Social care tops that side of the ledger. The promised Green Paper – and, at that, only a Green Paper, not positive proposals for action – appears as far away as ever. The ill-fated decision to call the 2017 general election alongside the pledge on social care in the manifesto that essentially offered one part of the Dilnot reform without the other – the cap on individual liabilities – produced outrage among the elderly and better off and lost votes. It provided yet another setback to all attempts to reach a resolution on social care. On the health side, her actions as Home Secretary contributed to the workforce crisis.
However, there are things – with some qualification – to put in the credit column. The most obvious are: the long-term financial settlement for the NHS; the decision not to fall out with Simon Stevens, the NHS England chief executive; the offer to amend the worst bits of Andrew Lansley’s 2012 Act; and the decision to retain Jeremy Hunt as Health Secretary and then appoint Matt Hancock.
Take those in reverse order. The political appointments speak for themselves. No-one loves the Health Secretary of the day – although in relatively recent times Alan Johnson may be the exception. Hunt, of course, had his critics – her decision to reappoint him followed his refusal to move on the grounds that it would be seen as a victory for the British Medical Association during the junior doctor’s dispute. Hancock does, of course, have his own agenda, but no-one would see him as a rabid, radical reformer in the Lansley mould. So his appointment, and Hunt’s re-appointment to become the longest-serving Health Secretary, have provided a degree of stability that the NHS has badly needed.
The offer to amend the Act may well come to nothing in this hung parliament. But it might, and it has at least opened a door that David Cameron was terrified of touching after the experience of the 2012 Act.
Not falling out with Simon Stevens was important. There was a decidedly tetchy period early on in their relationship – or, at least, in the relationship between Stevens and May’s closest advisers, who started briefing the media against him. But she saw sense. And it was, of course, Stevens who helped create the climate that helped her to announce, as the NHS’s 70th birthday present, a long-term settlement for the NHS.
‘Ah!’ I can hear you say, ‘but it is less than the sum that the combined wisdom of the three big health think tanks said was needed.’ And to judge whether it is enough, even on its own terms, we have to await the Spending Review – even assuming this government gets to an autumn statement. The promised 3.4 per cent a year real-terms increase covers only NHS England’s current expenditure. The monies for capital expenditure, public health, social care, research and training (and workforce is probably the NHS’s most immediate pressing problem) are all still awaited. If those figures are bad, the current settlement for will look worse.
But before you dismiss it entirely, reflect on this. It is only the second time in its entire history that the NHS has been given a long-term settlement. And if it is not perfection, it remains a platform on which more might be built – depending on the performance of the economy and the willingness of the electorate to pay more in taxes. Furthermore, it was delivered by May against the wishes of her Chancellor, Philip Hammond, on the entirely understandable grounds that no Chancellor wants their hands tied by someone else for five years out. Gordon Brown, you may remember, was furious when Tony Blair announced his long-term pledge on NHS spending. But Brown had to, and did, deliver that.
May probably also deserves some credit for pushing mental health further up the agenda.
So, when it comes to health, history may be kinder to her than her immediate critics allow. It is, of course, true that many a headline measure of performance has got worse during her tenure, and the settlement might not stick. It will depend on others honouring it. But sometimes people are eventually remembered for the announcements they made for the long term, not just for what happened in the short term.
In health itself, there is a neat parallel – though not one she will immediately welcome. Enoch Powell, on his departure as Minister of Health, was remembered as a slash and burner. He got engaged in bitter a dispute over nurses’ pay that was at least as bad as Hunt’s over the junior doctors’ contract. He doubled NHS prescription charges and raised others. He switched much more of the funding to National Insurance and away from general taxation. That raised money, but also meant that the better off contributed less. The shift was described, somewhat hyperbolically, by the welfare state guru Richard Titmuss as ‘the final stick of dynamite under the welfare state’. But the extra cash Powell raised helped to persuade the Treasury to give him the money to launch the mighty Hospital Plan – the first proper building programme the NHS had seen since its foundation nearly 15 years earlier. And he made the famous ‘water towers’ speech, which announced the closure of the great Victorian lunatic asylums. Those two things mean that – whatever else he is remembered for – Powell ranks in most historians’ eyes as one of the great health ministers. May is unlikely ever to rank so high. But for the NHS settlement, some credit is due.
Nicholas Timmins is too generous. Hunt and May have presided over the implementation of much of the very worst consequences of the Lansley reforms. The NHS now is a fragmented, stripped-out shadow of its former self and privatisation creeps on apace. Brexit bungling has put it even more at risk - the impact on NHS staffing is in train but its real impact is yet to be felt.
Having to fund daily visits of care assistants from a private enterprise home care provider in an expensive part of London, we are thoroughly behind the analysis in Gillian's letter in Guardian today. The quality is good but what are the employment terms of the carer teams? Are they within the terms of reference of the CQC and where are the public service unions? We need to ask.