100 hours to save the NHS...Labour's manifesto analysed

Labour's spending pledges and commitments on comprehensive healthcare are welcome - but campaigners shouldn't turn a blind eye to the worrying gaps and inconsistencies in their plans. 

caroline m.jpg
Caroline Molloy
4 May 2015

Flash Gordon style NHS campaign tactics - but do they convince?

Yesterday's Mirror proclaimed that there are ‘only 100 hours to save the NHS’, as Shadow Health Secretary Andy Burnham embarked on a whistle-stop pre-election tour of the NHS.

Such Flash Gordon-style tactics are a little facile - if Labour don’t win, those campaigning to protect the NHS are unlikely to hang up their placards for good on May 8.

But if Labour do win, is that it? Job done? NHS saved?

Of course, it's not as simple as that - but a close examination of Labour’s manifesto and campaign pledges is important to see where we should feel reassured - and where we need to focus our attention.

Ed Miliband commits to “rescuing our NHS…so that it has time to care”.

How? Labour makes a welcome pledge to fund “8,000 more GPs, 20,000 more nurses and 3,000 more midwives”. They also commit to GP appointments within 48 hours, cancer tests within one week, and an expansion of the ring-fenced ‘cancer drugs fund’ to cover more treatments. All this will be funded with £2.5billion from a Mansion tax, tobacco levy, and tax avoidance measures. 

Whilst arguments have raged about whether this pledge is “better or worse” than the Tories unfunded £8bn pledge, the media has largely failed to question what the remaining NHS budget will – and won’t - be spent on in future, under a Labour (or any) government.

Labour’s ‘big idea’ is to “bring together services for physical health, mental health and social care into a single system built around the individual.”

In fact that’s basically the Lib Dems and the Tories big idea, too – integrating health with and social care provision, and boosting mental health - though Labour stress ‘support’ for local councils to drive the process.   

But what - given that social care is currently extensively privatised, unsatisfactory and means-tested - does this all mean? Would social care become more like the NHS – or vice versa? 

And how would Labour tackle the market to avoid the constant expensive ‘re-disorganisation’ every time another bit of the service comes up for tender, or a private provider walks away or changes its sub-contractors on a whim?

One welcome commitment is in Labour’s separate health manifesto (though not its main manifesto) where it states that Labour would “Restore the Secretary of State’s historic duty to provide a comprehensive health service and ensure proper democratic accountability”. This  has been a key demand of campaigners (and of OurNHS) since that duty was finally abolished in the 2012 Act.

But there are still big unanswered questions over what we can expect to get, how we will pay for it – and who will provide it.

Andy Burnham has regularly claimed that “integration” of health and social care (and delivering more care at home) will save most of the additional money that the NHS needs. And the manifesto offers 5,000 new home care workers, a ‘new wing’ of the NHS.

But the idea that “integration” will fill most of the £30bn (not £8bn) annual NHS funding gap (with or without an extra £4bn to pay for some free social care) whilst still providing the same, or better, quality of service, has been criticised by most experts, from the Health Foundation and the Nuffield Trust, to the Health Services Journal who has called such assumptions in the past “magical thinking” and “messiah concepts”.

Pressed by experts at a Kings Fund debate on NHS funding, Burnham admitted “there will come a point where we have to have a different debate about how are we going to pay for all of our care in later life and I think that will have to be a new consensus that is achieved amongst the public about paying for a fully integrated health and social care service”.

Translation - Burnham has not been able to persuade Ed Balls to allow any financial pledges.

So he hasn’t rejected the idea – put forward in Labour’s health policy review by Sir John Oldham – to launch, immediately post-election, a full-scale review (in conjunction with the Tories and the Lib Dems) of ‘the scope of services provided by, and the future funding of, health and social care’. The Lib Dems have already indicated they are keen.

So - how we pay for the NHS ( through progressive tax or otherwise), and what we get in return – all neatly shunted away from voters til the election is in the bag? Hard to see much sign of electoral democracy, in that.

As for the question of ‘who will provide’, there are more mixed messages from Labour.

Their rhetoric has certainly shifted against NHS competition and markets, as Andy Burnham made no apologies for to Andrew Neil on the BBC's Health Debate.

Burnham has won many fans by regularly acknowledging that New Labour “went too far with the market” and that this “and “is not the right way to run a health service”.

But it’s curious that, in all this scrabbling around for ways to plausibly fund populist spending pledges, they are largely ignoring the huge administrative savings (likely to be at least £10bn a year) possible if they seriously got most of the bureaucratic competition and markets out of NHS service provision.    

On the positive side, Labour’s manifesto contains the welcome pledge that “We will repeal the Government’s Health and Social Care Act, scrapping the competition regime…”

The Health Manifesto adds the detail – Labour would scrap “the role of Monitor and the Competition and Markets Authority as economic regulators enforcing competition, and scrapping the ‘Section 75’ regulations that have effectively made tendering statutory. This will be replaced with an ‘NHS Preferred Provider’ framework, to ensure that the NHS is not destabilised by market competition.”

So it’s not quite “getting the market out of the NHS” as much as trying to help the NHS within the continued market – hence Labour estimate the savings from these measures as a modest £100million.

Some who campaigned against the Health & Social Care Act have welcomed these commitments, nonetheless. But both the Kings Fund and many leading NHS campaigners have suggested that our government would need to do much more than just remove some of the most recent regulations and regulators duties, if it wants to protect the NHS from enforced competition under current EU law. Campaigners have put forward a cross-party back-bench bill (the NHS Reinstatement Bill) which would restore the NHS to a Scottish-style system, organised in a way that truly protects it – but the Labour leadership has refused to support it so far.

