Manifesto destiny

What are the three main parties really saying about the NHS and funding; and do they have anything to say about IT? As the general election campaign continues, Lyn Whitfield asks what health tech should take away from the manifestos.

Turn on the TV, pick up a newspaper, flick through a social media feed, and it’s impossible to miss the general election campaign that will end on 12 December. Or to avoid noticing that while this election matters because it will decide if and how Brexit happens, the NHS is the focus of attention.

The three parties likely to win the biggest share of seats in the next Westminster Parliament have all been trading pledges over funding, staffing, ‘privatisation’ and… car parking. Of which, more later. This may suggest that healthcare and the tech companies that want to work with it face an uncertain future.

However, a trawl through the Conservative, Labour and Liberal Democrat manifestos suggests the three parties are closer on most issues than the campaign noise would suggest. It’s what they don’t say that is more interesting than what they do.

Show me the money

On traditional and social media, the three main political parties have been engaged in a bidding war over how much they will spend on the NHS. In all cases, the baseline is Theresa May’s June 2018 pledge to give the NHS an extra £20 billion a year by 2023, to mark NHS70 (BBC, 2018).

This summer, Boris Johnson and his chancellor Sajid Javid found some additional funding for the coming year, in the form of £850 million for 20 hospital building projects, £1 billion for basic maintenance, and £250 million for an NHS AI lab.

At the time, there was a row about whether this money could be counted as “additional” funding, since most of it came from trust reserves (The Guardian). However, the Conservatives have taken May’s money and this money and presented it in cumulative cash terms in their manifesto as “a record £34 billion a year, by the end of the Parliament.”

At the start of its election campaign, Labour announced a “£26 billion real-terms… rescue package” for the NHS and billed this as “over £6 billion more in real terms than the funding announced by the Tories last year.”

Channel 4’s fact checking service pointed out that the last bit is only true working from May’s promise: if Johnson and Javid’s “additional” funding is counted in, Labour is promising around £3.2 billion more.

Meanwhile, the Liberal Democrats have said they would direct some of a new capital fund to the NHS and raise £7 billion a year “in additional revenue by putting 1p on income tax”. However, this money would go on both health and social care, for which Labour is promising an additional £10.2 billion a year.

So, in practice, the three parties are making quite similar pledges, all of which come in at less than the historical increase in NHS funding of 4% a year. That’s probably enough to address some demand pressures, but not enough to shift investment or transform the health tech market.  

The NHS is not health and care  

To underline the point, none of the parties’ have set out fully-costed spending pledges that cover all aspects of health and social care.

The King’s Fund pointed out that the Conservative manifesto is silent on training, capital, public health and social care; promising just £1 billion in stop-gap funding for a sector that Boris Johnson had promised to fix “once and for all” (Guardian).

The Lib Dems have some limited proposals to tax food and drink, but also lack “a credible and comprehensive plan to address the social care crisis.”

Labour’s far more detailed manifesto contains significant proposals to address health inequalities, reduce the NHS’ carbon footprint, and create a National Care Service, with a £100,000 cap on lifetime care costs, and “free personal care” for the elderly.

However, as the Nuffield Trust points out, it doesn’t say what these would cover or how they would be paid for. Meantime, all the manifestos promise a lot of extra staff without credibly explaining where they will come from, with 100,000 vacancies and Brexit on the horizon (iNews).

Lansley’s troubled legacy

Where the manifestos get interesting is where they move away from the ‘retail offer’ to voters and start to give some indication of what the main parties are thinking on big picture issues.

Specifically, on what they would do about Andrew Lansley’s unloved Health and Care Act 2012, which aimed to pep-up the internal market by pitting clinical commissioning groups against trusts and putting contracts out to tender.

The NHS Long Term Plan, which May’s “birthday present” is supposed to be funding, effectively tore up much of the act by reintroducing a single NHSE/I with regional offices, shifting towards population-level planning and funding through integrated care services, and reinforcing the drive for integrated care delivery.

To the fury of some right-wing think-tanks, health secretary Jeremy Hunt and his successor Matt Hancock have gone along with this agenda. In a surprise move, the Conservative manifesto goes further by promising to pass a set of legislative proposals drawn up by NHSE/I to support it “within three months” (HSJ, £).

The Lib Dem manifesto makes a very similar promise, prompting the NHS Confederation to issue a sigh of relief that it is not proposing another “harmful and costly” reorganisation.

