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Cowper’s Cut 327: Health and care manifestos reviewed; ConfedExpo - don’t mention money or politics!

Cowper’s Cut 327: Health and care manifestos reviewed; ConfedExpo - don’t mention money or politics!

Sorry for the late arrival of this issue of ‘Cut’: this was due to circumstances. Buckle in: here we go.

Should we take the 2024 General Election manifestos on health and care seriously, or literally?

In 2016, US political journalist Salena Zito wrote of then-candidate Donald Trump that “the media take him literally but not seriously; his supporters take him seriously but not literally”.  It’s great both as an observation and a line, and offers a neat frame to review the health and care content of the most influential Westminster political parties’ manifestos for the 2024 General Election.

Liberal Democrats
With media stunt after media stunt, Lib Dem leader Ed Davey appears to be having more fun than the other 649 prospective Parliamentary candidates put together. 

Their manifesto title, ‘For A Fair Deal’, hints at the Lib Dems’ likely best-case scenario role: returning as a top three Westminster party, and influencing the national debate while a losing Conservative Party tears itself to pieces with a vicious postmortem-cum-leadership fight.

Their care offer is significant: unsurprising, given Davey’s high-profile role as his son’s carer. They pledge to introduce free personal care based on the model introduced in Scotland in 2002, whereby provision is based on need, not ability to pay.

The aim to “establish a cross-party commission to forge a long-term agreement on sustainable funding for social care” is discouraging: cross-party commissions, like Royal Commissions, are usually ‘kick it into the long grass’ exercises in pretending that difficult choices on funding can be avoided. They cannot.

The Lib Dem vision pledges to:

• Create a social care workforce plan, establish a Royal College of Care Workers to improve recognition and career progression, and introduce a higher Carer’s Minimum Wage.

• Establish a cross-party commission to forge a long-term agreement on sustainable funding for social care.

• Give unpaid carers a fair deal so they get the support they so desperately need, including paid carer’s leave and a statutory guarantee of regular respite breaks.

• Develop a digital strategy to enable care users to live tech-enabled lives.

Commitments on health and social care in England alone would cost £8 billion, with Barnett Formula consequential for higher funding for Scotland, Wales and Northern Ireland. They plan to raise extra revenue by closing a Capital Gains Tax loophole and making the richest 0.1% pay more (£5 billion), with a further £4.25 billion acquired by increasing levies on banks. A new aviation tax penalising frequent fliers would try to raise £3.6 billion, alongside a super-tax on private jet flights, which might bring in £380 million. Their pledge to crack down on tax avoidance claims that investing £1 billion in HMRC will allow them to raise £7.2 billion.

Their headline health pledges are to:

• Give everyone the right to see a GP within seven days, or within 24 hours if they urgently need to, with 8,000 more GPs to deliver on it.

• Guarantee access to an NHS dentist for everyone needing urgent and emergency care, ending DIY dentistry and ‘dental deserts’.

• Improve early access to mental health services by establishing mental health hubs for young people in every community and introducing regular mental health check-ups at key points in people’s lives when they are most vulnerable to mental ill-health.

• Boost cancer survival rates and introduce a guarantee for 100% of patients to start treatment for cancer within 62 days from urgent referral.

• Help people to spend five more years of their life in good health by investing in public health.

Their offer is the most generous of the three main parties, but with scant detail how they’d deliver their pledges. They even risk a Brexit reference in “faster access to new and novel medicines and medical devices by seeking a comprehensive mutual recognition agreement with the European Medicines Agency”.

The realism of their plans on the woeful state of NHS estates is good: to “implement a ten-year plan to invest in hospitals and the primary care estate to end the scandal of crumbling roofs, dangerous concrete and life-expired buildings”. There is no clarity how they’d deal with the more than half of the current £12 billion NHS capital and maintenance backlog posing safety risks to patients and staff.

But we must mark the Liberal Democrats in context. Their 2010 choice to enter the Coalition with David Cameron’s austerity-era Conservatives ended in the near-extinction event of their 49 Commons seat losses in 2015, moving them into fourth place in the House of Commons behind the Scottish National Party.

