News analysis: spend, spend, spend

While the general election has been billed as the Brexit election, in the first few weeks of campaigning there was a strong case for renaming it the NHS election. As the parties rowed about funding, privatisation and US influence post-Brexit, the public elevated the health service to the number one concern affecting voting intentions.

This is not unusual – the NHS is usually in the top two or three public priorities with or without an election. The parties’ health policies are for England only, with health and care devolved to national executives. When the public says it is concerned about the NHS, it usually means it wants the service to be given more funding. Whoever wins, more money will be available, with the traditional top three parties in England setting out spending increases after years of relative austerity for the NHS.

The Conservative government had already outlined its NHS England revenue spending plans up to 2023/24. This amounts to £20.5bn in real terms. To support his health spending credentials, Tory leader Boris Johnson told the CBI he would postpone a planned reduction in corporation tax to pay for increased funding to the NHS and other public services.

With the NHS needing to replace and upgrade buildings, and backlog maintenance rising to £6.5bn, Mr Johnson also promised higher capital funding. Under the Health Infrastructure Plan (HIP), £2.7bn has been allocated to six trusts in the first phase, covering the next five years.

However, the Conservatives’ claim – reiterated in its election manifesto – that its funding would lead to 40 new hospitals over the next decade has come under fire. While six trust projects have been given £2.7bn funding, a further 21 have only been given seed funding to develop schemes. Critics claimed the funding is far from guaranteed and the cost unknown; the Tories said it was agreed by the Treasury.

Jeremy Corbyn’s Labour Party has promised the biggest funding boost – £26bn by 2023/24. In addition, funding would be provided for free annual dental check-ups, and the abolition of prescription and NHS car parking charges.

While removing parking fees would cost around £270m a year, Labour said free prescriptions could increase drugs costs by 5% – after adjusting for an increase in uptake. Earlier this year, Labour said removing prescription charges would cost £754m a year.

By 2023/24, annual capital spending under a Labour government would rise to £10bn a year. The party said the capital funding would be used to rebuild hospitals and community facilities, and clear the maintenance backlog. The overall amount would include capital funding for mental health, together with a £2.5bn fund to overhaul the primary care estate. And £1.5bn would be earmarked for an increase in CT and MRI scanners to the OECD average.

Liberal Democrats leader Jo Swinson said that, if elected, she would increase NHS and social care funding by £35bn over the next five years – £7bn a year paid for by increasing income tax by 1%. The party also promised a £10bn a year capital fund.

Workforce is a significant concern, regularly highlighted by finance directors as one of the biggest risks to the delivery of local services. There are currently 100,000 vacancies, including 40,000 vacant nursing posts. The Lib Dems said it would tackle staff shortages within five years by retaining freedom of movement for European Union citizens, reinstating nursing bursaries and creating a national workforce strategy that matches training places to future needs.

Labour also promised to reinstate nurse bursaries, while its manifesto pledge to increase NHS pay by 5% in its first year of government – followed by above-inflation awards in the following years – pleased health unions.

Labour pledged to recruit a further 24,000 nurses and expand GP training places to 5,000 to create 27 million more appointments with family doctors. The Conservatives promised to recruit 50,000 nurses and 6,000 GPs to create 50 million more appointments at GP surgeries.

But while Labour spoke about GP appointments, the Conservative plans indicate an increase in appointments across all staff in primary care. And the Tory nurse recruitment plans are said to include training 19,000 extra nurses (5,000 via apprenticeships) and retaining 18,500 who might otherwise have left the service.

Leaving aside the fact that around 12,500 would probably have to be found from overseas, there are question marks over how many nurses can be trained – nurse numbers have increased by only around 5,000 since 2010.

Labour said restoring bursaries would likely cost less than £600m a year by 2023/24, while training an additional 1,500 GPs would cost an estimated £273m.

The Conservatives removed nursing bursaries in 2017 believing universities would meet demand by creating more places. The bursaries were worth up to almost £10,000 a year, but there was a ceiling on places. According to the Royal College of Nursing, removal of the funding led to fewer applicants – in February this year, it said there had been a 30% drop in applications (more than 13,000) since 2016.

Now, the Tories say they would introduce a student nurse maintenance grant of between £5,000 and £8,000 a year. However, tuition fees would remain. The party said its plans on nursing recruitment, training and retention would cost £759m in 2020/21, rising to £879m in 2023/24. Increasing appointments in primary care would cost £399m next year, rising to £695m in 2023/24.

Mental healthcare remains a priority for all three main parties. The Liberal Democrats said they would introduce a range of mental health measures, including new maximum waiting times and giving patients with chronic mental health conditions free prescriptions.

Labour said mental health funding would increase by £1.6bn a year if it is elected – the funding would be drawn from the increase in the NHS England budget. A £2bn mental health infrastructure fund would abolish dormitory wards and invest in more beds to end out-of-area placements and a new fleet of crisis ambulances.

The Conservatives’ plans for a limited abolition of car parking charges would produce a revenue cost of £93m, rising to £99m. Some £257m in capital funding would also be allocated to extend NHS car parks to meet the expected increase in demand.

There were pledges on other non-NHS spending. Labour plans to deliver a £1bn increase in the annual public health budget. Funding would also be available for the public health nurse workforce, delivering an extra 4,800 health visitors and school nurses.

King’s Fund chief executive Richard Murray welcomed Labour’s funding pledges. But he added: ‘The success of any NHS funding policy will rest on the ability to recruit and retain enough workers to staff NHS services. Labour’s pledge to reinstate a training bursary for nurses is welcome, although it will be critical to focus on retaining existing NHS staff over the next few years, at a time when many are leaving the service due to the intensity of their workload.’

Potentially hinting at structural reform of the NHS, Labour said it would scrap the Health and Social Care Act 2012, introducing a joined-up model of community care, with greater funding allocated to close-to-home services, and the internal market abolished.

The Labour manifesto said outsourced services would come back in-house, adding that its ‘urgent priority is to end NHS privatisation’.

On social care, the Conservatives promised an extra £1bn a year in April 2020, while seeking a cross-party consensus on long-term reform. Labour said its commitment to free personal care and relaxing eligibility rules would cost almost £11bn by 2023/24.

NHS Confederation chief executive Niall Dickson welcomed the Conservative commitments on recruitment and retention. But he said the Tories and other parties had ducked the need for a long-term settlement for social care for too long. ‘We have some serious commitments, with the Lib Dems and the Conservatives promising they will work to deliver cross-party consensus and with Labour committed to free personal care,’ he said. ‘These pledges mean the next government will be committed to producing a sustainable long-term solution – and they will be held to account for that, no ifs, no buts.’

Whichever party wins the election, the NHS in England will receive more money – the devolved nations will get Barnett funding as a result. While this will be welcome, the NHS will remain worried about the future of social care and whether the same pressures will remain when the next election is called.