Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: What the party manifestos should cover on health and social care but probably won’t

BMJ 2024; 385 doi: (Published 05 June 2024) Cite this as: BMJ 2024;385:q1202
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on X @mancunianmedic

A general election is set for 4 July, and the next UK government will be key to the future of health and social care. The main political parties have set out some policy positions, but none has yet published an election manifesto. While not intended to be detailed programmes for government so much as statements of intent, to be fit for purpose these manifestos should have credible positions on some crucial health policy areas. I doubt that we’ll get this, especially given current economic constraints and the contentious issue of immigration control, but we can hope.

So, what are these essential issues? Firstly, the performance of core NHS services needs to improve considerably. As a tax funded, politically accountable, universal public service, the NHS is currently failing too many citizens too often. Ask people what matters to them, in major surveys or focus groups, and there are three key issues: access to primary care; long waits and huge waiting lists for elective care; and long waits in urgent and acute care.123 I realise that people are also concerned about quality of care, communication, continuity, and coordination when they do receive these services, but it’s mainly about access and waiting times. In the NHS we know that wider community and mental healthcare services are crucial too, if perhaps visible to fewer voters.45 But those first three are the holy trinity.

We need realism about the time required to turn things around, but we needn’t be defeatist. Recent history shows that by 2010—after a concerted programme of service improvement, targeted performance management, and investment under the last Labour government—long waits in urgent and elective care had been largely abolished, primary care access was working well, and, unsurprisingly, patient and public satisfaction were at a historic peak.67 Yet at the 1997 election NHS services had also been performing very poorly across a range of domains. The deterioration in performance since the 2010 election has not been some inevitable phenomenon, some inherent feature of the NHS model and its founding principles, but the result of poor or ducked policy, not least around funding and workforce planning.89

Training and retention

Key to all of this is the workforce. Unsurprisingly, staff satisfaction scores mirror those of the public using the services: by 2010 the NHS staff survey showed record high scores, which have recently hit record lows.10 Those same public surveys and focus groups show that people blame short staffing for many of the NHS’s problems, rather than the individual clinicians who support them when they do manage to access care.

To my mind, any credible manifesto must contain commitments on workforce training, recruitment, and retention to provide more homegrown workers, continue ethical overseas recruitment, and do more to stem attrition and improve morale. I’ve been critical of aspects of NHS England’s workforce plan,11 as has the National Audit Office12—but since this plan took years to lobby for, develop, and deliver, a good start would be to support its principles, commit to long term funding, and agree to consult on some of the contentious or missing aspects, reviewing and updating the plan rather than starting from scratch.

There’s also the issue of long term adult social care: its funding, eligibility, and provision. The past 25 years have seen too many false dawns, broken commitments, and more recently serious cuts to local government budgets and social care provision, even as need has risen.1314 Even respected legislation such as the 2014 Care Act wasn’t backed by funding. Immigration rules have damaged the supply of social care workers in a sector already struggling to compete with others on terms and conditions. To attract or retain staff, this has to be tackled.15

Next is population and public health. Life expectancy has stalled in recent years, healthy life expectancy has declined, and health inequalities have grown.16 This isn’t just about good healthcare but about effective public policy on the wider socioeconomic determinants of non-communicable diseases and ill health: action on housing, poverty, air quality, smoking, obesity, food environments, and unequal access to healthcare.1718 We need to restore the local public health funding that’s been cut in recent years,19 but we also need cross cutting solutions across all government departments and agencies, with the principle of “health in all policies.”2021

Funding and investment

The NHS, in comparison with health systems in other industrialised nations, has underinvested in capital expenditure on buildings, facilities, equipment, and technology.22 This affects our ability to deliver good and timely care, as capital budgets are repeatedly raided for running costs. And we need some concrete commitments on ringfencing this expenditure, not just magical thinking about digitally enabled care or discredited promises of new hospitals.23

Underpinning all of this, we need commitments on NHS funding. You’ll hear Conservative spokespeople say that the NHS is receiving record levels of absolute funding. This may be true, but it’s also disingenuous. After record average annual real terms funding uplifts during the Blair-Brown government, the years from 2010 to 2019 saw the lowest real terms annual increase in NHS history.6824 If we’d kept up with the average across 14 EU nations from 2010 to 2019, when we spent around 20% less, it would have meant an additional £40bn a year in the UK’s total healthcare budget, according to a Health Foundation analysis in 2022.25

The economy is in much worse health than when Labour won in 1997, 2001, or even 2005—and NHS funding will be tighter this time, whoever wins. But we need some explicit commitments on funding and preferably a multiyear settlement to allow predictability and planning. Finally, we need the politicians to level with us about what can be realistically achieved and how quickly—and to be honest about what cannot. I’m not holding my breath.