What do the main political parties really have in store for health? – with Rachel Wolf and Stephen Bush

The Health Foundation (2023). Health in 2040: projected patterns of illness in England. 

The Health Foundation (2023). Public perceptions of health and social care: what are the priorities ahead of a general election? 

The Health Foundation (2023). What should be at the top of the political agenda for health and care? 

The Health Foundation (2023). Health Foundation responds to the Prime Minister’s announcement of smoke-free measures.  

The Health Foundation (2023). Social health insurance: be careful what you wish for.  

Institute for Government (2023). The NHS productivity puzzle: why has hospital activity not increased in line with funding and staffing? 

The Times. Tories as the party of change: that’s a hard sell (2023).  

Ipsos. Ipsos issues tracker: July 2023 (2023).  

Jennifer Dixon:

The next general election is already looming. No party can ignore the NHS. It tops voter concerns, needs a growing share of public spending and features daily in the media. The health of the nation is also moving up the stakes, as ill health is the main factor why 2.6 million working-age people are economically inactive. And social care, for how long can governments ignore reform given the growing ageing population?

So, what are the main parties saying about all of this? What are their plans as we head into the next general election? Have the party conferences revealed anything? Well, with me to discuss all this, I'm delighted to welcome two seasoned political commentators: Rachel Wolf, who is Partner at Public First, a consultancy specialising in public policy, public opinion and campaign strategy. Rachel previously co-wrote the 2019 Conservative manifesto. And Stephen Bush, who is Associate Editor and Columnist at the Financial Times, where he writes Inside Politics, a daily newsletter covering the latest developments at Westminster and in national policy. Welcome both.

We're recording this just after the Conservative Party Conference, just before Labour, and obviously Lib Dem has had their conference the week before the Conservatives. So, I think the first question as we're approaching election year, really, to you both would be, what do you think is the mood in the main political parties at the moment, understanding where the polls are in terms of favorability score with the public? What's in their minds now, more broadly, as they gear up to facing the electorate in the next year, Rachel?

Rachel Wolf:

I suppose in terms of mood of the two main political parties, I would say the Conservatives are more buoyant than they ought to be, and Labour is less buoyant than it ought to be. That is reflected in their approaches. So we have the slightly bizarre situation, where the Conservative Party is trying to present itself as the change candidate after its conference, where it's announced a bunch of policies, despite having been in power for 13 years. And the Labour Party is acting a bit more like an incumbent, that is very worried about dropping the vase as he carries it across the room, and not announcing too much. Of course, for the Labour Party, the big incentive for them is to keep people focused on their anger at the current government as opposed to what they might do instead.

Jennifer Dixon:

Stephen?

Stephen Bush:

Well, I suppose, in terms of the big two parties, the Labour Party will be feeling optimistic but weighted down by their well-earned historical anxiety. It's really important to remember the first election that Keir Starmer ever fought was 2015. He was someone who expected that they would win that election in 2015, and then, of course, they didn't. It's easy also to forget that he's actually older than he looks. He was an adult in 1992, so were many of the key people he's brought back into his inner circle behind the scenes. But most of his key shadow cabinet allies were people who were teenagers who expected to win the 1992 election and didn't.

To talk to the average person at the top of the Starmer Project is effectively to sit there, watch them recite the polls, talk about the economic and social headwinds the Conservative Party faces, and then for them to say, but I still think we'll lose. Whereas, on the Conservative side you kind of have the reverse dynamic, right? A party that usually wins, led by a Prime Minister, who for all I don't think this often comes across obviously on television, is really good at inspiring loyalty, particularly among his staff. So, there is, at the heart of the government still, I think, a real belief that they can turn it around, although I don't think that belief is particularly spread throughout much of the rest of the Tory Party even.

Jennifer Dixon:

Looking at the polls and how the parties have put themselves across in the last few weeks, my feeling would have been the opposite to what you've just said. You're closer to it, Rachel. In that the Conservatives can't really win on health it seems, given the record, particularly with waiting lists being as they are. And on the other hand, Labour don't feel as if they need to say very much. So I was wondering whether, despite the NHS almost topping the voter concerns polls, whether they would both be relatively quiet about health or is that a wrong interpretation?

