient safety, the new government could relax the targets that providers are expected to meet in order to reduce activity and the spending associated with it. This would almost certainly mean an increase in waiting lists and waiting times, contradicting promises to improve access to care. With more money expected to go into mental health services and primary care to fulfil manifesto commitments, continued neglect of these services is no longer an option. Cuts could be made to community health services but would risk delaying the implementation of new models of care closer to home and increasing delayed discharges of care from hospitals.
In view of the declining state of NHS finances, politicians should be explicit about the phasing of the spending increases they have promised to enable the NHS to plan ahead. Analysis by my colleague, John Appleby, to be published next week will compare the commitments of the main parties in more detail, and will show the risk that extra funding for the NHS towards the end of the parliament, welcome as this undoubtedly is, may come too late to avoid damaging patient care. Certainty today is as important as jam tomorrow to secure the future of the NHS.
In the absence of an early injection of additional funding, and with no easy options for cutting spending on NHS care after five years of austerity, the next government may have no alternative but to raise taxes to fund additional spending on health and social care. This could be done via an increase in National Insurance, as under the Blair government, perhaps by focusing on high earners and older workers, as the Barker Commission recommended. While tax rises might be unpopular, and for some parties contradict promises made during the election campaign, they could be preferable to presiding over an NHS in which finances and performance continue to decline and a social care system slipping into crisis.
The prospect of a coalition or minority government adds unprecedented complexity to these speculations given that no single party is likely to have a majority to take decisions of this magnitude. And as we learnt in 2010, the process of forming a coalition means that election commitments may not be a reliable guide to future performance, to borrow the parlance of the financial services industry. For these reasons, the future of the NHS will be shaped more by events after 7 May than before, with the battle lines now being drawn but engagement yet to commence.
Whatever happens, it is clear that the NHS must play its part in rising to the challenges that lie ahead, with NHS leaders redoubling their efforts to deliver more value through the resources at their disposal. We shall be reporting soon on our assessment of how the NHS can do this even in straitened financial circumstances. In the time-honoured formulation, investment must be linked to reform and improvements in productivity to ensure that every pound is used as wisely as possible. The stakes could hardly be higher.
This blog is also featured on the Health Service Journal website