Election special: NHS budget, community services and the workforce question

Key:

• AM:     Andrew McCracken (Host)

• SW:      Sally Warren

• SA:      Siva Anandaciva

AM:       Hello, and welcome to this the latest episode in the King’s Fund’s General Election 2024 podcast mini-series. Each and every week of the campaign we are here to help you navigate the various health and care announcements, and there has been several since we last recorded an episode. Every week we will be asking three questions. The first is what is the big health and care story of the week? The second is what should be a big health and care story during this campaign? And the third is taking a question from you, our listeners. This week I am joined by Sally Waren, our Director of Policy here at the King’s Fund.

SW:        Hi Andrew, lovely to be with you.

AM:       And also by Siva Anandaciva, our Chief Analyst here at the King’s Fund.

SA:         Hi Andrew, good to see you.

AM:       And for this episode you have got me as your host, Andrew McCracken, Assistant Director of External Affairs here at the King’s Fund. Without any further ado let’s get into it.  So, the big health and care story of the week. There has actually been a few health and care announcements over the last seven days in the campaign, but the one I am going to pause on and get into with you both, is the Conservative’s announcement. It was their first health day of the campaign. They had various pledges around primary care and community care. Victoria Atkins was out and about on broadcast round on Sunday. I had been having a lovely calm, quiet, peaceful weekend with my in-laws but it was rudely interrupted by a Conservative press release that landed, and a few of us here at the King’s Fund spent a couple of hours trying to get underneath it and understand what they were pledging. So, with that Sally, would you be able just to run us through, what were the Conservatives pledging here, and a bit of your take on it.

SW:        Yes, of course. I am sorry to hear of your weekend being disturbed Andrew. That’s the thing with these election campaigns. They pay no attention to your social plans. But yes, so the Conservatives this week made a series of announcements really around shifting care closer to the home, closer to our communities. So, three main aspects to their commitments they made. The first was to expand Pharmacy First. This is a scheme that already exists that is about being able to go directly to your pharmacist to be able to get support rather than needing to go to your GP or to hospital, and they are expanding the range of conditions that Pharmacy First can support, including contraception, menopause, other conditions like acne and chest infections. The second was around modernising GP surgeries, where the Conservatives committed to 100 new GP practices and 150 modernised practices. And then finally building an additional 50 community diagnostic centres. And these are centres sometimes in hospital sites, sometimes out in communities, that have a range of diagnostic services that people need, and as we have talked about previously on the podcast, diagnostics is a really important part of somebody’s pathway to being able to understand what condition they have and what treatment options are best for them.

              I think if I think about all of those three in the round, what do I think about them? Well, it is definitely the right direction of travel. At the King’s Fund we have been talking for a long time about the need to focus outside of hospital and not just around hospital services, so the real importance of primary care, community health, and social care. So, we think it is a good direction of travel, but to be honest both the scale and the pace is a bit underwhelming. So, if I give an example, in primary care 250 GP practices might sound like a lot, but actually there is 6,000 GP practices in the country, so really 250 is a very marginal commitment to improving the capacity and the estate in primary care. And I think if we look right across the piece, that is the bit that I was really struck by, that kind of this is the next five years of their vision of how to shift care out of hospital, and we are talking about quite small improvements.

AM:       That’s interesting. So, the right direction of travel, but the scale of ambition is fairly limited. I mean, the other thing that we have seen from this election campaign so far is the parties are at pains to explain how they are going to fund all their commitments. We saw that come out as a real feature of those leader’s debates earlier this week. Siva, do you want to talk us through how the Conservatives say they are going to pay for this new policy.

SA:         Sure. So, I will just quickly say how they have said they are going to pay for it and then you give you my take on that. So, they have said they are going to pay for it by releasing up to about £1 billion a year towards the end of the next parliament, and they are going to do that by cutting back the number of NHS Managers broadly to where it was before the pandemic, and also by halving spending on management consultancy across the public sector. By dong that you get to £1 billion a year. Now, I would say a few things. One is, £1 billion is a huge amount of money to people like us obviously. It is not a huge amount of money when you look at how much we spend on health and social care, which is closer to £200 billion. So, £1 billion a year is not that much, and that makes sense, because going back to what Sally said, the scale of what they are trying to achieve feels marginal, feels incremental, it is not seismic. So, that is one thing. The second this is, my goodness, if you are going to try and release savings by taking out the number of NHS Managers, the whole system just starts to grind to a halt.

