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Manifesto! Ho! Ho!

Still practising

Chris Preece

Monday, 25 November 2019

AdobeStock_115118704_manifesto.jpgAs the nights draw in, the air becomes crisp, and Christmas looms, what better way to celebrate the season than with yet another election? ‘Tis the season for bold promises and misleading statements - for rebranding Twitter feeds, and gifting seats to political rivals. The last time we did this particular dance I created a brief guide to the Manifesto promises of the main political parties – so with a slightly heavy heart, I thought it would be prudent to do the same thing again.

Many of the same rules apply – I’m going to at least try to be balanced in my representation of each – which means I may not represent “your team” in quite the way you would like. I’m also leaving out parties which are only standing in one country – so apologies to anyone hoping for coverage of the SNP, Plaid Cymru, the DUP, Sinn Fein or Change UK.

Finally, for the really lazy amongst you, I’m going to end each summary with a score, Top Trumps style, for the following:

  • Change-o-meter – The likelihood that policies will result in real change (for better or worse)
  • Underpants Gnome Rating – A nod to an old episode of South Park featuring the Underpants Gnomes, who steal underwear with a view to making profit, but with no clear idea how the one will result in the other. Policies that state they will achieve an outcome without any obvious mechanism for doing so, will get a high Underpants Score.
  • Magical Money Tree Score – The higher the score, the more of Theresa May’s “Magical Money Trees” will need to be found to pay for the policies described. (If there’s a clear plan identified for funding a particular policy, no magical tress are needed.)

Right then, let’s get on with it…

The Conservatives:

Of course, the Conservatives come into this election with an immediate disadvantage – namely, “why haven’t they done any of this already”? Still, given that they’re opening with a guarantee to “get Brexit done” by January – something they’ve hitherto failed to achieve - it’s clear that the Conservatives have very much opted to lean in to this apparent anomaly.

It might be worth lingering on that opening guarantee a little longer, as after Brexit there’s an explicit statement that the Conservatives guarantee “extra funding for the NHS with 50,000 more nurses and 50 million more GP surgery appointments every year”. That last guarantee seems somewhat dependent upon the manifesto’s further promise of an additional 6,000 doctors in General Practice – a pledge that has unfortunate echoes with their previous promise to provide an additional 5,000 GPs by 2020, a number which (by full time equivalent) has actually fallen. (The change from additional GPs to “additional doctors in General Practice” raises an eyebrow too.)

The nursing pledge meanwhile was already being picked apart within minutes of the manifesto launch, on the grounds that it, seemingly, includes an estimated 18,500 nurses that they’re hoping can be persuaded not to leave their existing jobs. On a similar note the pledge to build and fund 40 new hospitals over the next 10 years has already been much debated in the media, chiefly because it actually amounts to a plan to reconfigure six with “over 30 that could be built over the next decade”.

Still, the promise to reinstate bursaries for trainee nurses is less controversial (even if other parties offer the same, and it’s the Conservatives who cut them in the first place), whilst the offer to end “unfair hospital car parking charges” will also likely be welcomed. (Although this offer will not apply to all staff and patients – some charges are apparently fair, in the Government’s estimation.)

In terms of funding the manifesto states that “between 2018 and 2023 we will have raised funding by 29%”. Which is, I think, a slightly obfuscatory way of describing the 3.4% annual increase they already announced in 2018 as part of their five-year plan. (I’m writing this on a Sunday afternoon, shortly after the manifesto has been made public, so some elements are as clear as mud.)

There’s a promise to “improve staff morale” with funding for training and “more supportive management” and a plan for an “NHS visa” to allow fast track entry to the UK for staff from overseas. The Conservatives also state that they will improve the early diagnosis and treatment of all major conditions (somehow), utilise “frontline technology” to improve patient experience, and “clamp down on health tourism”.

There is, inevitably, an assurance that the NHS “will not be on the table” in any future trade deals (a rebuttal to Labour accusations over the last few months).

Mental Health will apparently be treated “with the same urgency as physical health”, though the only specific legislation cited, is to ensure people have greater control and are treated with dignity and respect, so it’s not clear what, precisely, is going to change.

After much fanfare and discussion in the lead up to the election, the Conservative Party’s offer around social care is relatively slim. The most meaty element is a promise for £1 billion a year to be spent on staffing and infrastructure, but beyond this they simply commit to “urgently seeking a cross party consensus”.

As for how things will be funded? The Conservatives have released a separate Costings Document alongside the manifesto, although there’s no straight forward correlation between one initiative and a resource to fund it. (Their main proposed sources of revenue are keeping corporation tax as is, and charging immigrants for healthcare.) Their message seems to be, “we can make things better, but you won’t have to pay”, which seems optimistic.

  • Change-o-meter: 2/10 – Despite the fuss there’s remarkably little new here. The big headline is more nurses and GPs, but that’s about it.
  • Underpant Gnomes: 6/10 – The Social Care policy might as well have been written by the gnomes themselves, and much the same could be said of their approach to mental health.
  • Magical Money Tree: 5/10 – The advantage of not really changing very much, is that there’s little requirement to show where the money’s coming from, but even then, I’m not sure it adds up.

Labour:

Labour open with a pledge to increase health and social care expenditure by 4.3% every year. This is broadly in line with the NHS Confederation’s Securing The Future report which last year suggested 4% was needed if NHS services were to be improved – though it’s short of the suggested 5% a year for five years to address the “financial backlog” – and indeed short of the 5% that Labour themselves were pledging in 2018.