2024 sees the Lib Dems set to be recipients of tactical anti-Conservative votes. Pollsters forecast renaissance in their traditional heartlands of the south-west, and breakthroughs in ‘Blue Wall’ long-Conservative seats in London’s wealthy commuter belt, such as Esher And Walton.

The Lib Dems will not form the next Government, but they may offer constructive critique on Labour’s health and care agenda. They deserve a 4/10 in being taken literally, but a 7/10 in being taken seriously.

14 years of Conservative incumbency have left England’s health and social care systems in dreadful shape. The party in government’s record deserves scrutiny before assessing their manifesto.

Reviewing their tenure for positives, there are one or two. The Life Sciences Vision  had some sensible ideas and an economic approach. Some of health secretary Jeremy Hunt’s work on patient safety post-Mid Staffs Public Inquiry had benefits in outing understaffing.

Their eventual decision to agree a long-term workforce plan (for which Mr Hunt agitated as chair of the Commons health select committee) is also welcome. However, the financial plans behind it are unconvincing.

Other mid-lights are equally caveated: the 2012 Lansley reforms’ one semi-enduring positive legacy, the independence of NHS Commissioning Board/NHS England, was practically unwound by the 2022 Health And Care Act and ex-health secretary Steve Barclay’s determined domineering. The acclaimed Covid19 Vaccination Programme owed most of its success to Dame Kate Bingham’s Vaccines Taskforce; the independent-era Simon Stevens NHS England; and the successful involvement of the army and volunteers.

Set against this, the failures are legion. The incoherent Lansley reforms which became 2012’s Health And Social Care Act wasted huge political capital; took two years to pass; and then never in reality actually happened. Sure, they ‘reduced bureaucracy’ by replacing 150 local commissioning organisations with 219 local commissioning organisations, and creating the world’s biggest quango in England’s NHS Commissioning Board.

But in their stated aim to make choice, competition and clinical commissioning the new NHS operating system, the Lansley reforms were an utter failure. Their subtle subversion by NHS England boss Simon Stevens (hired by then-PM David Cameron to fix the NHS mess) in 2014’s Five-Year Forward View will be taught in politics classes for years.

The Conservatives squandered a golden legacy. In 2010, the NHS was by every objective measure performing very well . Waiting times were low; public satisfaction was at its highest since consistent measurement began in 1973; national targets were consistently being met.

The 2010-19 decade saw the lowest funding growth per capita in the NHS’s history. Austerity policies throughout the 2010s removed more than 40% of the central government grant to local authorities, with devastating consequences for social care and public health. Social care is important in and of itself: its unavailability also worsened problems in discharging medically well patients from hospitals.

Service access backlogs are huge. The measured waiting list, already 4.4 million before the pandemic hit, is now 7.6 million - and the latest monthly data release shows it still rising, by 34,000.

Many people still have difficulty accessing GP appointments, despite primary care having hugely expanded the number of appointments with no significant increase in resources. Deteriorating waiting times in A&E have been shown to be associated with higher mortality rates.

Access to and waiting times for mental health services are not consistently measured, but demand has risen inexorably. Ambulance service performance, while recently improving slightly, has been dreadful - particularly in 2022. Factors driving poor staff retention rates are under-researched: experiences of front-line working during the Covid19 pandemic undoubtedly play a part.

The Conservatives’ campaign is a headlong attempt to run from their record on health and care, rather than to run on it. While their manifesto ‘Secure Britain’s Future’ self-identifies as a “clear plan”, it’s telling that the health and care section occupies just three of the document’s 80 pages.

It offers to “increase NHS spending above inflation every year, recruiting 92,000 more nurses and 28,000 more doctors, driving up productivity in the NHS and moving care closer to people’s homes through Pharmacy First, new and modernised GP surgeries and more Community Diagnostic Centres”.

It claims that “dealing with a once-in-a-generation pandemic put a strain on our health and social care system and it has taken time to recover”. Covid-19’s impact was non-negligible, but the pre-pandemic backlog was already 4.4 million and national targets had not consistently been hit since 2013.

The plan to “return performance to the levels set out in the NHS Constitution by the end of the next Parliament” features no explanation how it will be achieved. This is policymaking of the ‘and then, a miracle happens!’ school.

