It seems like only yesterday that David Cameron and Nick Clegg were making their coalition vows in the sunlit Downing Street rose garden. Five years on, the coalition has stayed the course, and today we enter the short election campaign period where Parliament is dissolved and Government departments must postpone all important decisions and announcements until after the election. This period is more commonly known as ‘purdah’ and this has given us the chance to reflect on the issues which have defined the current Government.
And what a five years it has been in health! Little did people expect in May 2010, when the Conservatives and Liberal Democrats produced their programme for government, stating “we will stop the top-down reorganisations of the NHS”, that Andrew Lansley would – less than two months later – publish his white paper Equity and excellence: liberating the NHS which paved the way for the implementation of the 2012 Health and Social Care Act. Lansley’s controversial reforms dominated the headlines in the early days of the coalition, while more recently attention has shifted to NHS finances, the A&E crisis and political slanging matches as we approach the 2015 general election.
Health is already playing a prominent role in the election campaign. Not only does the Labour Party believe the NHS is its best asset, but voters rate health as one of their chief concerns too. In an age where sensible debate about the future of the UK’s health service risks being swallowed up by political parties’ focus on soundbites and dubious spending pledges – and with the election outcome as uncertain as it ever has been – MHP Health has sifted through the chaff and has examined what we consider to be the key themes that have shaped health policy in the last five years.
Our ‘Purdah Preview’ looks at all the leading issues in health which we believe the political parties need to address during the election campaign. From decentralisation to devolution, from A&E to social care, the next Government faces a critical in-tray on health that will require urgent attention if the NHS is to meet the challenges of the future. Is it possible that the NHS could ultimately decide the outcome of the election?
Does winning on the health debate mean winning the election?
The political battle in the run up to the General Election is set to have the NHS at its heart. Amongst a group of undecided voters, 55% said that the NHS was the key issue that could swing how they vote on 7 May. Having a good story to tell on health should be critical for all political parties.
The mud-slinging over the health of the NHS has been increasing in volume over the last six months, but the Budget sparked fresh attacks between Labour and the Conservatives about who would be best placed to protect the nation’s most precious service. What is clear from the single mention of “the NHS” in the Chancellor’s Budget statement and other set piece speeches is that, despite the imperative to capture undecided voters and the importance they place on the NHS, the Conservatives are reluctant to talk about the health service. They remain bruised from the fallout from the “biggest reorganisation in the history of the health service” and prefer to stay in their comfort zone, focusing on the economy.
However, linking the NHS to the economy may be a good strategy for the Conservatives and the approval of ‘Devo Manc’ – bringing together the entire £6 billion budget for health and social care across the region – appears to be a very smart tactic from George Osborne. While ‘Devo Manc’ is effectively a further structural reorganisation, it means that the Conservatives can talk about health in an entirely new way, linked to building the ‘northern powerhouse’. Apart from providing a new approach to discussing health it also, cleverly, gives the Conservatives a way to connect with voters they want to woo in the northern towns and cities.
The north-west is a key battleground in the election, with Labour currently holding 47 seats and the Conservatives holding 22. The Conservatives need to hold on to the seats they have here and also make gains from Labour. David Cameron launched the Tories’ election campaign in Manchester on Saturday which emphasised how important this region is to them.
Given the arguable lack of commitments on health by the Conservatives, Labour have set out a relatively detailed policy package in their Ten year plan for health and care. However, Ed Miliband has been criticised for running a ‘comfort zone’ campaign, leading on the NHS. Unsurprisingly, Labour unveiled their first election poster with the slogan ‘Next time, they’ll cut to the bone … The NHS can’t afford the Tory cuts plan’. However, the headline pledge to spend an extra £2.5 billion on the NHS, increasing the workforce and improving GP access, does not open enough clear blue water between the parties and Labour is vulnerable to the numbers not stacking up. Labour’s plan to ‘recommit to the Pay Review Body process and pledge not to renege irresponsibly on pay deals like current ministers’ means that if they give much-needed pay rises to existing healthcare professionals, vast sums of the extra money committed could be swallowed up very quickly. The electorate might not see the improvement in services they expect.