Rachel Wolf:

No, I think that's probably accurate. I think this is going to be a policy light election in general, and it's going to be more about failures of record versus ability to make the sums add up, than it is going to be about radically different visions about what you would do with public services. We're obviously in a relatively low economic growth, relatively high taxation and spending scenario, by British standards, at the moment, and both parties are very nervous about making big promises because they don't want to say that they're going to substantively raise taxes to fund them. So, I think that's correct. I think you are going to be in a situation where people talk less about the NHS than you might expect, given there was a poll that came out about a week ago, that when you ask people what they're most disappointed by, in terms of the government's record over the last decade, health comes higher than the economy. Health is a thing that people feel the government has most failed on.

Jennifer Dixon:

Also, the polls that we've just done show that 80% of the public polled want more funding for the NHS. And if you break that down by parties, over 60% of Conservative voters said that too. So, even though there's clear public appetite to support the NHS, you think that they'll be still relatively quiet because of the economic constraints.

Rachel Wolf:

I think that the problem is this. First of all, in every election people want more funding for the NHS. It's a huge area where people want support and funding. While people might in principle say that they are happy for taxes to go up to fund the NHS, when you drill down into the details, people feel poorer right now, that the cost-of-living crisis has really bitten. So, if you say, well, okay, well, you pay more income tax, would you pay more national insurance? I think support is actually not very high. So I think that's one big issue. And a second issue is that, although I'm sure lots of listeners will feel the NHS is relatively underfunded compared to where it should be, if you look at every other part of the public sector, the NHS has done relatively well.

We've actually had a situation where real-terms funding has increased in the NHS, much more than it has in almost any other part of the public sector in the UK. So, my assumption is that just as she has for the last year, Rachel Reeves will focus on fiscal credibility, meaning not borrowing too much money, and relatively low taxation for people and for most businesses. And that means they're not going to make massive promises.

Stephen Bush:

Although the Conservative Party at times during this conference, the leadership I would say tended towards the hubristic, I don't think they will be quite hubristic enough to want to talk about the NHS going into this election. And indeed about health care more broadly. I suspect that smoking vote will be quite bruising internally for the Conservative Party, because it seems to me just an act of supreme political foolishness to take an issue on which your opponents are, broadly speaking, united. There are some Labour MPs who go, oh, I'm quite uneasy about this ban, only 5% of the group will be affected by this ban, do smoke anyway. So, there are some Labour MPs who will privately go, I'm not sure about it, but it's not a salvation issue for them, they're not going to row about it on the telly or on the radio or in the friendly press. I spoke to one Labour MP who was anxious about it, and they said, ‘Well, it's going to pass, and clearly it's more helpful for us if we are all united and they're all divided and rang about it, so I'm going to vote for it.’ Whereas, on the Conservative side, there is a, and I have to be honest, I think a correct visceral objection to using what is quite a heavy sledgehammer to crack quite a small nut.

Rachel Wolf:

So I think the other problem with it for the Conservatives is it makes it impossible for them ever to attack Labour's policies as nanny state. And I don't want to overdo how useful an attack that is, but if there were now sweeping measures on obesity or on alcohol, it's really difficult for the Conservatives to say, look, this is same old Labour, telling you what to do, what to think, because they've just done it on smoking.

Stephen Bush:

And in terms of the wider public health outlet, it is just wildly incoherent to have a situation in which the Prime Minister apparently believes that it is more illiberal for someone to not be able to drive an old banger into the centre of London than it is for an adult to choose to smoke. It does feel to me like that was not a good call. And then, of course, you've got the broader stuff: the NHS is not in a good state. On the flip side of that, the Labour Party, for all of the reasons Rachel was talking about earlier, is not going to want to go into the next election doing anything which will allow them to be attacked on tax and spend.