The manifesto has also committed that “Where private companies are involved in providing clinical services, we will impose a cap on any profits they can make from the NHS.” But despite ritual protests from the right, it turns out this profit cap will not be applied across the board – and it appears not to apply to the back office “commissioning” and “integrated” services that offer the fattest and most tempting profits to private health and insurance firms.

Labour are not being particularly bold in disavowing ‘competition’ and ‘markets’. Oddly, the health and insurance industries themselves, having used these concepts to successfully begin to break down the NHS monopolies, are now looking for more efficient ways to get their hands on state cash, than endlessly dysfunctional, contentious and wasteful ‘competition’ and tension between ‘purchasers’ and ‘providers’.

So – dressed up as “co-operation” and “integration” (again) we are now offered “provider frameworks” and “networks” that reduce competition – not by ending privatisation, but by giving away huge ‘bundled’ long- term contracts, with complex and secretive sub-contracting to provide a figleaf of NHS and charity ‘partnership’.

Virgin has just won one of the first of these new contracts, £1/4billion to manage elderly healthcare in part of Staffordshire, and is bidding on similar but fatter contracts in neighbouring areas.  

As exposed in yesterday’s Observer, another set of ‘frameworks’ has just given companies including United Health (the old employer of NHS boss Simon Stevens) the chance to allocate £5bn of NHS funding in an “integrated” fashion. And Stevens himself – who, prior to his time at United Health, helped Tony Blair and Alan Milburn design the earlier round of privatising measures - has offered up his Five Year Forward View (5YFV) entailing an ‘integrated’ ‘new provider network’ of new public/charity/private partnerships.

Labour’s manifesto is silent on Stevens’ plans. When questioned on it directly Burnham told the Health Services Journal, “the Five Year Forward View is fine as far as it goes but in and of itself it leaves many big questions unanswered. I reiterate my commitment to it but it isn’t of itself… a detailed plan for the NHS.”

But where is this detailed plan for voters to consider? Labour’s manifesto merely repeats vague promises that everything will be ‘joined up’. Its Health Manifesto tells us “Local areas will be supported to develop NHS integrated care organisations and networks.”

Burnham explained to the Kings Fund that these organisations will have an incentive to keep patients out of hospital. Sounds good. But who will really be running these organisations, and in whose interest? Labour’s policy review held up private organisations in the US and Spain as good examples to follow, as did Stevens in his plan.

For more clues as to Labour’s thinking, we have to turn to the wider manifesto. We find it heavy on the idea that Labour will “ask more of individuals and communities”. “Everyone will need to contribute and play their part”, it tells us repeatedly.

But what is this part we are expected to play? There are hints we are expected to do far more in future than just turn up to work if we can, pay our taxes, and receive taxpayer funded services in return. Labour tell us that’s “the old command and control economy [where] too much power is unaccountable, concentrated in the market and the state, at the expense of individuals and their communities.”

Instead Labour proclaims that “We will end a century of centralisation...Instead of imposing change on communities, we will give them more control over schools, health care…We will promote and encourage a model of citizenship based on participation and shared responsibility… giving individuals and communities more control over their design and delivery… by pushing power down and organising them around individuals and families not centralised bureaucracies.”

What forms will this shared power - and responsibility - take?

Labour’s manifesto states that the sickest people will be given the right to manage their own “Personal Health Budget” – something Simon Stevens is already rolling out.

They tell us service users will have a “place at the table” in any redesign – though say nothing of how they will stop the table being set by the management consultants, disguising service withdrawal and privatisation as ‘self-care’, ‘co-production’, and ‘empowerment’.

And Labour tells us that “Our charities, mutuals, co-operatives and social enterprises are pioneering new models of production that enhance social value…and give individuals and communities power and control.”

The manifesto language is remarkably similar to that of Cameron policy right hand man Frances Maude MP, who says “For too long, delivery of public services has been shackled by a top-down, Whitehall-knows-best attitude…We are looking beyond the old binary choice of monolithic monopolistic state provision or full-blooded commercial outsourcing…mutuals, charities and social enterprises are often much closer to the people we want to help…More and more services are going to be delivered from outside of the public sector.”

Whatever Maude's motivation, an optimist might see Labour as genuinely motivated by a desire to empower patients and 'service users'.

But do we all actually want to become personal budget administrators, ‘co-producers’ and social entrepreneurs, fending off the private sector hawks ever looking for ways to exploit our needs for their profits, as collective state service provision steps back? Does this really “empower” us?

The polls tell us that the public want nationalised services, and that there is little appetite for these third sector “solutions” and private sector “partnerships”. But Labour has remained quiet as Frances Maude has hustled NHS hospitals towards ‘spinning out’ of the NHS into supposed “mutuals”, without public consultation.

It is curious that, just as the expensive failures of unfettered markets and privatisation became too obvious to ignore over the last few years (as consistently exposed by OurNHS), the dominant intellectual force within Labour has embraced ‘Blue Labour’ ideas, criticising the “state” just as much as the “market”.

Voters may decide that Labour is the only, or best, chance to save the NHS. But one thing’s for sure. The battle won’t be over in (less than) 100 hours. Whichever party (or parties) form a government on May 8th, campaigners won’t be able to hang up their placards just yet. In the months and years following the election, it will be all the more necessary to hold the plans and soundbites up to scrutiny and ask, “what does this really mean for the future of our health service?”

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