How likely is a general election to transform health and social care?

If the polls are to be believed, there will be a change of government at the forthcoming general election. The first in 14 years. Indeed, leaving aside the change from a coalition to the Conservatives in 2015, there have been only three switches between the two big parties – the Conservatives and Labour – in 45 years.

Relatively few people working in the NHS and social care will have adult memories of the switch from Labour to the Conservatives in 1979, and those with memories of what it was like to work in the system in 1997, when the change was the other way round, will be in their forties. Memory, both personal and institutional, can play tricks. And while it might be thought that a big change of control – from one party to another – will be the catalyst for major, rapid change that may not automatically be the case.

1979 Labour to Conservative

The defining moment for health in the May 1979 general election campaign came early on when David Ennals, the Labour health secretary¹, and Patrick Jenkin, his Conservative shadow, appeared jointly on BBC TV’s Newsnight. Both were resplendent in dinner jackets, having come from a Motability dinner.

In its final Budget before the election, Labour – still reeling from the political disaster of the ‘winter of discontent’ – had included a significant three-year spending increase for the NHS.

By contrast, the Conservative manifesto, which was decidedly skimpy on health, had declared, ‘It is not our intention to reduce spending on the health service.’ Jenkin knew he would be challenged on whether that meant that the Conservatives would hold spending steady or would honour Labour’s plans.

Earlier in the day, Jenkin had phoned Geoffrey Howe, the shadow Chancellor, to tell him that this was the election interview on health and ‘I’ve got to be able to say we will, for those years, maintain the planned expenditure figures’. Howe replied, ‘I understand. You have my authority to say that.’ Which Jenkin did, judging it as ‘one of the most valuable things I ever did in government’. It meant that, as virtually every other part of government received massive cuts in the early years of Margaret Thatcher’s government, the NHS did have a degree of protection.

It did not feel like that. The crippling public sector strikes of the winter of discontent had been ended by the promise of a huge pay comparability exercise. It came home to roost. Its recommendations, which the Conservatives had promised to honour, cost appreciably more than had been allowed for in NHS budgets. In addition, the so-called RAWP (Resource Allocation Working Party) formula, which was redistributing NHS cash from London and the South East to the less well provided North and the Midlands, began to bite. So while NHS expenditure overall was not cut, it was cut in London, in the place where the national media was encamped, while, at the same time, big reductions in university spending saw London’s medical schools forced into some shotgun marriages.

The net effect of all this was that the transition from Labour to the Conservatives felt more like a continuation of the dispiriting days of the late 1970s rather than any kind of big change for the better. This sense of continuity even applied to Jenkin’s major piece of legislation. It abolished area health authorities – the middle tier of the vastly bureaucratic arrangement of districts, areas and regions that the massive 1974 reorganisation had engendered. It was, however, already received wisdom that this was needed. By way of confirmation, a Royal Commission on the NHS, which Labour had set up, recommended such a move not long after the election, and had Labour won it would have done the same, or something remarkably similar.

The one exception to the sense of continuity – where it did feel that things were different – was in the way that Jenkin, his Minister of State Gerry Vaughan, and the government more broadly, actively promoted private health insurance, while, at the same time, in various backroom studies, it toyed with changing the way the NHS was financed.

This culminated in the leak of a report from the Central Policy Review Staff – a Cabinet think tank – which, among other monumental changes to the welfare state, proposed charges for visiting a GP and a switch to private health insurance.

The reaction included what Nigel Lawson, the future Chancellor, described as ‘the nearest thing to a Cabinet riot in the history of the Thatcher administration’². That in turn led to such ideas being scrapped, and Mrs Thatcher’s famous declaration to the 1982 Conservative Party Conference that ‘the National Health Service is safe with us’.

Thus it was that real policy change in health came not so much from the transition from a Labour government to a Conservative one but from a change of ministers. In late 1981 Norman Fowler arrived as Secretary of State for Social Services with Ken Clarke as his Minister of State for Health.

The promise to honour Labour’s spending plan was coming to an end. With money getting ever tighter the pair launched a maelstrom of centrally driven initiatives aimed at increasing efficiency without cutting clinical care. These included putting cleaning, catering and laundry services out to competitive tender, selling nurses’ homes and surplus land (which did allow some hospital building), the introduction of some manpower targets and the first proper set of performance indicators. Ministers started reviewing regional performance against agreed targets, with the regions reviewing the districts – the beginnings of performance management.

