Throughout my decades of working with the NHS, the system has remained change-suspicious and predominantly reluctant. But what happens when no change is the risk? As we enter a new political era, after years of Conservative-led austerity, what might a hung parliament mean in change terms? It would be easy to think that this could curb the Conservative’s ability to impose further cuts, and thus feel relieved. However, in the absence of more available funding in the Treasury coffers, I am more concerned about the potential for impotence across all parties when it comes to agreeing a new way forward, risking leaving us with the existing way forward that we all know is both failing and putting lives at risk, not to mention careers.
The NHS Division
Whereas Brexit was undoubtedly divisive at a national level, the NHS is probably more so at a cross-party level. Labour, with a much stronger degree of support, are vehemently opposed to further NHS austerity, the continuation of many principles of the Health & Social Care Act 2012 and many of the more recent changes to funding models or reform… but they lack the strength to impose change. They do, however, coupled to sympathetic partners, hold far more ability to resist it.
Both Scotland and Wales believe in a healthcare system different to the direction of travel to England. The Liberal Democrats have long campaigned, under Norman Lamb, for a cessation of austerity and additional emergency funding. None of these parties have the ability to introduce an alternative to the current plan. Collectively with Labour, they represent a formidable force of resistance to more of the same.
So, if not more of the same, then what?
Herein lies the problem. The Conservatives are forming a weakened Government, on an already significant degree of criticism for their healthcare policy. The pre-election leak of a tender discussion to invite significant US Accountable Care Organisations into the UK to assume capitated responsibility for billions of care funding appears to be the desired direction of travel. That appears to sit at odds with just about everybody else’s view. Just how do they progress that in the absence of a big enough majority?
The answer is predominantly that you can’t. You are stuck. The more radical your plans, the greater the majority support needed to carry them through. The more bland and benign your plans, the lesser their likelihood of solving deep-seated NHS problems to the degree necessary.
The Conservatives are also caught between a rock and a hard place over funding. Labour wanted to increase funding through additional taxation of what is probably best described as the upper middle & upper classes in income terms. A large part of this group has been traditionally Conservative. With a shaky hold on power, it is highly unlikely that the Conservatives will want to attack their supporters but without that additional taxation income, or the ability to move the care responsibility to ACOs, and with a commitment not to increase borrowing significantly, they are left with the sole funding option of repatriating funding from other sources, such as the Social Protection budget, or Education.
This is not going to happen. Social Protection and Education, the only budgets big enough to provide any meaningful funding to the NHS, happen also to be the favoured pots of spending for Labour, with its enhanced ability to resist raids on them. The Conservatives have already been heavily criticised for their austerity in policing and counter-terrorism and matters such as these will also need to be addressed if their thin, non-majority support is to remain.
At the risk of sounding depressing, we are faced with a somewhat depressing reality:
- Commitments not to borrow substantial sums
- Likelihood of prolonged economic uncertainty over Brexit negotiations (based on calls already to slow down the process)
- Almost no ability to repatriate funds from other budgets of any meaningful size
- Reduced ability to bring in money from outside sources that could be construed as either privatisation or what I’ll term ‘foreignisation’ of our health system
- Major political risks to the party not quite in power if they increase taxation
That picture pretty much guarantees no meaningful additional funding and yet, at the same time, the real likelihood that any alternative plans will take years to progress through protracted political debate, with no party having the political strength to impose their will.
The Typical Outcome of Disagreement
These early thoughts, to be tested by reality, are in complete alignment with the typical outcome of an approximately even disagreement – stalemate or stagnation. This is the true risk we now face.
The NHS itself will demonstrate (is already demonstrating) that a change of plan is vital to avoid a clinical and staffing catastrophe. I would argue that this is already patently obvious but there will come a point where even Jeremy Hunt (assuming he survives as SoS) has to admit that the plan as it stands is not working. However, agreeing the need to change is not the same as agreeing what change is needed. This is hugely problematic when you have such powerful and evenly distributed opposing views.
No Party holds a mandate. The loss of a majority quite potentially means that the only significant change the Conservatives could lead is one that is acceptable to both their own party members and the majority of other parties. It will not be lost on the other parties that opposing Conservative healthcare policy is a sure-fire way to have the Conservatives seen as failing the NHS and push towards another election. Whereas you might think they could be accused of holding the NHS to ransom for political gain, that would unlikely hold true if their opposition to the changes proposed was seen by the population as protection of the very NHS principles and rights of the under-dog that has given them their more powerful position. In effect, they could be seen as holding the Conservatives to account in doing the ‘right’ thing (in the populations eyes), which just happens to be the ‘wrong’ thing, apparently, in Conservative eyes.
This article has no politically leaning. It in no way suggests what is or isn’t the right thing or wrong thing to do for the NHS. The point that I believe we should all be reflecting on is that we face stagnation because no party has a strong enough mandate to carry significant change when the ideological views are so polar opposite and there isn’t a majority to rely on. If the NHS was even remotely currently stable, that stagnation could be seen as a welcome rest. But our NHS is not stable. It is quantum leap away from stable. It is teetering on the edge of a catastrophe and it has been waiting to see which way the wind blows.
The Conservatives have plans. They are wildly controversial. They were banking on a blue wind, of near-galeforce strength. They have ended up with a light breeze, maybe sufficient to ruffle a few feathers.
With this new-found reality, I would suggest that our NHS reality is an immediate future much the same as a drought-ridden nation of little internal resource, faced with a squabbling bunch of aid agencies that say “we’ll get back to you in 5 years’ time when we have finished squabbling over a right thing to do that we can finally agree on”. In the meantime…