The BMA has called for politicians to stop using the NHS as a political football but rather they focus on finding a long-term solution to the crisis the NHS is facing. At a time of unprecedented budgetary pressure this will only get worse as the population ages and the cost of healthcare rises. This needs tackling regardless of who forms the next government. It is Simon Stevens’s Five Year Forward View, rather than any of the parties’ manifestos, that has the greatest focus and the £8 billion funding need frames the argument more clearly than ever before. Many argue that that, with this central plan in place it almost won’t matter who is in Richmond House after the election. The real question is how the next administration, beyond a handful of vote-grabbing announcements, will imprint their vision in a meaningful way on the Five Year Forward View and make sure that the NHS doesn’t end up needing life support.
The devolution dilemma and the most trusted party on health (the SNP…)
Much has been written about Labour’s potential ‘wipeout’ in Scotland, defending 41 seats and set to lose up to 29 and Labour’s positioning as ‘the party of the NHS’ isn’t helping them.
In Scotland, as those working there will tell anyone from England with a wry smile, the NHS has not been subjected to the far-reaching reforms we have seen south of the border over recent years. The same unified health boards have been taking care of all health needs for an area since 2004.
However, despite this long (in health policy terms, very long) period of stability all is not rosy in the NHS in Scotland. In December NHS Scotland missed its target of treating 90% of patients within 18 weeks for the second time, and it has never met a legal obligation which came into effect in October 2012 guaranteeing that patients receive planned inpatient or day-case treatment within 12 weeks of the treatment being agreed. A&E targets have also been missed, with 87% of patients seen within four hours against a target of 95% and reports that “At Scotland’s main A&E hospitals, the performance was worse than at comparable sites in England”. Added to this the NHS in Scotland has seen a 0.9% cut in real terms funding.
Negative stories have been tempered by the Scottish Government’s response on NHS staff pay which has been much more sure-footed than that from their Conservative counterparts in England. Health Secretary Shona Robison boasted that they would give NHS staff in Scotland “a better deal than their counterparts south of the border”. Meanwhile, in trying to land blows on the SNP, Labour recently succeeded only in wounding themselves as leader Jim Murphy had to delete a YouTube video and tweet after making false claims about cancelled operations in Scotland based on a misreading of the data.
The outcome? Far from the 14 point lead on the NHS Labour enjoys over the Conservatives among all-important undecided voters in England, Labour trails the SNP by 27 points on health issues in Scotland.
In Wales the picture is rather different. Labour’s 26 seats look much safer as they lead in the polls with 37%, ahead of the Conservatives on 23%. Defence of their NHS record in Wales has been equally strong, but challenges remain. As we’ve written elsewhere there is enough bad news about the Labour-run NHS in Wales to allow the Conservatives to undermine Labour’s claim to be the party of the NHS. It is however far from a slam dunk as Labour points to investments in social care offsetting cuts in the health budget.
To the north and to the west we see health playing a crucial, and for Labour particularly challenging, role in the dynamics of the General Election. But we needn’t look that far to find the devolution dilemma for Labour. The recent announcement of the devolution of health responsibilities to Manchester has divided the Labour party itself with leading councillors backing the move but the Westminster party opposing it. Labour wanted to own the wider devolution debate, trying to steal a lead over Lord Heseltine’s devolution proposals with their own Adonis review in 2014 but it seems that the health moves of Simon Stevens, himself a previous Labour adviser, have given the lead back to the Conservatives.
Devolution is a dilemma for Labour, and it could just cost them the election.
Financing the NHS
With the future of the NHS set to be one of the central themes of the General Election campaign, it is surprising that its future funding has yet to feature much beyond broadly rhetorical terms.
Labour’s claim that the NHS is unsafe in Conservative hands is based on increasingly alarming data on waiting times and A&E performance. Their slightly more spurious claim that there is a dastardly plot under way to privatise the entire system has been harder to back up, with data indicating private sector involvement is up only marginally in the years since 2010.
The Conservatives’ counterclaim that satisfaction with the NHS is at an all-time high is also supported by data gleaned from patient surveys. At this stage they remain committed to their 2010 manifesto commitment to ring fence and ‘protect’ the NHS.