So, essentially, a good way to think about what Labour will say across every topic at the next election is, what can they do then they could plausibly say could be funded by closing loopholes. And basically, if you're not at the […] this is an amount you could raise by equalising CGT or whatever, it ain't going to get spent, and ultimately the NHS is well beyond that kind of thing. So, there'll be some kind of doctors’ excellence programme, you can see it where they're talking about increasing the number of NHS dentists, because it's small bore enough that it fits within their political imperative not to get done over on spending.

But in an odd way, the NHS I think will be the subtext of a lot of this election, because it is a, again, as Rachel was setting out, it's a key thing that the government is seen to have failed on that people feel that the government is responsible for, and it contributes to this general mood, and the country's in a bit of a state and we need a change. But neither party's going to want to talk about it because the Conservative Party will have gone through this awful vote over smoking and the Labour Party will be terrified and it'll wake up in 1992 or 2015.

Rachel Wolf:

Danny Finkelstein, I thought, wrote a very interesting column this week, and he had this line which was that the Labour pitch will be: Britain is fundamentally broken and we're going to do absolutely nothing to fix it. It's a slight exaggeration for effect, but I don't think that there is going to be dramatic policy change fought over at this election, maybe after, but not during it.

Jennifer Dixon:

The question then is, what's happening below the waterline in terms of what they might be thinking about, both the NHS, which they can't ignore, health because of the 2.6 million working-age people who aren't working due to ill health it seems, and probably more who are underactive economically, and of course social care. So beneath the waterline there will be some thinking you would think about those things. What are you picking up from maybe the think tanks or maybe sotto voce whispers going on inside the party about how they really feel they should be tackling some of those things?

Rachel Wolf:

I don't think health reform is a big part of how the Conservatives are thinking right now. I'm not seeing huge numbers of ideas emerging and I think there is very little appetite to do health reform. Lansley cast a long shadow, and people are very hesitant about health reform in the Conservative Party. I think there's excitement about bits and pieces, like technology, but without a huge amount of specificity underneath it. I think the interesting thing is all the incentive is still to push for more headline staff numbers. More nurses, more doctors, more training places, and that's on both sides. There seems to be very little evidence that that's the big constraint in the health service right now.

And then the second thing that seems to me interesting is, and I'd love Stephen's view on this, there is, it seems to me, still a bit of a tension within the Labour Party about whether the Blairite model of public services is broadly the right one. In which case, you would see a move back, which I would think would be great. A move back to more autonomy, a bit more choice, a bit more competition, more freedom, or a slightly more soft left status interventionist approach, which probably double down on the ICSs as the route to good health, pours a lot into prevention and systems around it. Now, that doesn't have to be either or, but it's not obvious to me that there is a subtle view within the party about what a better health system looks like. But Stephen might know better.

Jennifer Dixon:

Yes. Before I bring Stephen in, can I just then put this one to bed, Rachel? All the screeching commentary in the Telegraph, the Times, some in the Spectator, of, we need a new model, we need the German social insurance model, etc, etc, is just screeching commentary and no more, or is there something behind that?

Rachel Wolf:

It's inordinately unlikely that the current Conservative leadership would ever go near a social insurance system or any other kind of insurance system. Depending on how catastrophic the defeat is for the Conservatives and who becomes leader next time, you might imagine that becoming more of the debate. I'm not against the German social insurance model, I think that health system's fine.

Jennifer Dixon:

We just produced a piece on examining, well, what would it take if we did do that? Listeners can find it on our show notes. But it's an enormous amount, this is a 10-year programme. The question is, we've got no bandwidth anyway let alone doing something like that, but-

Rachel Wolf:

I would be really surprised if a plausibly winning Conservative opposition or government ever went there. Or went there in the near future.

Jennifer Dixon:

Okay, we'll put that to bed for the moment. Thank you. So, Stephen, what do you think is bubbling below the waterline of Labour?

Stephen Bush:

Well, this is the fascinating thing, because essentially all of, with the exception of the Ministry of Defence, and of course, the climate change department, where Miliband is, all of the spending departments and all of the delivery departments on the Labour side now have a Blairite or at the very least Blair-ish politician in them. And mostly when you talk to those politicians, they will still have exactly as Rachel says, a quite Blair-like model of what they think they need to do. Most of whom, when you talk to them privately, will have quite Blairy ideas about how to reform the public services. But you can feel that they have this anxiety, that they go, okay, well, I know that that's not Kier Starmer's original political trajectory, am I here because I've been loyal, I've done a lot of media?