Jenkin’s legislation had, however, left in place the so-called ‘consensus management’ of the 1974 reorganisation. Under that, in an attempt to ensure teamworking, the principal officers of a health authority – the administrator, treasurer, senior nurse and doctor – were meant to reach consensus on major decisions: an approach that worked well in some places but in practice gave each of them a veto. Too often, decisions got put off or pushed upstairs. This left ministers – Ken Clarke in particular – holding the view that the NHS did not have ‘a management system worth the name’. The result of that, at Mrs Thatcher’s instigation, was the appointment of Roy Griffiths, the then managing director of Sainsbury’s, to undertake a management review which concluded that if Florence Nightingale had been walking the wards she would have been looking for the person in charge. And the result, in turn, of that was the appointment of general managers (who were pretty rapidly to restyle themselves as chief executives) as the person in charge, putting an end to consensus management.

In hindsight, this was a defining moment for the NHS. Not least because without general managers there would have been no one to deliver the much more radical ‘internal market’ reforms of 1991 that saw hospitals become competing and nominally self-managing trusts, with health authorities and GPs purchasing the care from them. All that, of course, came after Margaret Thatcher’s third election victory, not her first, and without a word of it being in the 1987 manifesto.

1997 Conservatives to Labour

In contrast to the skimpy references to the NHS in the Conservatives’ 1979 manifesto, Labour’s 1997 manifesto was positively garrulous. The section on health ran to more than 1,000 words. Quite how Labour planned to manage the service, though, remained far from clear. There were promises to ‘end the internal market’ but to keep planning and provision as distinct functions. There was a promise to scrap GP fundholding but also to leave GPs in the driving seat. Hospital boards were to be made more representative of their local community, but they would also ‘retain their autonomy’. There would be no return to the ‘top-down management of the 1970s’.

This felt like a bunch of unsquared circles. So it was perhaps unsurprising that when Tony Blair appointed Alan Milburn as Minister of State for Health (Frank Dobson was the Secretary of State), Blair told him: ‘We haven’t got a health policy. Your job is to get us one.’

However, the defining feature for health in the first two years was that Labour had promised to stick to Conservative spending plans that were so tight that when Ken Clarke set them, Andrew Dilnot, Director of the Institute for Fiscal Studies, suggested that the Chancellor was ‘having a little joke’ at Labour’s expense.

Initially, there was next to no extra money. The NHS was in a far worse state than either Labour or the media had realised. So much so that Frank Dobson rapidly had to translate an election promise to take 100,000 people off the waiting list into an ambition that would be achieved over the parliament – not rapidly.

It is not easy now to recall how bad things were. Public satisfaction with the NHS was decidedly low. Influential voices had only recently been arguing that some form of rationing was pretty much inevitable, while Liam Fox, the Conservative health spokesman, said his party had ‘moved on’ from a fully comprehensive NHS. Procedures such as hip replacements, hernia and cataract operations could be covered by private insurance for which there would be tax breaks, he said.

Short of additional cash, the result was an element – despite the manifesto promise – of a return to ‘command and control’ plus a dose of structural reform. Some of it more successful than others.

More successful during the first term was the creation of NICE (the National Institute for Clinical Excellence) and the first proper NHS-wide inspectorate – the commission that would eventually become what is now the Care Quality Commission (CQC). Less successful, as the alternative to fundholding, was the creation of primary care groups which morphed into many hundreds of primary care trusts, whose numbers were then slashed in Labour’s third term. Higher up the superstructure, over Blair’s time in office the number of regional offices went from eight to four before they were abolished altogether, while the number of intermediate (area) authorities (the level above primary care trusts) went from 96 to 28. And then down to 10 strategic health authorities. From Patrick Jenkin’s time in the early 1980s and on to the coalition government in 2010, ‘organisation, reorganisation and re-disorganisation’ became what might be dubbed the English NHS disease.