Nor is there clarity on social care, bar being “committed to supporting a high-quality and sustainable social care system, building on our additional investment of up to £8.6 billion over the last two years”. The imprecise number here relies on local government putting up Council Tax. They also laud their Dental Recovery Plan, widely regarded as a costly failure.

Surreal, unlikely, curious: the voters’ choice on health
Andy Cowper examines the Conservative, Labour, and Liberal Democrat manifestos for the 2019 general election The Tory manifesto has an air of the surreal, and it’s hard to know where to even start with such a blatant cocktail of the misleading and the untrue: it promises “40 new hospitals, while delivering 50 000 more nurses and 6000 more doctors.”1 These pledges imply that there is a magical warehouse of doctors, nurses, and GP appointments. The reality is that the NHS has a longstanding workforce crisis,2 and solving it will be expensive, take years, and probably require significant immigration. It is clear that just six hospitals have actually been promised money for significant redevelopment by 2025, with another 38 pledged “seed funding” sums of money to plan for redevelopment.3 Yet Boris Johnson has repeated his claim of “40 new hospitals,”45 though the party’s costings document gets the numbers correct, referring only to “20 hospital upgrades” rather than new hospitals.6 The costings document also makes a pledge to “reduce the incidence of ‘health tourism.’” The notion of the NHS suffering from too much health tourism is one of the classic health policy zombies: …

Restating their plans for 40 New (If Fictional) Hospitals, whose implausibility I reviewed in their 2019 manifesto, they offer to “build or modernise 250 GP surgeries, focused on areas of new housing growth, and build 50 more Community Diagnostic Centres, including in underserved areas, resulting in an additional 2.5 million checks a year”. These are funded by their pledge to “cut waste and bureaucracy in the NHS, reducing the number of managers by 5,500, releasing £550 million for frontline services and simplifying and streamlining oversight and accountability”. Yet the NHS is under-managed by international standards with the Lansley reforms having cut management by 45% based on the 2008-9 level.

This pledge to increase community capacity is an encore of the heroic over-claiming and under-delivery of the New (If Fictional) Hospitals Programme, highlighted by the Commons Public Accounts Committee and the National Audit Office.

The Conservatives face at best a dreadful defeat, and at worst an extinction-level reduction to a rump of MPs.

It’s unsurprising that the health and care section of their manifesto has such a ‘will this do?’ vibe, but it scores at best a 3/10 for being taken literally and deserves a 0/10 for being taken seriously.

Labour’s disciplined messaging and strategy on their planned spending restraint hangs over their campaign like a cloud. It shapes their manifesto commitments on health and care, limiting promises.

This might be inevitable: disappointing UK economic growth since 2008’s global financial crisis, exacerbated by subsequent costs of Brexit, the Covid19 pandemic and the Ukraine war energy crisis and broader inflation spiking the cost of living makes for a grim fiscal inheritance. New Labour enjoyed the ability to spend their inheritance of strong economic growth in the late 1990s.

Labour’s ‘Change’ manifesto’s headline promise on their health ‘mission’ is to “get a grip on the record waiting list. We will return to meeting NHS performance standards. That means patients should expect to wait no longer than 18 weeks from referral for consultant-led treatment of non-urgent health conditions”. It notably lacks a date by which this will happen, although shadow health secretary Wes Streeting has repeatedly said that he wants this done by the end of their first term.

Private hospitals boss says they’re not the answer to NHS crisis
Justin Ash, chief executive of Spire Healthcare, said private hospitals were already busy and couldn’t be expected to help cut waiting lists overnight

It aims for 40,000 more appointments a week (allegedly funded by a tax crackdown and new non-dom measures), delivered by incentivising existing NHS staff to work extra sessions at evenings and weekends. It pledges to use spare private sector capacity, of which there is little.

The practicality of their idea to “pool resources across neighbouring hospitals to introduce shared waiting lists to allow patients to be treated quicker” is yet to be proven at scale.