When he was trying to modernise the party and tackle the problem of antisemitism in the Labour ranks, is it then he's just had to attack more to the right than he would like? And ultimately, I think that's a question that's only going to be answered when they get into office. Because you can see, in terms of the stuff Wes Streeting was talking about publicly, and some of the stuff he talks about privately, what does effectively look like a return to a Patricia Hewitt-like approach. Eroding more of the powers of GPs, returning to some would say Labour's traditional hostility to small GP practices in particular, focusing on that type of NHS reform, and of course, focusing on anti-smoking measures of the kind that Patricia Hewitt drove through with a great deal of internal resistance. But whether or not that's where they actually land in office is the big known unknown, because Kier Starmer still is a bit of a black box for essentially everyone not called Kier Starmer.

Rachel Wolf:

It's also interesting your detail there Stephen, because when I think about the Blairite model, I suppose I tend to think more about the Julian Le Grande, Alan Milburn, foundation hospitals, a few top-down targets and then you kind of get on with it, and some choice and competition. Whereas, what you are describing is quite substantively different from that. So there's also flavours of Blairism even before you figure out what Kier Starmer thinks.

Stephen Bush:

Well, yeah, that is exactly it. In domestic politics, there are essentially three flavours of Blairism, and they're all sort of still present in the shadow cabinet. And the person who we would expect to decide is someone who came up and came into the Labour Party as a project of Ed Miliband and the London Labour Party, which is dominated by the party's middle and soft left. So, it is I think going to be a bit of a learning experience for everyone involved.

Rachel Wolf:

I think the other thing that's going to be quite interesting is what kind of prime minister he'd be. So, Cameron for example, was very chairman-like. He was pretty happy for people to try and do the reforms. And sometimes it worked, in my view, reasonably well, like with Michael Gove, and sometimes it was a catastrophe, like with Andrew Lansley. He was happy to try it out. Whereas, Gordon Brown, Theresa May couldn't be further from chairman-like. How much do you think there's going to be at some point a prevailing theory that he tries to grip and push through every department, versus let's let these guys do stuff?

Stephen Bush:

I think essentially Kier Starmer's model as Prime Minister will be very similar to his model as Head of the CPS. He does talk about it a lot because he knows that he needs to remind voters who he is, but he also talks about it a lot because it is actually a huge influence on his mode of thinking. He does really care about structures, and so there will be a lot of, I suspect, if you are a secretary of state, of the Prime Minister does a visit, whether it's to a hospital or a job centre or whatever, talks to a bunch of people on the shop floor, and comes back with five memos for you about what you should be doing. But between those, here are some targets, they will get quite a lot of latitude and leeway, as we've seen a bit in opposition. One of the things which has occasionally made some members of the shadow cabinet quite grumpy, including ones who have risen under Kier Starmer, is this feeling that they essentially have to feel around to be told not to do something, and I suspect that will continue on. So, in some ways it will be, although I'm not sure Kier Starmer would thank me for this comparison, it will be quite Cameron-esque in that respect.

Jennifer Dixon:

What I'm seeing, what we're seeing, is a whole lot of previous advisors from 25 years’ ago also advising on health, and the ingredients there do seem to be very similar to what they were saying in the past. So, targets performance management, or ‘terror’ as it used to be called, public service agreements, perhaps, combined with a blend of financial incentives and competition and choice, maybe to ginger up the NHS and get it to face some challenge from the external suppliers. That was in the toolkit of the advisors that seemed to be brought back in again.

So, the question is, is do you think that, from what you're hearing, is that the mix? Or is there something new that's going to be added in? Particularly because if you look at all the challenges that are facing the NHS, with the baby boomers retiring, all the costs of morbidity, you've got the shrinking of the working-age population, you've got all the public debt that we know about, and not much money, and you've got this huge challenge of technology, there is a question about whether that blend that was Blairite could possibly act fast enough to offset some of the challenges. If Labour are in, what else can they do?