The challenge remains that whilst this will see NHS spending rise in line with inflation, ever increasing pressure on the system means that such increases will continue to feel like real terms cuts for those operating within it.
So far, Labour’s commitment to outspend the Conservatives has been limited to a pledge to spend £2.5 billion a year more, funded through the application of an additional tax on tobacco companies and the introduction of a mansion tax.
Opening salvoes in the campaign suggest that further headline-grabbing interventions will follow.
Labour’s somewhat technocratic commitment to limit the amount of profit that private companies can derive from providing clinical services within the NHS will no doubt bolster the support of those who were already committed to vote for them, but it will lack much headline appeal beyond that.
The Conservatives, meanwhile, in promising to deliver a ‘truly seven-day NHS’ may have come up with something with retail appeal, but the commitment inevitably raises questions about how that could be funded in a cash-strapped system, and what that service might actually look like. Amid scepticism from NHS and doctors’ leaders; and confusion about what the commitment would look like on the ground, it seems unlikely that the pledge will achieve the kind of cut-through that the Conservatives had, no doubt, hoped for.
A relatively non-contentious, semi-independent, blueprint for reform exists in the Five Year Forward View developed by Simon Stevens at the end of 2014. Many commentators have predicted that one or other of the major parties will follow the Liberal Democrats and pledge to accept and implement his recommendations – including the eye watering, but widely accepted, funding request – in full.
Both Cameron’s pledge on a seven-day NHS and Hunt’s weekend noises on funding suggest that they may be edging towards such a commitment, but it falls well short of full implementation.
For either party, doing so would provide an unarguable commitment to be spending £8 billion more on the NHS each year by 2020.
That neither has done so points to the parlous state of the broader public finances and the fact that, so far at least, neither party knows exactly how they might fund such a commitment.
Improving the nation’s health – in the ‘too difficult’ box?
Six months after the coalition agreement was signed, the Government set out their strategy for public health recognising the alarming levels of the nation’s lifestyle-driven health problems. The solution that was promoted involved devolving responsibility to local communities, creating Public Health England (PHE) to provide central leadership; and directing the food industry to play a role in promoting healthy living.
The Responsibility Deal, often criticised by health campaigners, has not fundamentally changed the nation’s eating habits while PHE resorted to expressing its disappointment when the Government u-turned on minimum pricing for alcohol. The Local Government Association (LGA) keeps reminding us that local authorities can only fulfil their duties if they are adequately resourced so it’s not surprising that the Conservatives are keeping quiet on public health – but where does Labour stand?
Ensuring the public are empowered to make healthy choices is a cornerstone of Labour’s strategy although the exact same words can be found in the Government’s 2010 Public Health White Paper. Where Labour’s approach differs is their explicit commitment to improve child health through pledges such as setting maximum levels of fat, salt and sugar in foods marketed substantially to children. How ‘substantially’ will be defined remains to be seen, and while food manufacturers have made progress in reformulating products, Labour thinks more can be done and that the days of voluntary approaches are over.
Labour could argue that whilst in opposition, they could take credit for the ban of smoking in cars when children are present, along with the recent introduction of plain packaging for cigarettes; although they have offered limited solutions to support the millions of smokers annually who want to quit. Labour have also promised a new ‘national ambition’ on physical activity while expecting financially constrained local authorities to deliver change on the ground.
The former Home Secretary Charles Clarke coined the phrase ‘too difficult box’ to explain why politicians often opt out of taking action to fix long-term problems. In many ways public health could fit in this box as it is often sidelined in debates about the NHS. The statistics are stark – the UK is still among the worst in Europe for the level of overweight and obese people and we are also among the most inactive. The problem for politicians of all colours is that there are no easy headline-grabbing solutions while politically, the extent to which individuals are responsible for their own health remains a topic for a lively debate.
More worryingly, there is a risk for the debate to become so polarised that little progress is made towards implementing effective public health interventions. Across the country there are great examples where local authorities have embraced their new role, so the challenge for the Government and PHE is to boil it down to something that every local authority can implement.