It describes “a new ‘Fit For the Future’ fund to double the number of CT and MRI scanners, allowing the NHS to catch cancer and other conditions earlier, saving lives. It is also clear that NHS estates are in a state of disrepair after years of neglect. Labour is therefore committed to delivering the New Hospitals Programme”.

Mmmm. If not mmmmmmmmmmmmm.

Committing to the N(IF)HP is very much not the same as addressing the £12 billion capital and maintenance backlog: the poor state of the estate is a major part of current NHS capacity problems.

Another pledge offers power to patients: their plan is to “transform the NHS app, putting patients in control of their own health to better manage their medicine, appointments, and health needs. This will include giving performance information on local services, and notifications of vaccinations and health checks. Patients will be able to see the medical guidelines for the treatment they should get, to hold health services to account and understand what their choices are”. This sounds sweet: the track record of patient choice’s real impact is underwhelming.

Warm words on patient safety and modernising the NHS to become a Neighbourhood Health Service follow. There is a mention of shifting resources to primary and community care, but there are no numbers, or timelines. It sounds as if polyclinics (Darzi centres) will make a policy comeback.

There’s an interesting aim to “take the pressure off GP surgeries, by improving access to services and treatment through new routes. We will create a Community Pharmacist Prescribing Service, granting more pharmacists independent prescribing rights where clinically appropriate. We will allow other professionals, such as opticians, to make direct referrals to specialist services or tests, as well as expanding self-referral routes where appropriate”.

There are commitments on dental contract reform, mental health, and on social care: it is not clear in the manifesto, but Labour has since pledged to match the Conservative plan to introduce the £86,000 lifetime personal care cap by 2025. A fuzzy pledge aims to “build consensus for the longer-term reform needed to create a sustainable National Care Service”: Long Grass Alert duly triggered.

Labour’s health manifesto ends with a long endorsing quote from ex-University Hospitals Birmingham chief executive Dame Julie Moore: “I’ve worked in the NHS for a long time and I remember how Labour, the party who created the NHS, transformed it to be the best-performing health system in the world. It is heartbreaking to see its decline over the last 14 years. It will be difficult but I believe that, under Keir Starmer, Labour’s plans, short and long term, will once again restore the NHS to deliver top-class health care for the people of this nation, reducing waiting lists and times and transforming it to be fit for the future”.

We must hope that her optimism is well-founded. Labour’s detail-light approach deserves 5/10 for being taken literally; but given the certainty that they form the next Government, it gets an 8/10 for being taken seriously.

A major electoral threat to the Conservatives is the return of Nigel Farage, owner of the new ‘Reform’ company. Mr Farage already politically remade the Conservative And Unionist Party once from outside it, in the Brexiteer image of his UK Independence Party. Now he wants his Reform company/party to replace it.

Why most people regret Brexit
A majority of British voters now believe the split was a mistake

It’s fascinating how Mr Farage’s communications skills and ‘bloke of the people’ populist image blind his fans to the manifest unpopularity of his lifetime big idea: Brexit , which is now a matter of clear Bregret.

But Reform’s surge of support in repeated opinion polls demand that we consider their ‘contract’.

Here goes!

The cover alone is a joy, with a picture of Mr Farage looking as if he has just pickpocketed someone’s smartphone. From this visual highpoint, ‘Our Contract With You’ just keeps delivering.

Brexiteer-General Mr Farage has decided that when it comes to health systems, they do things better in Europe. No, I didn’t see that one coming either.

He told the BBC election debate that the UK’s single-payer model for the NHS was to blame, suggesting that “the model through which we fund health is wrong” and that a French-style social insurance funding model would be better.

The document’s NHS section is bracingly reminiscent of Viz comic’s ‘Top Tips’. “Front-line” NHS doctors and nurses will get three years’ basic rate tax exemption, to solve the workforce crisis. While doctors and nurses may like this, it won’t generate more of them (and would cost the Treasury significant lost revenue).

More tax revenue will be foregone via “tax relief of 20% on all private healthcare and insurance. This will improve care for all by relieving pressure on the NHS. Those who rely on the NHS will enjoy faster, better care. Independent healthcare capacity will grow rapidly, providing competition and reducing costs”: a fantasy from the wilder shores of the right-wing thinktanks of Tufton Street.