Stephen Bush:

The big additions in addition to the usual stuff people say about AI, big data, etc, etc, will be this continued focus. So, in some ways there are two phases to Blairite modernisation of the health service, the new structures phase at the beginning, and the Patricia Hewitt phase, the scepticism around small GP practices, and you can see the ways that Wes Streeting clearly shares that, and ways that effectively talked about further pulling those into the system. Plus, of course, there will be quite a lot of ambitious public health policies, not least because, as Rachel was saying earlier, the ability of the Conservative Party to rail against those has suffered a pretty major blow with this smoking announcement, and given Labour's anxieties about revenue raising, there isn't going to be a meat tax, but there certainly is going to continue to be a sugar tax, and a whole bunch of anti-obesity taxes and regulatory changes.

Partly, of course, to try and leverage in money for health care. The thing that Kier Starmer wants to do strategically, is his plan with all of the five missions, is effectively to get a mandate for the ends so that when he gets into office he can say, look, here are the means and you voted for them. Broadly speaking, it's kind of what he did as Labour leader. He ran going, we keep losing, we need to stop losing, vote for me and we'll stop losing. Here's some reassuring pablum about how I'm actually going to be Jeremy Corbyn with a better suit and nicer hair. And then became leader and went, yeah, by the way, when I said I would be Jeremy Corbyn with a better suit and nicer hair, what I meant was I won't be Jeremy Corbyn. And actually, you can find, if you go looking for it at Labour Party conferences, people who are very angry about that. They are mostly people who didn't vote for him anyway.

What he's successfully done is take that two-thirds of the Labour Party who backed him in 2020 on the journey he hopes he can take the country on. But as you say, those Blairite levers did take quite some time to work, and they were also going with the grain of the internal market reforms. Whereas, to the extent that... Obviously, part of the problem is we now have a NHS structure, which itself is going against the grain of what it wanted to do in 2012 anyway. But it's one thing to go, I'm going to put more money and more impetus behind the internal market, it's quite another to go, I'm going to put not very much more money and a completely different impetus around the structures of the Health and Social Care Act.

I think the big question is going to be, look, to what extent are the problems that the NHS is experiencing, now that funding has started to climb back up to the OECD average? To what extent are we just seeing the hangovers? So some people in the Department of Health will say things like, oh, well actually the flow problem is starting to be fixed, but we've got a stock problem in terms of the condition of patients and the care they receive. If that's right, of course then the Labour Party may benefit from just coming into office in the right time. Then some of the spending that we've seen will start to actually be felt. But my fear, if I were in the Labour Party, is that they end up effectively having the same parliament that Rishi Sunak had, where they had a bunch of promises they couldn't reconcile on tax and spending, they had to break that promise with the social care levy, that was incredibly disruptive to the... You can draw a direct line from Boris Johnson's impressionistic promises on tax and spend to Liz Truss's catastrophic budget.

Jennifer Dixon:

So, just standing back for a minute. I entered the policy world in 1990 and then the guiding light, it was definitely the Reaganite, Thatcherite competition and choice, and reduced role of the state, etc etc, which rippled into the public services and more laterally into the NHS. And that really, as far as I could see, rippled until mid-2000s, maybe 2010 in the health service. But it's gone as a major loadstar for change, and it's very difficult to see what other administration defining loadstar there is now. Do you think that there is some kind of project like that, or idea, or are we just going to have to be in spotty pragmatism, the kind of Blairite mantra of what counts, is what works? Because that's probably true of all of the parties, don't you think? There isn't almost an ideology guiding them any longer?

Stephen Bush:

I think that is about fair. I was speaking to a very senior member of the Conservative Party at their conference, and they were talking about the budget and what might happen next, and they said, ‘Well, yeah,’ they said, ‘look, ultimately this is not going to be a 90s style election in which you have the Conservative Party going, we'll use this to cut taxes, and the Labour Party going, we'll use this to spend more money on the NHS and schools.’ Now, in an odd way, the slight caveat to that is that both political parties would like there to be a bigger ideological difference between the two of them. It's not quite like that and there are important differences between all the three policies I'm about to name. But actually, the kind of major Blair-Cameron consensus was also about a shared agreement about methods and levers. Whereas, the Starmer-Sunak consensus is about shared constraints.

