Main manifestos: Certainty is lacking in post-election prospects

The once deafening silence on NHS funding has given way to a cacophony of commitments and contested claims as election day approaches.

‘Extra funding promised by the three biggest parties needs to be injected sooner rather than later’

This reached a crescendo recently amid the Conservatives’ promise to find an extra £8bn a year for the NHS by 2020-21 and the release of other parties’ election manifestos.

What then are we to make of the commitments made by the three main political parties?

At first glance, it is striking how much common ground there is. This includes the welcome emphasis placed on health and social care integration, mental health and improving patients’ access to care, as well as commitments to increased NHS spending.

More worrying is the limited discussion of social care, other than in the context of integration, and the shared desire to pool budgets.

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Obscuring the issue

Debate about how much funding the NHS needs by 2020-21 has obscured more pressing questions of how to deal with immediate financial pressures.

Providers are expected to report deficits of almost £1bn in 2014-15 and, according to NHS Providers chief executive Chris Hopson, these could rise to double that figure in the current financial year.

‘Politicians should be explicit about the phasing of the spending increases they have promised’

This means that the additional funding promised by the three biggest parties needs to be injected sooner rather than later to avoid the black hole in NHS finances becoming bigger.

Failure to do so would require cuts in spending locally that would likely involve reductions in the amount of money spent on staff.

This could involve reduced spending on agency workers, as well as cuts in the number of staff employed directly by the NHS.

Safety risk

The risk then is that providers will compromise patient safety and fall foul of Care Quality Commission inspectors.

To avoid this, the new government could relax the targets that providers are expected to meet in order to reduce activity and the spending associated with it. This would almost certainly mean an increase in waiting lists and waiting times, contradicting promises to improve access to care.

‘Certainty today is important to secure the future of the NHS’

With more money expected to go into mental health services and primary care to fulfil manifesto commitments, continued neglect of these services is no longer an option.

Cuts could be made to community health services, but would risk delaying the implementation of new models of care closer to home and increasing delayed discharges of care from hospitals.

In view of the declining state of NHS finances, politicians should be explicit about the phasing of the spending increases they have promised to enable the NHS to plan ahead.

Five years too late

Analysis by my colleague John Appleby, published last week, compares the commitments of the main parties and shows that extra funding for the NHS towards the end of the Parliament - welcome as it would be - might come too late to avoid damaging patient care.

Certainty today is important to secure the future of the NHS.

‘The battle lines are now being drawn but engagement is yet to commence’

In the absence of an early injection of additional funding, and with no easy options for cutting spending on NHS care after five years of austerity, the next government may have no alternative but to raise taxes to fund additional spending on health and social care.

This could be done via an increase in national insurance - as under the Blair government - perhaps by focusing on high earners and older workers, as the Barker commission recommended.

While tax rises might contradict promises made during the election campaign, they could be preferable to presiding over an NHS in which finances and performance continue to decline and a social care system slips into crisis.

Coalition complexity

The prospect of a coalition or minority government adds complexity to these speculations. As we learnt in 2010, election commitments may not be a reliable guide to future performance, to borrow the parlance of the financial services industry.

For these reasons, the future of the NHS will be shaped more by events after 7 May than before, with the battle lines now being drawn but engagement yet to commence.

In the time honoured formulation, investment must be linked to reform and improvements in productivity to ensure that every pound is used as wisely as possible. The stakes could hardly be higher.

This piece was originally published on the King’s Fund website

Chris Ham is chief executive of the King’s Fund