A Reform government “will harness independent and not-for-profit health provision in the UK and overseas”: this already happens in the English NHS with domestic provision. Save for very simple elective operations, there are obvious reasons why overseas providers are not used.

Reform pledges a voucher system: “NHS patients will receive a voucher for private treatment if they can’t see a GP within 3 days. For a consultant it would be 3 weeks. For an operation, 9 weeks.” Even if the private sector capacity to use these vouchers existed in the real world, its cost would be astronomical - and its reward for the privately insured would be immense.

The reality level gets no more granular, with pledges that “operating theatres must be open on weekends … Nail down better prices using economies of scale. Review all NHS Private Finance Contracts for significant savings potential”. Reform means saying the private sector’s better, except when it’s not, evidently.

There is one non-stupid suggestion here: that “rotas must be planned further in advance”. Ah well: even a broken clock is right twice a day.

Most remarkable is the plan to “cut waiting times with a campaign of ‘Pharmacy First, GP Second, A&E Last’. We will offer tax incentives for new pharmacies and those who employ more staff to assist in relieving pressure on A&E”: a heady mix of faith in public awareness campaigns and tax breaks incentivising imaginary clinical staff to work in theoretical buildings.

The proposed cost of this is put at £17 billion a year: a figure with zero credibility. The section on pensions and social care is completely uncosted. Clearly, Reform means never having to say you’re numerate.

This back-of-a-fag-packet ‘contact’ deserves 0/10 for being taken either literally or seriously. But it is by far the funniest of the manifestos.

ConfedExpo 2024: no discussing money or politics

I had no intention of going to ConfedExpo 2024 until a client asked me to attend. Its programme contained the bizarre omissions of any sessions on the main managerial issue of 2024, regaining control of NHS finances; nor any on the equally pertinent issue of national politics and the general election campaign.

The omission of any finance content is only explicable if NHS England had a compete veto over the programme, in which case the event should rebrand as NHS England Expo. Looking at the delegate list, that is to a great extent what it now is. A big NHSE awayday: a bouncy castle of hot air.

On the absence of the main parties’ politicians (who had all agreed to attend), the excuse of purdah does not apply: the event simply needs to give equal prominence to all the speakers. This could have been done by giving them all equal speaking time in a main stage session with a briskly-moderated Q&A. The politicians had also agreed to this kind of format.

So what scuppered a politics session?

Rishi Sunak puts Jamie Dimon and Eric Schmidt forward for UK honours
JPMorgan boss would ‘be a strong candidate for knighthood’, says Conservative minister

The sponsors did, I’m told. The event’s main sponsors were Google Health and Novartis. It is perhaps worth noting this reliable report that Rishi Sunak put forward former Google chair Eric Schmidt for UK honours.

It was sweet to see Confed CE Matthew Taylor telling Health Service Journal that a new government must not ignore ICSs and deal only with hospitals.

Labour warned against ‘disruptive’ move to ‘bypass ICSs’
The NHS Confederation chief executive has warned Labour against “bypassing” integrated care systems in pursuit of elective care targets, if the party forms the next government.

This is of course precisely what Labour are going to do, but the Confed wants to try to keep all its networks happy, as well as keeping NHS England even happier: a sure recipe for extreme, ineffectual blandness.

Speaking of NHS England, the conference was rife with talk of when NHSE chair Richard Meddings and chief executive Amanda Pritchard will be put out of their leadership misery.

Multiple sources confirmed that the Labour leadership has already talked to former health secretary Alan Milburn about taking the chair role, and he has not said ‘no’.

Equally, Mr Milburn has not said ‘yes’ until he has clarity on who is in contention to replace Mrs Pritchard as NHSE CE. Jim Mackey’s name is again being mentioned, but I find this highly implausible: he clearly doesn’t want to do the job, and could have had it for the asking at any time since late autumn 2022.

There is no clarity on the defenestration timeline, either. There is a school of thought that would favour swift action once in office, but another whose view is to leave both in place to carry the can for what is nailed-on to be another atrocious winter crisis, and then act.