And the big question, whether it's a Labour or Conservative government, let's face it, it's going to be a Labour one, will be whether or not the things they can do on the economy, which they think will get growth going and allow them to escape some of those constraints work? But if they don't, we’ll have this, essentially the Conservative idea is, well, we'll keep doing these expediencies and then magic will happen and we'll be able to be more like ourselves.

Jennifer Dixon:

In the meantime, if the magic doesn't happen, then you push to more extreme views that are gaining ground, as we're seeing particularly within the Conservative Party, as things get worse and this pragmatism doesn't seem to work. Which could happen on the Labour side too, yes?

Stephen Bush:

So, there are multiple reasons why parties tend to go a bit mad in their first term in opposition, but one of them is that the constraint of having to actually do the things you say, imposes a sort of level of sanity and coherence. If/when the Labour Party enters the office, they will start to sound a lot more like chapter and verse of Jeremy Hunts book, Zero. And then on the Conservative side, they will start to do a lot more of the, what I think, obviously, I would simply move to a French-style health system. And it's like, oh wow, God, what will you do on the second day? Because it's very easy to see a situation in which the next Labour government is very rapidly overwhelmed by its inheritance on all fronts. They spend 1 year getting stuck in the mud, and then 3 years just miserably losing every single local and bi-election until they go back out of office again. And that experience would drive the Labour Party quite far away from where they fought the 2024 election. Right?

Jennifer Dixon:

That's my worry, that actually, they're overtaken by… anyone, it's not just Labour… Whoever the new government is, is just overtaken by events because they're not acting confidently enough because they may not understand the speed at which change will happen, particularly on the demand side and on the technology side. That they may face headwinds that they've never faced before. And it's not just us, of course, it's other countries also. And I can't wish the sense of confidence yet, what I can sense is, is that we did it before last time and it seemed to work, let's use some of those tools, kind of thing. And this is where, in a sense, Tony Blair Institute's quite interesting, because they're going full on pelt on the technology side in a techno-ecstatic way, but without it yet thinking through what that actually means for a practical programme.

Stephen Bush:

Absolutely. To me, there've been two conferences this year, which sum up my... Well, I think it's fair to say our shared anxiety about whoever wins the next election. The very techno-optimistic bit of the Tony Blair Institute's conference this year, where, yes, there are lots of exciting potentials about artificial intelligence, however, I would say the history of health policy is that the more effective you get at treating current illnesses, the more expensive that people become. And then the second was Rishi Sunak saying, well, there's no reason to believe that people have got sicker in the last decade, which, actually, even before you get into the global pandemic, people lived through things they wouldn't have lived through. This complete removal from, under new Labour, you would not have been able to fill a conference hall with 90-somethings. Now you can.

Jennifer Dixon:

There's all the illness from the ageing population, which is going to be four-fifths of the morbidity load to 2040, which our analysis shows. But there's also the other thing which is the increasing demand from people who are not yet sick, but getting risk scores attached to them about their future prospects real health. So, there'll be maybe hundreds of thousands of people who may be receiving information that's making them jittery about their wellness in the future. So there's, potentially, there's a whole new mix of demand that they're not factoring in here, I think.

So Rachel, just to round off, overall, looking at the political parties we have spoken about first, the main two, are you optimistic or pessimistic about their chances of really making meaningful difference in the health sector, particularly in the NHS?

Rachel Wolf:

I don't think they're going to say anything before the election, that is particularly interesting and is likely to make a difference. As Stephen was saying, the hope has to be, although I have my own issues with this, that after the election, they start doing more meaningful reform. That does have its own challenges. If you don't go in with any kind of mandate from the electorate, it's both more difficult to get things through, and also does tend to accentuate an already pretty high anti-politics sentiment in the country. But let's assume for example that's what they do, that point, it's not very clear to me what they do.