So what can we expect post-election? More powers to local communities, further reform to PHE, and a wider debate on the future of Responsibility Deal. However, only limited progress can be made without national leadership and for the moment it looks like public health risks being forgotten.
The Five Year Forward View – the glue that binds?
Twelve months in and one Five year forward view (FYFV) later, few would question whether Simon Stevens is the right man to lead the NHS through the quagmire of cultural, clinical and financial change. His vision – real terms spending increase aside – is the glue that binds the parties in an otherwise mud-slinging pre-election theatre. But what allows that glue to stick is what appears to be an evolutionary approach to change in the NHS signalled in the FYFV – rather than a revolutionary approach which tends to create division.
In both the FYFV, and the wider announcements that have accompanied it, a number of different ways forward have emerged. On the provider side, the new models of care set out a range of possible approaches for local health economies to take. On the commissioner side, Simon Stevens has spoken of five distinct colours of commissioning – with a combination of any or all of CCGs, NHS England, local authorities, the aforementioned new provider models, and individuals themselves working to secure high quality care against a core, national ‘offer’. The super-sized ‘Devo Manc’ arrangements, adopting shades of each, creates a veritable rainbow.
In years past, the NHS favoured a pilot approach to the testing of new ideas and ways of working. However, this presented challenges. Pilots may be comfortable territory for the NHS, but applying the learnings and spreading them to other parts of the system has proved more difficult. Take the 2009 Integrated Care Pilots (ICPs) programme and the very recent Integrated care pioneers. The cumulative impact of these efforts isn’t really known. Either the NHS isn’t capturing the right learnings, it isn’t generalising them, or the learnings simply fall on deaf ears. What makes the new models of care any different?
In fact, the new models of care – and of commissioning – are different to the pilots of the past, and in a very significant way. They are not pilots the NHS is seeking to test and encourage the adoption of if they work; they are instead ‘vanguards’ which the NHS is expected to emulate over the next five years. In the past, pilots were sometimes selected on the basis of where the need for a new model of care was perceived to be greatest. The FYFV signals a deliberately meritocratic approach, which aims to nurture high, rather than poor, performers; and stimulate peer-to-peer learning and competition to ignite change across the broader system.
The risk is that this approach, rather than levelling up care across the country in a uniform way, instead creates a two-tier NHS as those areas which can best make use of the new freedoms and flexibilities are allowed to forge ahead whilst others languish behind. In some ways we see this happening already: the areas that are most enthused by new models of care are the forward-thinking commissioners who agree that if you start with a measurable patient outcome that you want to improve; and then work backwards; the collaboration, efficiencies and quality will necessarily follow. The FYFV freedoms simply allow them to knock heads together.
Even in non-vanguard areas, recognised NHS innovators are feeding off the dynamism triggered in some areas by the FYFV. Innovation in West Suffolk is one example of how it should work – where a lack of vanguard status is, if anything, a spur rather than an obstacle to improvement.
Ultimately, time will tell whether the FYFV results in an equitable NHS – where best practice is spread easily and adopted widely – or an elitist NHS, where only those areas able to harness the potential of more autonomy can truly take-off. If elitism reigns and benefits are confined, the FYFV will increasingly be seen as a revolutionary rather than evolutionary approach to delivering improvements in the NHS – and the glue may begin to come unstuck.
A healthy dose of competition: The ‘big ticket’ health conditions of the election and how they are shaping the political landscape
While investment and provision for the NHS was noted by only a brief mention in George Osborne’s budget, for a topic that is seen as the third most important to the impending General Election, it cannot be ignored in the election manifestos. However, when it comes to the designation of services related to a specific disease area, pre-election pledges can feel like a little bit of a popularity contest. So, how do parties balance a commitment to improve services for specific conditions with the potential to ignore other high need areas completely and risk upsetting patients, clinicians and stakeholder groups?
A very clear example of this balancing act is the Cancer Drugs Fund (CDF), first mentioned in the Conservatives’ 2010 election manifesto. Established in response to growing concerns around the lack of access to new cancer medicines and widely supported at the time, five years on and many questions have arisen around the transparency of which drugs are included in the fund, whether it has achieved value for money for the NHS and could that money have been better spent elsewhere?