The latter approach would be by far the better plan, allowing Labour time to actually make some workable plans for how it will deliver reforms and non-legislatively tweak the current system to enable the regaining of financial and operational control.

The speeches were … yeah, they were much.

Lord Adebowale’s was a compendium of the implicit: the unsaid things that were notable by their absences.

Matthew Taylor’s extolled “a distinctive model of progress. One which better balances top-down, lateral, peer-to-peer and bottom-up drivers of change. This has meant being willing to challenge ministers and NHS England when we feel that short-termism and micro-management are stifling improvement and collaboration”. Well, yes, but NHS Confed never actually does challenge ministers and NHSE, obviously, because they pay its bills.

The Tao of Amanda Pritchard

Many people commented on the improvement in Amanda Pritchard’s delivery of her speech (“rousing” - M Taylor), which presumably prevented them from having to notice how deeply delusional its content was.

“Missions motivate, especially when they’re as crucial as ours. But they can also weigh heavy, especially when we feel we aren’t achieving them. And it would be easy to feel that.” One must have a heart of stone not to laugh.

It got better: Mrs Pritchard warned of the importance that “we don’t collude with defeatism. Yes, the post-COVID NHS is damaged but it is not destroyed.”

“Not destroyed” = WINNING! Strong NHS managers fainted at the sheer implausibility, and had to be helped to safety by weaker colleagues.

What, then, is her vision? Whither Pritchardism?

“Far, far more to do, on everything.

But going in the right direction.”

It’s almost a haiku. Running a major public service as performance art.

“the NHS will need to grow.

But we can’t afford for the NHS just to grow.

We’ll need to re-imagine, to do things differently.

And we’ll start with primary care.”

The Tao of Amanda Pritchard. And lucky old people working in primary care: given NHSE’s fantastic track record of re-imagination, they must be feeling super-confident and stoked with motivation.

With the perennial pedigree political antennnae of a struck match, Mrs Pritchard picked out the hot topic of physician and anaesthetist “associates – a small part of the plan, but an important one.

“So we must work with clinicians, with royal colleges, the GMC, to ensure their roles are clearly understood, that they are well deployed, well supervised, well regulated and crucially, well supported as colleagues.”


It is impressive that the penny is yet to drop at senior levels that the wider introduction of the associate roles has struggled to rise to the level of the terrifyingly inept and unregulated. This is already going to cost the President of the RCP her job for being associated with the attempted gerrymandering.

If anyone associated with this agenda thinks the associate concept is actually worth saving, then they are going to have to call a halt to it now, for a major and sector-wide rethink and redesign.

At present, the expansion of associate roles is heading for outright failure and rejection.

Labour on pensions and strikes 

Labour abandons plans to bring back lifetime cap on tax-free pensions savings
U-turn will be welcomed by wealthier savers including hospital consultants

This week saw Labour pains, with a sensible U-turn on their quarter-baked plans to return to a low-ish lifetime cap on tax-free pensions savings, as reported by the Financial Times. Had they pushed the future sensibly north to something unachievable to all but the private equity crowd (£3 million?), this would never have been a problem.

Call off strike and let’s do a deal – Wes Streeting tells junior doctors
WES Streeting is calling on junior doctors to cancel their strike – promising a Labour Government will end the dispute. The man who could be Health Secretary in three weeks’ is asking medics to “do…

Labour has also been vainly trying to persuade the junior doctors’ leaders to call off the strike planned for just before the GE2024 vote, with Streeting writing this for The Sun.

Internal support for the action among junior doctors remains very high.

The JDC leaders’ statement seeks “more detail about what this proposal really means and how Mr Streeting intends to work towards fully restoring pay for junior doctors”.

As I wrote a couple of weeks ago, the junior doctors’ apparent strategy remains one of trying to bluff an offer of a deal out of PM Rishi ‘The Brand’ Sunak to scope what their committee could accept - and Tory polling is stubbornly refusing to improve at all.

Rob Findlay’s analysis for HSJ of the latest month’s data showing a 37,000 increase to RTT waiting list and the rise in longer waiters.

The Guardian reports another development in the PPE Medpro saga starring Everybody’s New Favourite Noble Baroness, liar and Tory peer Michelle Mone.