You know, we have just gone through about two and a half years, though it has felt longer, of NHS England merging itself with other organisations whilst also trying to reduce headcount. Integrated Care Boards are trying to do the same. So, all of this is just going to lead to quite a turgid feel, if that is how you are planning to release money. And I just wanted to make two final slightly nerdy technocratic points. One is, it is quite odd to say that you are going to reduce the number of NHS Managers and also reduce consultancy spend, because what you are essentially doing is saying, “We need less management overall, whether it’s permanent staff working in the Civil Service or the NHS. or managers we get in to do specific tasks. We just need less management. Well, you know deciding where you are going to put 100 new GP surgeries. Which 150 of the 6,300 you are going to modernise? You know, how you are going to expand the Pharmacy First Scheme? I hate to break it to you, but that is all management. So, how are you going to do it? And the final thing I would say about this is, which is really nerdy and technocratic, but if you are a politician, what do you think your delivery mechanism for change is?

Because at some point there will be a new Secretary of State probably for health and social care behind a desk somewhere in Whitehall. They will be drafting legislation, writing policy documents, trying to change things. You know, the 1.3 million frontline workers, and that includes frontline workers in the NHS, aren’t going to sit down and read that guidance. An important part of your delivery mechanism for changing things are mangers. So, at the same time you are making commitments, you are shooting yourself in the foot for how you are going to deliver those commitments. So, not a lot of money, and also I would say not an entirely logical package, to me at least.

AM:       Yeah, it was depressing how it was not surprising that one of the parties would be talking about cutting NHS management. It feels like the sort of thing you would expect to come out in an election campaign. Can I just also pause, if anyone finds themselves in a pub with Siva he needs to buy the first round, because he did just say £1 billion isn’t very much money. So, let’s hold him to that.

SA:         I did say that, after I said to people like you and me it is a huge amount of money.

AM:       Okay. You’re still getting a round in (laughter).  I just want to also pick up on that point about scale of ambition again, because there is something that feels like a bit of a theme to me here about the election campaign so far and the pledges we have seen. So, you know the Conservatives saying that they would create or modernise 250 GP practices in a context where there are over 6,000, it’s a drop in the ocean.  Labour saying the previous week that they would create 40,000 extra appointments a week. I mean, in the context of the amount of interactions with the NHS, it is quite small. The Lib Dems today saying that they would enshrine in law a target that already exists. I mean, what is your take there Siva, on the sort of scale of ambition that we are seeing so far in this election campaign?

SA:         Yeah, it’s a good question because we were talking about this earlier this week weren’t we, and it just feels more like, you know when I listen to political podcasts and you read the papers, you get the feel that this is a seismic once in a generation election, and then when you look at the pledges so far, they feel much more like the sort of thing you read in annual planning guidance in the NHS that nobody except people like us really get that interested in. You know, as Sally said, it is heading in the right direction, but they are sort of baby steps. It just doesn’t have that feel of seismic change. But we haven’t had the manifestos yet, so it might be that all this stuff is there to wet the appetite, but it is pretty thin gruel if that is what you are trying to do.

AM:       Okay, brilliant. Thank you both. I am now going to move us onto our second question. So, this is the part of the show where we ask what should be the big health and care story, and regular listeners will know that last week we were discussing public health, population health, how to prevent illness in the first place. Since we have had that podcase we have had a public health announcement from the Lib Dems. They clearly listened to the Kings Fund podcast because over the weekend they pledged that if they came to power that they would invest a further £1 billion a year in the Public Health Grant. So, having last week said that it was an issue that needed more airtime, well the Lib Dems were there in the last seven days making that pledge.

This week, in terms of issues that we think should get more airtime than it has done so far in the election campaign, we wanted to touch on workforce. We know that for the parties to do anything across the NHS, social care, public health, any aspect of health and care, it needs staff, and that has been one of the key rate limiting factors in recent years. But yet curiously there haven’t been many big announcements when it comes to workforce so far. Sally, would you mind just giving us a bit of a rundown of what we have heard and your take on where the debate on workforce is so far in the campaign.

SW:        Yes of course, Andrew. I think what we have seen with workforce is it sort of featured as almost a bullet point in a press release, or as a detailed notes to editor in a press release. It hasn’t been core to any of the announcements we have seen so far. So, we have had Labour when they announced their commitment to deliver 18 weeks, talked about the biggest ever expansion in the NHS workforce, but with absolutely no detail about what that would mean. The Conservatives have focused on reducing the number of NHS Managers that Siva has talked to us about. The Liberal Democrats, when they have announced their policy on free personal care, talked about increasing care workers pay.  But for me, as I say these have all been kind of bit parts in different sets of announcements around the deliverables for the public. What we have not heard is any coherent sense of, when you look at the workforce across the NHS, across social care, across public health, what are the government and the political parties policies and offers about how are you going to recruit and train enough staff, and really critically how are you going to retain those staff that you do train? So, for me a lot of focus will be on training numbers, “We are going to train this many more doctors and nurses.”

