Brexit may be dominating political debate, but the NHS cannot be ignored

Party conference season saw some positive noises about politicians’ plans for the NHS. But serious issues have still not been addressed, says Anita Charlesworth.

Autumn is upon us. For young people that means heading off to university, for politicians it’s off to party conferences. Attending a party conference bears striking similarities to fresher’s week. The parallels between university life and political conferences were most stark at Labour, which is reinventing the party conference as we know it.

The main parties’ conferences are now over and the dust is settling on the post-election landscape. The NHS’s position in that landscape is complex. The health service clearly matters to the public – according to one poll it was second only to Brexit in shaping people’s voting decisions in the last election. However, despite the service’s undoubted salience, it’s also clear that the focus of Westminster is fundamentally elsewhere. This is not surprising given scale of the Brexit agenda and the limited bandwidth of politics. More fundamentally, after seven years of austerity our political parties are struggling to find answers to the big long-term challenges facing the health and social care system, of which money is central.

The key issues

The Labour conference was a further reminder of the powerful grass roots energy that has been unleashed over the last few years. The NHS needs to take more notice of this movement. Opposition to STPs and specifically accountable care contracting models, is growing rapidly as the galvanising issue for those Labour supporters who fear that the NHS is at risk. One of the key strengths of the Five Year Forward View was the breadth and depth of support for the aims and ambitions it articulated. If support fractures, this legitimacy is lost and the political climate offers little chance of progress. NHS leaders need to reach out and address these concerns, to ensure that they have the public’s understanding and support for the transformations they want to achieve.

Winter and workforce were the hot topics of the front bench conference speeches and loomed large in the fringe events. The Conservatives and Labour had positive announcements that are hard to oppose. Labour arguing for more money to help the system manage winter pressures. The Conservatives for the expansion of nurse training places and nursing associate apprenticeships. Both parties were clear that the centrally imposed pay cap has reached the end of the road.

The next big political event is the Chancellor’s budget statement on 22 November. Philip Hammond’s speech included no mention of either health or social care. He can’t maintain that silence in next month’s budget and will have to fill in the space left hanging after conference.

He needs to fulfil the expectations that have been raised for extra capital and resource funding. This month’s release of the latest capital investment data from the wonderfully named ERIC survey shows the reliance on capital funds to bail out revenue overspends is not sustainable. Across the NHS spending on equipment fell by almost a quarter last year.

The reliance on capital is the flip side of the revenue shortage. In the manifesto the Conservatives committed to some extra funding – the Prime Minister reiterated that commitment in her conference speech.

How the Chancellor manages the raised expectations on pay is one of his big challenges and an acid test for the budget. The NHS is struggling to recruit and retain nurses with one in 10 posts unfilled. Pay is far from the only or indeed main factor behind the growing crisis, but nurses have seen a 6 per cent drop in the real value of their pay since 2010.

Pay cap in hand

Pay restraint has been central to making the big efficiencies expected from the NHS, and ending it without proper funding will not work. Hospitals are already struggling to balance their books this year, before there is even a hint of winter pressures. If the pay cap is eased the Chancellor will have to look again at the size of the additional revenue funding.

Finally, there is the increasingly vexed issue of social care – the cause of much angst on the fringes and glaring silence on the main stages.

The Conservatives are feeling bruised by how their manifesto commitments played out in the election. Some Labour old hands remember that something not dissimilar happened to them with the so-called “death tax” in 2010. The lesson being that partisan attempts to address social care will not work: cross party agreement is an essential, not a nice-to-have. Beyond Westminster, many in local government clearly feel that they are being positioned to take the blame for a difficult winter because of delayed transfers of care. Some NHS leaders feel they argued for additional social care funding ahead of extra NHS resources pre-election but this has not delivered extra capacity. This buck passing helps no one. Now more than ever we need a thoughtful and careful policy debate on social care.

Given the tiny bandwidth for non-Brexit issues the NHS and local government must come together to work constructively on a sustainable solution for social care through the promised but much delayed green paper.

Anita Charlesworth is the Director of Research and Economics at the Health Foundation

This blog originally appeared in the HSJ online on 9 October 2017