In the second year of Labour’s first term, the financial situation did ease as, for once, social security came in under budget. That allowed some £2 billion to be redistributed, chiefly to health and education. The limited extra cash did allow the waiting list – which had risen by 150,000 rather than falling by 100,000 – to start a decline. But much of the money that was available was spent on centrally determined initiatives: a big rebranding of the NHS (which gave it the logo it uses ubiquitously to this today); the modernisation of some A&E departments; walk-in centres; cleaner wards; the creation of NHS Direct (a better version of which is now mainly 111).

These central initiatives took much of the money, with the result that the day-to-day bread-and-butter services on the wards or in general practice did not feel significantly better. The gap between the government’s rhetoric of ‘transformation’ and what it felt like on the ground led to accusations that the government was delivering ‘third world’ care.

Four things changed that. First, the expiry in April 1999 of the promise to keep to Tory spending plans. Second, Frank Dobson being persuaded to run for Mayor of London, a decision he later regretted. As he departed, he wrote Blair a personal note spelling out just how bad the service was, while warning him that ‘if you want a first-class service, you need to pay a first-class fare’. Third was the arrival of Alan Milburn as a radically reforming Secretary of State who believed that to make reform possible, much more money was needed. And fourth came Blair’s decision in January 2000 to bounce his Chancellor into that – by going on television to declare that all things being equal, a Labour government would get health spending in England up to the European average. An absolutely huge spending commitment of around 2 percentage points of GDP.

That was followed by the NHS Plan – essentially a promise of more of everything, and one that included the first proper waiting time targets. Then, after the 2001 election, came the Wanless Report, which supported the record sustained increases that Blair had promised, and the reintroduction by Milburn of a much more sophisticated form of the market-like mechanisms that Labour had rejected in its 1997 manifesto.

By 2009 the net result was the shortest waiting times for treatment in the history of the NHS and the public’s highest-ever level of satisfaction with the service – or at least the highest since the British Social Attitudes survey had started recording it consistently in 1983.

It is important to say that for this period, as with the period of Conservative administrations between 1979 and 1997, much else that is not recorded here happened in health policy and health performance. But an essential point remains.

In neither case did the change of government – from Conservative to Labour and then vice versa – produce any sort of rapid transformation in the NHS. At the time, both election results felt like a real break with the past. But in both cases, changes of ministers and subsequent general elections proved more important for the NHS than the initial change of government.

2010 Labour to coalition, and then Conservative

On the face of it, the 2010 election was different. And in one crucial respect it certainly was. After years of sustained spending increases, the money suddenly stopped flowing. The NHS was better protected than most public services from the huge round of spending cuts that became known as austerity. Nonetheless, spending per head declined in real terms between 2010 and 2015. NHS performance broadly held until 2013, when a steady decline in waiting times set in that was to be massively exacerbated by the Covid-19 pandemic.

2010 also felt different as Andrew Lansley arrived as a man with a pre-cooked plan. As Secretary of State, he intended to take politicians out of the day-to-day management of the service by creating a statutorily independent commissioning board. This board was to work to an annual mandate, or set of ministerial marching orders, with GPs doing much of the commissioning. Any willing provider – including the private sector – would be entitled to compete to provide NHS services, and a new economic regulator would be put in place to ensure that competition law applied to the service.

There were just three problems. First, the Conservatives had deliberately gone quiet about all this ahead of the election, so the public in the main had no idea that it was coming. Second, in coalition, Lansley’s plan had to be squared with the Liberal Democrats’ desires on health. This initially produced a completely cack-handed attempt to merge their manifestos. And third, the resulting untangling led to a reorganisation of the health service ‘so large you can see it from space’. It created a clutch of new quangos and hundreds of new clinical commissioning groups at the same time as it abolished two entire tiers of health authority and shifted public health to local government. All at a time when the Conservatives had repeatedly promised ‘no more top-down reorganisations’. Many believed that the object of the exercise was privatisation of vast swathes of NHS services. The resulting row was so colossal that the Bill to implement it had to be paused. It took until 2012 to get it through.

In practice, Lansley’s Health and Social Care Act proved a monumental diversion. The row and the reorganisation – many thousands of staff made redundant or having to reapply for jobs – took focus away from the existing drives to integrate care better and improve quality, while the Act’s enhanced ‘choice and competition’ agenda was undermined almost from day one as both NHS leaders and the politicians sought to unscramble the fragmentation it produced. By 2014, the NHS five year forward view had made integration, not competition, the primary goal, culminating eventually in today’s integrated care systems.