We can expect to see that over the course of the campaign. I am as interested in, how are you going to keep those staff? What are you doing about retention? What is your approach to flexible working going to be? What are you thinking about the wellbeing of your staff, many of whom are really, really burnt out and stressed and saying they are intending to leave. So, there is a whole set of questions for me around, if you seriously want to deliver improvement in health and care, the people working in health and care are absolutely critical to that, and yet we are not seeing any coherent proposals about how to support the workforce.

AM:       Yes, I mean that point about it feeling like a sort of afterthought in other announcements, I really felt that when I have seen the parties talking about immigration recently. Obviously, a hot topic for the selection campaign. You know, lots of Health and Care Services are very reliant on international recruitment to recruit staff and make sure we have enough to run the service. I mean, the other thing that has come up here and there but hasn’t been a major focus is industrial action. So, we know there is ongoing industrial action in the Health Service. Siva, I don’t know if you want to touch on that and give us your take on how industrial action has or hasn’t featured in the campaign so far.

SA:         Well, I mean it has featured more in the questions that broadcasters are asking politicians when they are announcing plans for the Health Service, which is absolutely what they should be doing, because you know you want these pledges and manifesto commitments that are going to come out to meet the moment. You know, absolutely they have to look ahead to the next five years and paint a vision for the country and the Health Service. But the reality is junior doctors are still planning to go out on strike. Other unions are going to re-ballot, and you know, I have got to say I have had a few chances to meet junior doctors, groups of junior doctors over the last four or five months, and I was just blown back by the levels of anger and hurt that they were expressing that go way beyond salary. As many people say, it is beyond a salary issue. So, you are really going to inherit a huge problem, and whatever your ambition for the Health and Care Service, if you haven’t got a plan for how you are going to tackle industrial action quickly and do all those wider things on retention and recruitment, including looking at migration policy, I find it really hard to see how any of your commitments and pledges are going to survive contact with that reality.

AM:       I think when it comes to workforce, it will be all eyes on those manifestos that we think are coming out soon. How far do they go, and what do they have to say when it comes to these issues? I did also just want to talk about social care briefly. So, we have in the last seven days seen one of the larger English parties make an announcement on social care, and that was the Liberal Democrats. They have pledged that if they came to power and led the next government, they would introduce free personal care in England, quite similar to the system they have in Scotland. But Sally, I am going to come to you for our regular question, which is of the two main parties, the two further ahead in the polls, have either of them in the past seven days said anything of substance about social care?

SW:        For this week, I am going t say that the answer is no. Neither of the two main parties have said anything of substance, and I am defining substance as that would mean more than 36 seconds worth of debate in the recent leader’s debate. So, unfortunately it is a no, but I think it is just worth briefly touching on the Liberal Democrats, because you are right, they have this week come out with a policy proposal, but I have also been really struck about the broader narrative that they have been trying to put into this campaign period about the importance of caring. So, we have seen some really personal videos and messages and just reflecting how caring is a core part of so many people’s lives, and really try to take that what can be quite invisible into a much more visible space. So, really really positive to see the Lib Dems trying consistently to get this into airtime, and I really do hope that the two main parties in England do follow that lead and come up with some substantial policy proposals over the course of the next couple of weeks.

AM:       Okay, so that is a run through of some of the issues that we think should be big issues in the health and care aspects of the campaign period. I am going to move us onto our third and final question. This is the part of the show where we get a question from one of our listeners, and this week it is from Paul Ogden. Thanks Paul. So, Paul wrote in to ask, ‘In 2015 the government removed the ringfence around health budgets and instead changed it to a ringfence around NHS budgets. In doing so that created an opportunity to raid the budgets for things like social care, public health, capital, training, all the things that we now have problems with. Is it time to redefine what we count as NHS or health spend?’ This feels like a question for you Siva, and I wonder if actually first where we should start is with a few definitions. So, what is the difference in some of those things we have just mentioned and how budgets are referred to?

SA:         Thanks Andrew. Thanks for the question, Paul.  If my previous answer about managers was technocratic, I mean buckle up. You know, how it worked before 2015 was, if you wanted to give more money to the Health Service, you would increase the budget with the Department of Health and Social. Care. That is how you did it. You would just boost that budget. But Paul is right, something did happen in 2015 that was a little bit different, because the government gave a major new multibillion pound funding deal, but it didn’t boost the whole Department of Health and Social Care budget. It only boosted the budget of NHS England. That had consequences because there are certain elements of the Department of Health and Social Care’s budget that are really important, that then get squeezed. Those areas include capital investment in buildings and equipment, they include at the time the education and training of the workforce, and they include some elements of public health spending. Nine years on from that, where are we? Well, we have got knackered buildings and equipment in parts of the NHS, we have got a growing obesity crisis, and we have got endemic workforce shortages.

