The Conservatives are back in power. With no Liberal Democrats to provide any check on their policies, and Labour in the throes of a leadership contest that looks set to distract if not consume it for some time.
What is that likely to mean for the NHS? It’s hard to think anything good, not least because the party’s manifesto has relatively little to say on the subject, so a lot is going to depend on how reforms already in train are allowed to play out in practice.
The manifesto: The Conservative Party manifesto says the NHS was “founded on the principle that no-one should ever have to worry about their ability to pay for their healthcare [and that it remains] a profound expression of our values as a nation.”
That sounds fine, but it’s an odd way of putting the health service’s founding principles. These are usually given as “a comprehensive service, available to all on the basis of clinical need, and free at the point of delivery.”
So this line was either written sloppily, or it implies that the party wants some wriggle-room when it comes to providing a comprehensive service – that is one that is (or that aspires to be) the same everywhere and to meet the needs of everybody – and to providing a tax-funded service that is free to users.
The first is likely to be more significant in the short term, because new service models are already being developed that will leave the NHS (and the social care services delivered by councils) looking very different from city to city.
The second could be more significant in the longer term, if there is pressure to find new ways of funding those new service models – some “small” charges here, a bit of means testing there… an insurance model that would still “provide reassurance to hard working families when they need it most.”
That £8 billion: Specifically, the manifesto says the Conservatives will “spend at least an additional £8 billion by 2020 over inflation to fund and support the NHS’ own action plan for the next five years.”
Much of the election campaign debate about the NHS focused on this £8 billion pledge, since Labour refused to match it, saying instead that it would set up a £2.5 billion ‘better care’ fund, paid for via a mansion tax.
However, it’s surprisingly ambiguous. Again, it could just be sloppy wording, but it’s not quite clear whether the Conservatives are planning to spend an extra £8 billion a year by 2020-21, or an extra £8 billion between now and 2020-21.
The difference is a huge amount of money. But in either case, what the manifesto doesn’t spell out is that “the NHS’ own action plan” requires the NHS itself to find another £22 billion of efficiency savings over the same period.
This is because the plan – the ‘Five Year Forward View’ issued by NHS England chief executive Simon Stevens in October – is designed to close the gap between rising demand and likely funding that could reach £30 billion without action.
Now, most policy experts don’t think the NHS has much chance of doing this. It has managed to make significant efficiency savings over the past five years, but mainly by holding down wages and the prices paid to hospitals for treatment.
The result, as NHS Providers keeps pointing out, is that hospitals are looking at a £2.5 billion deficit in the coming year. Meanwhile, the Conservative’s much-vaunted cuts to council budgets mean there’s something like another £4 billion of pressure on the health service coming from social care.
Vanguards – of what? Whatever the £8 billion pledge amounts to, therefore, the NHS is going to have to find some big ways to find even bigger savings over the next five years.
It has already started. Just before the official general election campaign got underway, NHS England issued a list of 29 ‘vanguard’ sites to test out two ideas.
These are letting acute trusts expand to take on some community and primary care work; and letting GP practices expand to provide more services, including some now provided by smaller hospitals.
In both cases, the idea is that removing the boundaries and gaps between different services will both provide a smoother “patient journey” and save money. But the implications for the way the NHS does things are huge.
At least two of the ‘integrated primary and acute care systems’ vanguards (Salford and Yeovil) are being allowed to effectively dismantle the ‘internal market’ that has operated in the health service for the past 25 years, by creating new vehicles (an integrated care organisation and a joint venture) to both commission – that is plan for and buy – care for its local population and deliver that care.
Up front, this looks like a move to overcome one of the big problems with recent attempts to ‘join up’ healthcare; namely that when a new service is set up to keep people out of hospital, the hospital loses the money it would have got for treating them – adding to its deficit.
If the organisation that runs the hospital holds the local health service budget, it has more incentive to cut its costs by setting up a service for which it will still be paid.
In principle – and in practice, for the moment – this can happen within a system in which all the organisations involved are NHS organisations, spending money raised from tax. However, there is also plenty of scope for the vanguards to let in the charity and private sector; both of which can trim costs by casualising their staff.
After all, the last round of Tory-led commissioning reforms, which led to the creation of GP-led clinical commissioning groups, pushed a surprising number of community and mental health staff into ‘community interest companies’, and handed chunks of primary care and out-of-hours services straight to private companies, such as Virgin Care.
There is also scope for these new models to evolve into something like the ‘accountable care organisations’ that have been set up in the US to run everything from primary to acute care services for patients referred to them by insurers.
Indeed, as Stevens spent ten years of his career in the US, at the giant United Health, there is plenty of suspicion that this is where the vanguard policy is heading. It’s safe to say that Labour and the Liberal Democrats would have been less happy with this – and more likely to resist it – than the Conservatives.
It’s also safe to say that some of the names being bandied about to take over from health secretary Jeremy Hunt might be positively enthusiastic about pushing the policy in that direction.
Fripperies: The Conservative manifesto doesn’t mention the vanguard programme, although it does express support for another initiative, the ‘Better Care Fund’ to bring together health and social care.
Instead, it focuses on more specific promises, such as better access to cancer drugs, more health visitors for new mothers, and improved access to GP services.
The manifesto promises a seven day a week NHS by 2020, which will surely only be possible if a good chunk of the NHS is delivered through online advice sites, call-centre triage, and phone or video consultations.
This is probably not what elderly, Tory voters in the shires had in mind. But local paper rows about whether a call to a doctor at NHS 111 constitutes a 24/7 GP service will be nothing in comparison to the potential upset that could be caused by a move to hospital-lite, accountable care organisations.
Of course, the NHS could yet avoid going in that direction. It’s just that the general election result makes it significantly more likely that it will.