Things can only get… tougher?

The NHS and the economy will be the biggest issues in this general election. The two are critically linked – limp economic growth means limp NHS investment (and ergo performance) and vice versa. Anyone with a serious interest in the NHS, and indeed health, must first assess chapter one of each of the main parties’ manifestos on their approach to boosting economic growth: the credibility of realising chapter two – on plans for the NHS – will depend on it. Current levels of real-terms funding growth (circa 1% each year) can’t sustain the NHS as we know it. And the situation is even bleaker for other vital public services.

As yet the manifestos aren’t published. Instead we have missions from Labour and a few pledges from other parties. On the NHS so far there are no surprises. The overriding aim will be to tackle waiting times.  

From Labour, the mood music from Wes Streeting is mixed. On the one hand, clear support for the NHS; on the other, strong talk about the ‘culture rot’ and ‘no extra funding without major surgery’. This may just be pre-election performative rhetoric but let’s see. Labour has set out detailed lists with specific targets – pledging to meet the standards set in the NHS Constitution. There is no timetable as yet apart from a commitment to end all those waiting over 18 weeks in 5 years. The overall direction looks sensible and could hardly be more familiar – boost the workforce, strengthen community and primary care, go harder on prevention, and far more technology enabled care.  

There is intent to strengthen social care and improve health and reduce inequality (by turning England into a ‘Marmot country’), with cross-government action and a target. And there are pledges for more staff and appointments, and paying staff to work more overtime, all funded by scrapping the non-dom tax status. As ever the challenge will be how to balance effort (and investment) on short-term practical must dos, with building resilience for the long term to meet the headwinds ahead.  

All sounds sensible and good enough for an election campaign. But the headwinds felt now are light breezes compared with those ahead. For example, the ageing population, rising levels of morbidity, an economy that (on current trends) may not be powerful enough to pay for an adequate standard of public services, a huge wave of technological change, and a hyper-centralised country with many areas left behind. So very soon we will need to see a credible approach from all parties to cope with the next year, not to mention the medium to longer term.

The parallels between now and 1997 are worth mulling over. New Labour had renewal of Britain as a clear intent. It benefited from unusual economic growth in the early 2000s that fuelled huge investment in the public sector, delivering record growth (and performance) for the NHS. New Labour also had a reforming lodestar – a mixture of market-style incentives (in the NHS to an extent inherited from the Thatcherite 1991 reforms) with unusual pragmatism (‘what counts is what works’) plus top-down direction. This brew produced results. 

Sifting through all the evidence, success was most likely down to heavy investment and focus on a small set of deliverables driven nationally (notably waiting, and hospital acquired infections) with ‘P45 targets’ to concentrate the minds of managers. Local competition and choice supported by creative design of financial incentives may have helped, but nowhere near the levels claimed at the time.

We all know this time, whichever party forms the next government, it will be very different. Gone is the money, gone the same lodestar guiding change. But zeal, strong commitment (public and political), and pragmatism could go a long way. This, along with intelligent exploitation of new assets: data, new technology, and the clear need for the state to take bolder risks. Helpfully, consensus is growing that health and care are so key to economic prosperity and security that they justify greater public investment.  

Expect all parties to reject distracting structural reforms – reorganisations sap energy for little gain – and to make reducing waiting priority number one. On new technologies, there may be a two-way approach. On the one hand enabling bottom-up trial and spread of innovation. On the other, perhaps some bold national demonstrators to test some ‘big bets’ – technologies that hold the most promise to transform care – in a process that could be developed for future waves of advanced technology. The approach to the workforce will need to be sophisticated – clear support and appreciation for sure as staff will be the most important asset to drive much of the change, particularly technological. But at the same time far more accountability and challenge on performance and productivity, with action on pay, conditions and workplace cultures.

Some clear immediate wins on health might include action on risk factors, such as getting tougher on junk food, enacting a form of Sunak’s tobacco sales ban, minimum pricing of alcohol, and further taxes on foods high in sugar, salt and fat. A strategy to reduce health inequalities looks likely, with a particular focus on early years and the health of the working-age population.

But the first real contact with reality will be winter. Clogged A&Es, lines of waiting ambulances and knock-on impact on elective waiting times will not be a good look for an ambitious new government. This means serious planning in the first 100 days and, above all, a spending review settlement that meets the risks. ‘Securonomics’ must mean something after all.

But given the context and immense public frustration with the status quo, early zeal will curdle without tangible change within 2 years. Labour for one knows that too keenly and, if elected, could drive a harder national directive approach than anyone expects. 

Jennifer Dixon (@JenniferTHF) is Chief Executive of the Health Foundation.

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.