So, the short answer to Paul’s question is yes, I think I would be in favour of returning to a time when you think about the unit you are trying to increase if you are talking about spending more on the Health Service, as being the entire Department of Health and Social Care budget rather than just NHS England. The only other thing I would say is you could go further. You could try and draw a line around all the things that try and keep us healthy and contribute to that and try and protect that and grow it. In a way a sort of pan-government version of what Patricial Hewitt recommended in her review last summer. I mean, that is slightly pushing the boat out, but I think the principle is, don’t salami slice and draw all these little ringfences about different pots of money in the Health Service, because all you end up dong is creating lots of skirmishes and wars around those budgets within the Health Service. If you want to spend more on health, spend more on health, not just the NHS.

AM:       I mean, with that Siva though, is there ever a situation where ringfences are a good thing? I hear what you are saying, that it can lead to these sort of skirmishes, but to put the other side of the argument, it did mean for the NHS at least that it did see real terms budget increases throughout the years of austerity when lots of other budgets were being cut. Is there ever a case where a ringfence is a good thing?

SA:        Well, let me give you the cynical answer first, which is we had a ringfence normally around capital spending, because capital investment in buildings and equipment has its own budget. That didn’t stop the government deciding to continually take money out of that budget to prop up day-to-day spending. So, the ringfence, you can get over, you can dig under, you can go around ringfences. It doesn’t guarantee anything. But I think you are right, there are certain conditions, and this is where the words actually have real meaning. If there is something you can identify and measure and actually draw a ring around, and it needs to be protected, and you need to fence it off from something, then there can be a case for doing it. I think in recent years people have argued that there is a standing to invest more in mental health, and yes there have been debates over, well what do you count as mental health spending, what don’t you include? But fundamentally the idea was, we are not spending enough on mental health. Let’s draw a line around some of that funding, protect it, and tell people to grow it. That sends quite a clear message to the system. But I think overall you have got to be really cautious and really precise about how you do it otherwise you end up with a budget that gives local leaders very little freedom over how and what they spend money on.

AM:       Okay, I am going to try and summarise by really stretching that metaphor and maybe mixing a few. So, it sounds like a ringfence could be a good thing as long as you can actually fence something in, as long as the fence is strong enough, and as long as it is a ringfence and you are not just boxing yourself in to not be able to have flexibility to act.

SA:         I like it, yeah.

AM:       Well, that brings us to the end of this week’s edition of the King’s Fund General Election podcast. Next week we are not going to be joined by Sally because Sally is away on holiday. Sally, do you want to explain to us why you are trying to pretend that has anything to do with work.

SW:        Yes Andrew, so it’s partly because I am so committed to health policy and our listeners that I am taking a task with me. So, we have talked a bit in this episode about how it can be quite hard to understand the scale of things when it comes to health and care, and Labour this week have been trying to create a way for the public to understand the scale of waiting lists. And the way they have done this is by saying that if everybody on a waiting list was to be in a line lying down from head to toe, that waiting list would stretch from Hadrian’s wall all the way to Australia. And us being policy nerds in the King’s Fund, we immediately thought, “Well, hang on a minute, Hadrian’s Wall is not one single point, it is a wall that runs for more than 90 miles from the East Coast to the West Coast of England, and Australia isn’t a single point, it is quite a large country.” So, the immediate question is where does that wall start? Where does the list start on Hadrian’s Wall? And because I am so committed, next week I am walking Hadrian’s Wall, and every day I will be seeking high and low to find the start of the NHS waiting list, and I will report back in this podcast in two weeks time.

AM:       Brillant. Okay, so that is the sort of incisive analysis that you get from the King’s Fund. Well, enjoy Sally. In the meantime, for our listeners, before next week’s podcast comes out you can keep up to date with all of our commentary and analysis on the general election 2024. We have got a brand new blog on our website about how the parties are avoiding talking about social care. We have also got a brand new blog from our Chief Executive Sarah Woolnough looking at what the priorities should be for the next government, and there is loads of explainers and latest data and data visualisations on there to keep you informed throughout the election campaign. As with every week, next week we will be looking to take a question from one of our listeners. So, you can get in touch with your questions via X, formerly known as Twitter, just tag the King’s Fund. You can also post on the King’s Fund’s LinkedIn page with your question. Or you can email us direct, and the details for that email are in the show notes. The producers this week have been Natalie Cleverly and Emma Sheffield. It has been edited by Bespoken Media. We hope you enjoyed. See you next time.