Beyond the manifestos: prospects for the NHS after the election

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The deafening silence on NHS funding I wrote about last autumn has given way to a cacophony of commitments and contested claims as election day approaches. The cacophony reached a crescendo this week following the Conservatives’ promise last weekend to find an extra £8 billion a year for the NHS by 2020/21 and the release of the parties’ election manifestos. A discordant note was struck by David Nicholson, who pointed out that even with commitments to spend more money the NHS is still facing unprecedented pressures and financial challenges.

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.



project Manager -Mid Essex Recovery College,
Comment date
19 April 2015
The culture of financing projects in NHS needs to be reviewed. Seems this is a waste of public resource when outcomes demonstrate health improvements to users and significant cost savings in the longer term and Commissioners withdraw funds because of short termism. And what's more this project I refer to improved outcomes for people with mental health problems, helped people back to work and further education and reduce d demand on acute services. And the point of the project was ?????? #joinedupthinkingneeded

Dr Umesh Prabhu

Medical Director,
Wrightington, Wigan and Leigh FT
Comment date
18 April 2015
Well said Chris. NHS needs urgent cash injection. But it also needs properly trained doctors, nurses and rest of staff to do job. It also needs good value based leaders who would use public money wisely and make sure that patients are put at the heart and also look after staff well so that they provide the safe and best care with good patient experience.

But injecting more cash without changing anything else including social services, community services and primary care will not change anything. Money will be wasted and will go to back-hole and spent on locum and agency staff and few will continue to make money out of NHS.

Public funds must be used wisely and we need leaders who make our NHS safe, good value for the money and good quality with good patient experience. Most of all if needs single management stream from health to social care.

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