It is always assumed that Labour has a poll lead on the NHS whatever policies it actually has. Going into the 2015 election Labour’s policies around health and care had general approval (in terms of polling evidence). The policies had been through the party policy development process and had a high level of agreement, also passing unscathed through party conference.
Whilst the public sort of liked the policies there was a lack of confidence in Labour to deliver anything, however desirable, as well as issues with Labour’s leadership. In terms of health there was a sceptical reaction from anyone within the system as the policies lacked any credible answers to questions about how they would be funded.
To gain votes from the widest possible group of electors on the issue Labour has to do more. It has to:-
- Articulate a credible and compelling vision about what a modern care system should be like (maybe like the Era 3 described by Don Berwick)
- Reassert the fundamental principles (free at point of need, universal, comprehensive, funded from general progressive taxation) extending these to all care over time
- Explain simply the governance to apply – what is our role, what role for bureaucracy what role for elected representatives (who decides what – locally and nationally)
- Set out some idea of the costs involved (and the underlying assumptions – bit like “fully engaged” Wanless scenario)
- Set out some idea about where the funding would come from (changes to social security as well as taxes)
- Set out how to get from here to where we need to be – transitional issues, costs, timeframe, risks. (Labour had an emerging 10 Year Plan.)
Much work on these issues was carried out before 2015, not all of it being published as it would have been contentious.
Still the policy in 2015 went far beyond denouncement of the dastardly Tories. There was a broader approach derived in part from the excellent work done on Whole Person Care, on Public Health and Mental Health. On the NHS Labour was clear it would abolish the market and competition (Part 3 of H&SC Act) but rejected any need for a top down whole system redisorganisation – instead showing how changing the relationships between existing bodies could achieve the same ends.
The big failing always came back to the issue of how a modern system could be sustainably funded.
Since the defeat of 2015 there is little doubt that the finance issue both in the NHS and social care is front and centre. Social care has got even worse. The much hyped agreement by the Tories to fund the 5 Year Forward View has turned out to be bogus; provider deficits in 15/16 reached new heights and the local Sustainability and Transformation Plans are unpicking. Both sustainability and transformation look like cuts. Every sign points to Treasury interference – to get finances back under control.
The response from Labour has been limited.
In terms of its own policy we now hear that Labour will move to a care system that is entirely publicly provided and free (including social care). This will be achieved in part by a major (biggest ever) top down reorganisation. In many ways that would make the English NHS quite like the Welsh NHS. The evidence shows the two national systems perform pretty much the same and have similar management and administration costs – making it unclear what exactly is achieved. What is certain is that the change proposed to remove the private sector would be very expensive and the change to redisorganise would be highly expensive and hugely (perhaps fatally) disruptive.
On funding the commitment is to stop the decline in funding as a %GDP (not to raise it to a sensible level) and to make savings from PFI, agency costs and better pharmacy procurement. This would of course require massive savings from core NHS services and has already been widely derided as impossible. The cost implications both up and down of removal of private provision is somehow included in this. Claims that efficiencies can fill funding gaps sounds more like the Tories than Labour. No details have been provided on any of it so the credibility gap just got wider.
This shift of policy back to a focus on demonization of the private sector gets applause at a certain kind of meeting and maybe even represents an aspiration many would share – but it fails every test of credibility. It also lacks any compelling vision about what exactly would be different; is it just to be more like Wales? And it is hard to see just how all private involvement can be removed – there has been private involvement in the NHS since it began; GPs, some mental health services, pharmacy, dentists and ophthalmology all pose issues; and social care is almost 100% private.
In the real world the action is around the STPs, even the BBC has finally caught up with them. A stupefying obsession with secrecy in some parts of the NHS has led to the absurdity of these plans (really they are just a strategy) being drawn up without any proper engagement with public, patients or staff – guaranteeing the plans will fail. Good ideas such as moving from competition to collaboration, encouraging integration through joint planning, directly involving local authorities and making plans and funding fit a defined populations’ needs – all get lost in the clamour that this is a secret plot (or 44 secret plots) to make cuts. And without more money (a lot more money) all these plans are dross.
Where then does Labour policy go next?
It should not go back to the 1970s but back to the widely agreed policy basis of 2015; this time with honest answers about funding and the consequences of not funding; a better description of how markets and competition can be removed without a reorganisation; clarity about the powers of the Secretary of State; clarity about what can be devolved and what can’t; with an outline for a ten year plan backed by a better communications approach to describe whole person care and its implications. And a lot more new ideas about what follows on after the end of the era of markets and competition, maybe ideas than can attract a wider support than the usual activists and campaigners.