So, I, through the research that we've done with you guys, have my own views about what you would need to start to tackle in hospitals and more generally, but we don't know if that's a theory that Wes Streeting and others share, because most of what they've said so far has been relatively minor. I'm sure GPs don't feel it's minor, whether they're in a partnership or contracted, but if you look at the massive problems that are facing the health system, this seems to me unlikely to make a massive dent either way.

Jennifer Dixon:

What are the top three things that then, if you were advising the new government, that you think they should be doing, perhaps building on the productivity report that you very helpfully did for us?

Rachel Wolf:

So, if you start with what makes anything productive, it's usually about people and then capital, in its broadest sense, so equipment, but also all sorts of other problems of capital, like technology, and then how those two interact. And what we've mostly done in hospitals over the last few years is put a lot more people into them. We do have a lot more staff in hospitals than we did a few years ago. Not as many as hospitals would like, given vacancies, but a lot more people. And we have both underinvested in capital and made it very, very difficult for hospitals to expand their own capacity. And also made it difficult for capacity expand out of hospitals so you can get people out of bed. So, we just badly need to make it easier to build more capacity, that's beds and diagnostic machines, and basic technology.

I think the second thing that seems to be a real problem is that we have massively expanded the size of NHS England, and the centralised power and number of people in the NHS, but we have allowed hospitals to be utterly undermanaged compared to other health systems and compared to any other part of the public and private sector in the UK. And when you talk to people who are trying to manage flow-through in wards, what they feel is they have no analytical capacity, they spend their life reporting upwards, and they don't have either the autonomy or the tools to actually make a difference on the ground. So I think that is another huge problem. And third, we make it really miserable to work in the NHS. That's a whole podcast in and of itself, but I think unless we start to deal with that, we're going to keep seeing this chat. Now, that's just hospitals, I would say even those three, prosaic as they might be, are more ambitious than anything I've heard from any of the parties.

Jennifer Dixon:

Stephen, how optimistic or pessimistic you feel that the main parties will face into these challenges?

Stephen Bush:

Look, by nature, I'm an optimist and one of the reasons why I am quite optimistic about, perhaps not the next 5 years, but the next decade, is that the Conservative Party will go into opposition and that will knock them out of the continual crisis fighting mode. And although I worry we'll see them move further from the reality-based community at first, it may also be a helpful time for them to go, oh yeah, there are a lot more 90-year-olds, oh, many children who would not have survived childbirth do, all of the stuff that we know. And the Labour Party will also get the useful infusion of rigour that only being in office provides, but while having a freshness that only a party that has come out of opposition really gets. And so, I hope that by the end of the decade, we will be in a much better place on health care policy debate and understanding of what the issues are.

If you're the Conservative Party, you don't really want to go too close to the scene of the failure, and if you are the Labour Party, you don't want to go too close to the source of the fear everyone has about you about tax and spend. But what would cheer me up would be if I started to hear them talk about 90-year-olds a bit more. Because it's the most obvious and tangible difference, not just between the last Labour government, but between the start of this Conservative government and the end.

And just if I started to feel I had some sense that they were at least preparing to talk to the public about that, and there was slightly less of the... Because exactly right about the, well, some people will want more pre-emptive care. I feel if I have to sit through one more thing where they go, well, the great news is we'll be able to predict all of these illnesses earlier, and say, okay, that's great, but that will also cost money. And so, I don't think it's really reasonable for us to expect either party to unilaterally disarm on the tax and spend stuff.

Jennifer Dixon:

So, we must leave it there. Thank you very much for the rich insights, Rachel and Stephen. As ever, there's more information on the things we discussed in the show notes, which you can find attached to this podcast wherever you get it from. Next month, we're going to return to the promise of artificial intelligence, in particular the fast moving world of generative AI in health care, and how we best prepare for it to harness the benefits and reduce the risks. So, join me then. Meantime, thanks as ever to Leo and Sean, here at the Foundation, to Paddy and team at Malt Productions. And goodbye from me, Jennifer Dixon.