The additional £8bn that is the absolute minimum needed to close the NHS funding gap has taken on iconic status, so you may be surprised to learn that the figure doesn’t actually appear in the NHS Five Year Forward View…

I wanted to start with a surprise because for most health policy watchers the Conservative party manifesto launched earlier today is unlikely to offer many revelations. There are certainly no prizes for correctly guessing that the manifesto highlights the Conservatives’ strong commitment to an NHS based on need not ability to pay and argues that a strong NHS requires a strong economy.

It also reiterates a number of recent policy pledges, most notably last weekend’s commitment to finding the additional £8bn required to deliver the NHS Five Year Forward View. But there’s not much by way of new policy or the mechanics of reform.

This wasn’t exactly unexpected. For the last five years, the Conservatives have been the largest party in a coalition government that legislated to liberate the NHS from day-to-day political involvement. Plus the party has already backed the vision in the forward view for tackling the challenges that lay in wait in the 2015-2020 parliament and beyond, as published by the main NHS national bodies last year.

The lack of detailed policy contrasts sharply with the Conservatives’ 2010 manifesto, which described many of the reforms that have since been implemented via the controversial Health and Social Care Act 2012. Arguably, the party is now reaping the benefits of those reforms: NHS England has already done much of the policy detail and the Conservatives have already pledged their support for it.

The 2015 manifesto does, however, raise a couple of issues that are worth considering. Namely:

  • Where is the additional £8bn coming from, and will it be enough?
  • What approach would a Conservative government take to managing NHS performance in future?

Where is the additional £8bn coming from, and will it be enough?

On the key question of funding that is currently preoccupying political debate, the Conservative manifesto reiterates the commitment to finding at least the additional £8bn required to deliver the NHS Five Year Forward View. This is welcome, but some important questions remain unanswered.

Firstly, where’s the money coming from? So far, the Conservatives have simply stated that the £8bn – along with all other spending commitments – is fully funded as part of the party’s fiscal plan. The Chancellor has declined to confirm whether the money will come from tax increases, extra borrowing or cuts to other spending. This matters, and not just because it is entirely legitimate to ask any political party how its spending commitments are to be funded. Finding the money by expecting other public services to endure deeper cuts could be counterproductive if, for example, local authorities have to find further savings from the social care budget that adds to the pressure on the NHS.

Secondly, what exactly would the additional £8bn mean for NHS spending over the course of the next parliament? The Conservative manifesto commits to continuing to increase NHS spending and finding the additional £8bn above inflation by 2020 (even though the latter isn’t actually mentioned in the NHS Five Year Forward View). So have the Conservatives now signed up to the ‘staged funding increases close to "flat real per person"’ set out by Simon Stevens? Or with the manifesto predicting that a future Conservative government would run a fiscal surplus from 2018/19, is the £8bn commitment loose enough to be met through a substantial uplift in NHS spending late in the next parliament? I’m not suggesting skulduggery, but it’s all frustratingly unclear at the moment.

Finally, how will a Conservative government ensure the extra money is enough? The additional £8bn is very welcome, but the NHS Five Year Forward View is clear that closing the projected £30bn funding gap by 2020/21 will also require the NHS to achieve annual productivity growth of 2-3%. The manifesto states the NHS ‘is more efficient now than it has ever been’ but the basis for that assertion is unclear. Our own work highlights that crude productivity for acute and specialist hospital care actually fell by almost 1% in both 2012/13 and 2013/14 after increasing in the first two years of the current parliament. There is a mountain to climb here, and the manifesto is silent on what a Conservative government would do to support and enable the NHS to transform how it delivers care.

The manifesto does, however, commit a Conservative government to achieving seven day a week access to GP and hospital services by 2020, plus guaranteed same day GP appointments for all over 75s. This may be another reference to the NHS Five Year Forward View – which does mention seven day hospital services and also extending GP access – but the manifesto appears to go further so extra funding would be needed. The pledge on same day appointments is definitely new and so would be an additional call on the extra £8bn funding. Excess mortality at weekends means there is a compelling argument in favour of seven-day services, but there is no detail about how the Conservative party would implement and finance it whilst maintaining and improving quality in other areas.

What approach would a future Conservative government take to managing NHS performance in future?

The manifesto mounts a vigorous defence of the Conservatives’ record on the NHS. Our recent briefing on how quality of care has changed during the 2010-2015 parliament agrees that standards are better in a number of areas, but also finds signs that progress on improving quality has stalled and may even be starting to unravel in other areas. The claim that hospital-associated infections have halved holds up for MRSA and C. diff, for example, but there has been less progress on tackling other infections such as MSSA which increased from 8,767 cases in 2011/12 to 9,290 cases in 2013/14. The section on waiting times for elective care neatly sidesteps the recent difficulties with achieving the 18 weeks admitted target, which is unlikely to be met for 2014/15 despite being a legally-enforceable right in the NHS constitution. A&E waiting times – where performance against the four hour target has hit a ten year low – is conspicuous by its absence.

Jeremy Hunt’s ambition of making the NHS the safest health system in the world appears in the manifesto, which is very welcome but there’s little detail about how this will be achieved. Much is made of doctors and nurses being too scared to speak out about poor standards of care under the previous government. Our recent safety briefing highlighted that fewer patient safety incidents go unreported (a very good thing), but that NHS staff are more likely to think that people involved in incidents will be blamed or punished (13% in 2014, up from 10% in 2010). That in 2014 nearly 40% of staff reported having been ill from work-related stress – recognised as a factor that contributes to errors – is cause for concern.

The Commonwealth Fund report that ranked the NHS as the best health system in a comparison of 11 major economies is also cited. Our recent briefing highlighted how the results of international comparisons risk being misleading when taken at face value, and that the UK has room for improvement on a number of key health outcome measures.

Going forward, the manifesto makes a welcome commitment that a Conservative government would focus on improving outcomes rather than ‘chasing managerial targets’. This is encouraging, given that the current government’s approach to using data for improvement and assessment has arguably gone backwards, reverting to a focus on a much narrower set of targets. But the manifesto then goes on to make a number of pledges that look quite a lot like old-school targets, including an ambition to improve friends and family test scores alongside the guarantee of same day GP appointments for over 75s. More clarity on the Conservatives’ approach would be helpful here.

We’ve set out nine actions that the next government could take to support the NHS to deliver better services for the future. A number of the Conservatives’ pledges are consistent with these. But we would encourage a Conservative government to provide more detail about how it would support the wider transformation of how the NHS delivers care, particularly whether it would establish a properly resourced transformation fund. It is also not entirely clear whether the party’s approach to assessing NHS performance will give as much weight to improving outcomes and ensuring that learning and improvement are prioritised as it does to short-term performance issues.

To end with another surprise: despite the Conservatives appearing to have spent the campaign thus far trying not to talk about the NHS, the health service now appears as the top pledge in the one page summary of the manifesto.

This is the second in a series of blogs which will examine the main political parties' manifestos with regard to health policy. To keep up to date with the series, visit

Tim is Senior Policy Fellow at the Health Foundation,

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