2010 undoubtedly was different. A period of record sustained spending increases was followed by a record squeeze. But with the benefit of hindsight – very much with the benefit of hindsight – what felt at the time like the final triumph of the application of market-like mechanisms to the NHS proved in fact to be their rather short-lived zenith. Elements do remain. The private sector’s share of NHS clinical services has grown. But the NHS remains essentially a publicly provided service, with integration rather than competition the current theme.

There is no absolutely consistent lesson here for the NHS from the past three big general election transitions of power – other than, perhaps, that an immediate change of government does not always produce the immediate change in prospects one might instinctively expect. Over the years, changes of minister, events and intermediate general elections have tended to be more important.

Social care

This account so far has covered the NHS. However, the story for social care is one of nothing but disappointment in terms of general elections producing large-scale change.

There can be few, if any, areas of public policy where more propositions and promises have been made only to then be broken.

Since 1996, there have been more than a dozen White or Green Papers on serious structural reform to social care. There have been two government inquiries – a Royal Commission that reported in 1999 and the Dilnot Commission in 2011. There have even been two Acts of Parliament, neither of which has yet delivered what was originally promised.

The first in 2014 adopted a version of the Dilnot proposals for a cap on costs and a more generous means test that was due to take effect in 2016. But while that was legislated for – and the core legislation still stands – it was never implemented. The second Act, in 2022, made that cap less generous. The current promise is that the amended, less generous, version will take effect in 2025. Given the current state of the public finances, it would take an optimist to believe that will happen

Public health

Public health did not feature in the manifestos for the 1979 election. But, with rather a slow burn, its salience rose following the publication in 1980 of the Black Report on health inequalities (which the previous Labour government had commissioned), the promotion by the World Health Organization from 1978 onwards of ‘Health for all’ – the ‘new public health’ movement – and the publication by John Major’s government in 1992 of The health of the nation, a groundbreaking document that set targets that included cutting rates of smoking, heart disease, stroke and breast cancer, along with sexually transmitted diseases, particularly HIV/AIDS. An official assessment judged it to have been symbolic while failing its full potential.

But at the 1997 election the rise of concerns over public health saw Labour promise the appointment of the first-ever modern minister for the issue, Tessa Jowell taking the post. Among other measures, Labour also promised a food standards agency and a ban on tobacco advertising.

The Food Standards Agency was established in 2000, but it took until between 2003 and 2005 to fully implement the ban on tobacco advertising and sponsorship. In 2007, England followed Scotland in banning smoking at work and in public places, although these were not, of course, the only public health measures during the Labour years.

By 2010, the Conservative manifesto was promising improvements to Sure Start, Labour’s flagship early years programme that has been shown to have a real impact on both heath and life chances, and to turn the Department of Health into a Department for Public Health.

The first part of that died by way of austerity: the budget for Sure Start was cut by two-thirds. The second part – Andrew Lansley’s desire to make running the NHS a job for a junior minister while the department became a public health one – never materialised. A cross-cutting Cabinet sub-committee on public health was established but it was abandoned in 2012 as ministers outside of health failed to attend – evidence that such committees are unlikely to work unless they have the whole-hearted backing of the Prime Minister and Treasury.

The challenge

Whoever wins the election, the challenges are clear.

Industrial action by junior doctors is continuing. Waiting lists are at a near record high, and while the longest waits for care are coming down, the average wait remains much higher than in 2010. The 18-week referral-to-treatment target has not been met for more than eight years. These will all have to be tackled when this year’s revenue settlement is effectively flat cash and, certainly in places, the service will be shedding staff to balance the books.

Satisfaction with the NHS is at its lowest in 40 years and the same is true of social care where additional investment looks essential, not just for its own sake but to enable the NHS to perform better.

The aims of integrated care systems – improving population health, reducing inequalities, and better integrating health and social care in order to improve health outcomes – are widely accepted: seen as essential to ensure a sustainable future for health and social care. The financial pressure on both the NHS and local government is making such investments difficult.