Labour’s stance is less clear. On the one hand, its manifesto contains a whole section on ‘joined up care’ that sounds like it wants what the NHS Long Term Plan wants. On the other, it says it will repeal the Lansley act and “stop privatisation.”

As the Nuffield Trust also pointed out, full-on repeal would be hugely disruptive, particularly if the aim is to achieve something NHSE/I has already been doing on the quiet, and it is “unclear” what “stop privatisation” means, since it could mean anything from establishing ICSs as public bodies to nationalising GPs.

Signals and noise

In practice, it seems unlikely that the direction of NHS reform, as set out in the NHS Long Term Plan and its predecessor, the Five Year Forward View, will be disrupted by the election. The next administration is as likely to be consumed by Brexit as its predecessors have been.

Even if it isn’t, the Conservatives have promised to back this direction of travel, while there is enough wiggle-room in the definition of privatisation to let Labour do the same. Also, it’s in line with developments in developed countries.

This should be reassuring to healthcare IT companies looking to sell integrated care records, population health management solutions, and patient activation services into emerging regions. With the caveat that all three manifestos have an old-fashioned view of service delivery.

Bricks, mortar and tarmac

The Conservatives have got into a lot of trouble for claiming that they are building 40 hospitals, when just six builds or refurbs have been agreed so far (Full Fact). But their manifesto repeats the figure, with the qualifier “over ten years.”

The Lib Dems say some of their capital fund will go on new hospitals, and Labour says it will draw up an infrastructure plan, to “complete the confirmed hospital rebuilds” and invest in community and primary care.

Getting back to parking, the Conservatives also promise to end “unfair parking charges” for some patients, while Labour promises free parking for all. This focus on bricks, mortar and tarmac is out of kilter with the recent commitment by Simon Stevens, the chief executive of NHSE/I, to reduce the climate impact of NHS activities.

It’s also out of line with the NHS Long Term Plan Target to reduce outpatient appointments by 30%, which will mean fewer buildings and more remote consultations and monitoring. Or, to put it another way, the manifestos don’t back policies that would require an investment in digital records, decision support and communications, but do back building programmes that could suck-up management time and capital.

Dropping out of the conversation? 

The manifestos do mention health tech, but only in passing. The Conservative manifesto says: “We will use frontline technology to improve patients’ experience, provide staff with flexible working, and save lives… and hold an annual health technology summit.” 

The Lib Dem manifesto mentions health technology in the context of making sure that primary and community care is “well connected” to other parts of an integrated care system. The Labour manifesto says its infrastructure fund will invest in “modern AI, cyber technology, and state-of-the-art medical equipment.”

This is something of a break with recent history. Former prime minister Tony Blair was a technology enthusiast and New Labour’s manifestos, which linked “investment” with “reform”, paved the way for NHS Direct and the National Programme for IT.

Blair’s successor, David Cameron, was also a technophile and Conservative manifestos of his era, which sought to use consumerism to push reform, promised patients platforms on which to “rate services” and “read-write” access to their records.

More recently, Hunt addressed the effective failure of NPfIT in hospitals by launching the “paperless 2020” vision, the Wachter Review, and the global digital exemplar programme. While, in the 2017 Conservative manifesto, leader Theresa May promised a big expansion of transactional services and apps.

This break feels like bad news. Even allowing for the distractions of Brexit and the flimsy nature of the Conservative manifesto, it suggests tech is in danger of falling out of the conversation about the best way to address the problems of the NHS.

IT needs political clout, to overcome the pull of bricks and mortar, get the attention of boards, and secure funding. Particularly at a time when Hancock’s NHSX initiative has yet to find its feet, clarify the future of the GDE and LHCRE programmes, or make any substantial announcements of its own.

We need to talk about trust…

A final thought: for the past decade, healthcare digitisation has not just been seen as good for the NHS but as good for UK Plc. Cameron and May both pushed for digital health records on the basis that they would make “every patient a research patient” and deliver a boost to the life sciences and pharma industries (BBC, 2011).

This year’s Conservative manifesto is silent on this justification for tech investment; and Labour’s manifesto is against it. Labour says it will “ensure data protection for NHS and patient information, a highly valuable publicly funded resource” and “ensure it is not exploited by international technology and pharmaceutical corporations.”

That’s an interesting straw in the wind. One that could clip the ambitions of a number of US corporations. One that suggests the health tech industry has work to put into convincing the public and patients that it can be trusted with their data.