A rose by any other name? Perhaps feeling that they can learn from the challenges of the CDF, Labour has committed to a new Cancer Treatment Fund. Worth £330 million per year, it would improve access to all forms of innovative cancer therapies, including radiotherapy and surgery. Yet, there is widespread agreement among stakeholders that the fund would not be viable in the long term and a better solution needs to be found, which may reduce the potential for this proposal to open up clear blue water between Labour and Conservative plans.
In this election, it is mental health that looks set to receive the biggest boost: an additional £1.25 billion has been allocated over the next five years to young people and maternal services, which patient groups and the NHS have widely welcomed, while highlighting that it has come ‘not a moment too soon’. Why the focus on mental health? Far from being a rare condition, 1 in 4 people will experience a mental health problem in any given year, so the potential that this announcement will be positively received by a large number of voters is high. In their ten-year plan announced in January, Labour also focused on mental health, pledging, among other things, that they would create a new right to talking therapies in the NHS Constitution.
Dementia care has also featured heavily. Our ageing population and improved screening services are contributing to an increased prevalence of dementia, which is only set to grow, making it a necessary target for focus and effort. Dementia is also one of the conditions that the voting public – the median voter age was 49 in 2010 – is most worried about. In February 2015, the Prime Minister announced that private, public and philanthropic sectors were uniting to establish a multi-million pound fund to discover new drugs and treatment that could slow down the onset of dementia or deliver a cure by 2025.
The election comes at a critical time for health and care services and, regardless of which party or parties form a government, there is hope that this will mark an acceleration in the changes required to better deliver support and services for the conditions demanding the most urgent attention.
Research here, sell elsewhere?
One area that is unlikely to feature highly in any of the election manifestos is the future of the Office for Life Sciences (OLS) or the progress of the Innovative Medicines and Medical Technology Review.
The launch of the OLS by Lord Drayson under the previous Labour Government was widely welcomed by the industry. Pharmaceutical companies in particular had been bruised by the out of time renegotiation of the PPRS and the dark noises about the industry taking its R&D elsewhere seemed more convincing than the usual ‘cries of wolf’ from industry at negotiation time.
There is also no doubt that the creation of the OLS resulted in material policy developments that benefited the sector, or some players within it.
The patent box underpinned the Government’s commitment to keeping and continuing to attract high level R&D into the UK, and progress was made in speeding up the process of gaining approvals for and recruiting patients to clinical trials.
The baton was picked up by the current Government, most notably with the launch of the 2011 Strategy for UK Life Sciences by David Cameron and David Willetts. Macro-economic policy will have also helped underpin the attraction of the UK for British companies operating in the sector, with significant reductions in corporation tax across the period.
Despite all this, the challenge remains as how to best convince companies undertaking R&D in the UK that they will ever see their innovations deployed in the NHS.
Repeated piecemeal interventions seem unable to address the underlying problems.
The Cancer Drugs Fund, forged in the heat of the 2010 campaign, was envisaged – by Government at least – as a short term measure that would provide innovative medicines to patients until a new system of Value Based Pricing could be developed to fix the entire process.
Coming out of the Life Sciences Strategy, processes such as Innovation, Health and Wealth, were born, but rapidly came to be seen by industry as little more than talking shops, the circumlocution offices of the life sciences world, where the same discussions are had for years on end, with little discernible progress being made.
The latest great hope is the Innovative Medicines and Medical Technology Review. That it had to be convened at all is a measure of the failure to make progress in the time since the OLS was first established.
The frustrations of companies operating across the space remain and a fundamental dichotomy sits at the heart of the Government’s strategy towards the sector.
On the one hand, as the approach to Pfizer’s attempted acquisition of AstraZeneca showed, they prize the highly paid, high skilled R&D jobs that the life sciences sector can bring to the UK. On the other, the UK health service remains less likely to embrace and pay for the resulting innovations than those in other comparable countries.
At the end of the next Parliament, the OLS and its successor bodies will have been around for more than a decade. At some point, this is a circle that they and their political leaders will need to square.