Do the manifestos cut it on health?

On social care, the Conservatives propose delivering the reforms set out in a December 2021 white paper, People at the heart of care, including a (Dilnot) cap on lifetime costs of care of £86,000 and raising the assets threshold from £22,000 to £100,000 before public funding of care kicks in. But these promises ring hollow. In the words of the parliamentary Public Accounts Committee in March, ‘2 years on from its long-awaited white paper – a 10-year ‘vision’ for adult social care – plans for reform have once again gone awry.’ That’s in part because in the face of inflation and rising pressures the Department of Health and Social Care had to reprioritise scarce government funding and effort to provide local authorities and care providers with financial stability. How will the future be different?

Labour has omitted the cap from its manifesto, though Wes Streeting subsequently said it does intend to implement it. After years of delay by successive governments, this hardly inspires confidence. The manifesto does offer a vague commitment to build consensus for the longer term reform needed to create a sustainable National Care Service. This makes sense but has a ‘never never’ feel about it – meantime the ageing and health needs of the population go ever upwards in an alarmingly steep curve. Time won’t wait.

The Liberal Democrats have the luxury to be bolder, pledging free personal care based on the model introduced in Scotland in 2002. As we know from Scotland, social care is not entirely free of personal costs, but lifts more of the burden from individuals than in England. It costs a lot (more on this below) and raises questions about the right balance between individual responsibility for care and that of the state. That was the straw that broke the back of the Sutherland Report on the subject in 1999, with two senior advisors (David Lipsey and Joel Joffe) submitting a significant public note of dissent with the recommendation to make access to personal care services free. The lack of progress in England since then is difficult to forgive.

Turning to prevention and population health, all three parties want to reorientate more investment into prevention – hallelujah. Labour hint at a health inequalities strategy by aiming to halve the gap in healthy life expectancy between the most and least wealthy areas in the country. The Liberal Democrats want to increase healthy life expectancy by 5 years but don’t say how. The Conservatives appear to have dropped their earlier policy goal of adding 5 years of healthy life expectancy by 2035 – perhaps after reading our assessment that on current trends the goal would be achieved in more like 192 years. Instead, they stick to secondary prevention by confirming the publication of a major conditions strategy, as (long) advertised by Chief Medical Officer, Chris Whitty.

On risk factors, all want to limit junk food through curbs on advertising, or, in the case of Labour and the Lib Dems, taxes on unhealthy food. The Conservatives and Labour would enact legislation to ban the sale of tobacco and some vapes akin to the bill that was dropped when the election was called. Despite bloodcurdling suggestions by Labour’s Wes Streeting on going after commercial companies selling ultra processed food, not much is in evidence in any of the manifestos. And not a peep about booze, given the harmful effects of alcohol abuse and positive impacts on health of the policy on minimum unit pricing in Scotland and Wales.

And on the very significant issue of working-age health and high levels of economic inactivity, the Conservatives and Labour propose to reform the benefits system, in particular health-related benefits. The Conservatives go harder by proposing a cut in the projected welfare bill (an eyewatering £12bn), reforming benefit assessments and extending sanctions for people on benefits for over a year and not engaging in looking for work. Labour offered more in terms of supporting the over 2.8 million people out of work due to ill health to get back into the workplace. 

So if those are the choice of fillings, what about the bread? Slice one is investment. Very little to see here, yet some pledges (eg getting NHS waits down) have high costs. Labour have costed many (not all) of its more specific pledges on health, but not given any idea about the long-term trajectory of total investment that the NHS, social care and the public health system desperately need. The Conservatives have promised only ‘not a cut’, by pledging increases ‘above inflation’ in each year of the next parliament. The Liberal Democrats have pledged to increase revenue funding for health and social care by £8.4bn a year by 2028/29, plus a £1.1bn boost in capital. Only the Green party seemed to buck the trend of cautious investment, with a £50bn pledge for health and social care by 2030 to sit alongside a £20bn capital investment. 

Slice two is reform. Campaign speeches are usually full of tough talk with little detail at all. And the manifestos bear this out. Clearly there is not yet any new administration-defining guiding star. If anything, technology is the main hope, but the manifestos are very light on this too.

Perhaps the most significant chapter to read in the manifestos on health and care is, in fact, what the parties are saying about tax and spend and growing the economy. The truth is that the main reason health and care are in the state they are in is because wider economic growth has been too limp to support adequately the models we already have in place. Many commentators have expressed deep frustration at the opacity of politicians, not just about the state we are in, but on the plans to get out of it. For example, the Institute for Fiscal Studies notes that on current forecasts Labour’s plans leave no room for any more spending than planned by the current government. And those plans do involve cuts both to investment spending and to spending on unprotected public services. Yet Sir Keir Starmer has effectively ruled out such cuts. How they will square the circle in government we do not know.

As Martin Wolf in the FT put it recently, the politicians are treating the public (us) like mushrooms – keeping us all in the dark, then throwing us some manure from time to time to keep us satiated.

Meantime we will have to put up with these substandard sandwiches, make a choice in 3 weeks’ time, but grow ever hungrier for something more.