Some key pledges include the removal of prescription charges (though 89% of prescriptions are currently free already), free hospital parking, free dental check-ups, and increased funding for close-to-home services. They plan to increase GP training places with a view to offering 27 million more appointments. (There is little about how they will address the exodus from the profession – barring a general commitment to mental health support for NHS staff and creating a better working environment). Similarly, they will reinstate a training bursary for nurses and midwives. There’s also a planned additional £1billion for Public Health, and a commitment to more health visitors and school nurses. They will double the funding for Child and Adolescent Mental Health Services, and spend £1.6 billion a year on ensuring access to Mental Health treatment is “on a par with that for physical health conditions”. (Which leaves a fair bit of room for interpretation…)

One big commitment from Labour is that they will repeal the Health and Social Care Act, and with it end the requirement for health authorities to go out to competitive tender. What’s not entirely clear is what they plan to install instead of the existing Act, and precisely how much upheaval this is likely to create (or indeed how much of that 4.3% will be gobbled up by NHS restructuring in the first few years). They say they will put an end to, and “reverse” privatisation within the NHS, but it’s again unclear how they will ensure that such work moves smoothly back into the NHS system.

Another big ticket item is the promise to establish a generic drug company, to try and ensure fair prices for generic drugs. Which sounds great in theory, but again practical implementation might prove complicated, and one can imagine how drug companies may respond to such a move, particularly when pricing non-generics for the NHS market. On a similar note Labour have promised to exclude and protect the NHS when it comes to any International Trade Deals (presumably with Brexit in mind).

Finally, Labour acknowledge the need to invest further in Social Care, with considerably more detail than the Conservatives. They propose a National Care Service, offering free personal care (initially for the over 65s, but ultimately for all), and a promised life time cap on care costs of £100,000.

It’s not directly clear in their manifesto how all of this will be funded, though presumably much will come from its much debated taxation of both those with incomes above £80,000 and increased corporation tax. Whether this will truly be enough (and how much the taxation of corporations will impact on those with lower incomes), remains to be seen.

  • Change-O-Meter: 10/10 – Tearing up the act, reversing privatisation, free care and prescriptions. Oh, and lots of taxes.
  • Underpants Gnomes: 5/10 – Whilst there are some clear policies here, there are also an awful lot of vaguely defined “strategies”
  • Magical Money Trees: 4/10 – A lot of money’s getting spent, but Labour does at least acknowledge the need for increased taxation to pay for its plans (above and beyond health). Is it enough though, and is it really true that Labour’s plans won’t impact those on earnings <£80,000? (Spoiler alert – the answer is probably “no”.)

Liberal Democrats:

Unsurprisingly the Lib Dems open with a discussion of the perils of Brexit, particularly with respect to recruiting staff, the spectre of Donald Trump, and damaged economic growth – they suggest therefore that as the explicitly Anti-Brexit party they are the only ones to deliver us from such a picture. (An argument I don’t plan to explore too much further here, as your view on Brexit is likely well established by now.)

They have a very clear commitment to increasing the Health and Social Care budget by £7 billion a year, funded by a ring fenced additional 1p rise on income tax rates. (This works out at about 3.8% per year). They also plan to spend £10 billion of capital funding to remedy the £6.5 billion backlog of NHS repairs, and bring NHS facilities “into the 21st Century”. In the longer term, they plan to establish a Health and Care Tax (offset by tax reductions elsewhere) and establish a budget monitoring body for health and care. Despite a promise to relieve the crisis in Social Care, like the Conservatives there’s little about how this will be achieved, barring a cross party convention to look at it, with a cap on care costs as a “starting point”. 

Beyond this the Lib Dems have largely focussed on three areas, mental health, access, and public health. With respect to Mental Health there are a number of commitments to act on existing recommendations, such as the Wessley Review, as well as promises to introduce free prescriptions for chronic mental health problems (which could conceivably affect presentation rates), better perinatal and post-natal support, and that those admitted receive care close to home.

In discussing access, the Lib Dems are scathing in their assessment of the current Government’s failure to fulfil targets for GP recruitment – whilst setting their own to “end the shortfall” by 2025. It’s a shame therefore that they’re not entirely clear about how this will be achieved, barring a national workforce strategy and commitment to do “what works” to aid retention.

Perhaps surprisingly the party plans to keep public health within local government, but more predictably, promises to reinstate their budgets. They plan to make a statutory requirement that any effective public health intervention approved by NICE is available to all qualifying people within three months. They also intend to impose various steps themselves – from restricting the marketing of unhealthy foods, to introducing minimum unit alcohol pricing and introducing a legal, regulated cannabis market.

  • Change-o-meter: 2/10 – Beyond cannabis legalisation this is mainly a manifesto about keeping promises that weren’t kept by the Conservatives, rather than doing anything new.
  • Underpants Gnomes: 4/10 – A weird mix of very clear plans, referencing existing strategies – and vague promises to stop bad things happening.
  • Magical Money Trees: 1/10 – Where money is to be spent, it’s generally clear where it’s coming from, at least in the short term.

The Green Party:

The Green Party manifesto is largely concerned, as you would expect, with policies relating to the environment, with The Green New Deal taking up a full third of the document. Nonetheless, there are a series of specific policies relating to health and social care.

Firstly, they promise to increase NHS funding alone by £6 billion a year – a 4.5% increase. (Previously quoted percentages for Labour and Liberal Democrats were for Health and Social Care as a whole.)  Like Labour they want to completely repeal the 2012 Health and Social Care Act and remove the internal market, whilst reinstating the nursing bursary.

Like many parties, the Greens are suggesting that Mental and Physical Health should enjoy parity, but here do at least provide a more concrete commitment around this – stating that everyone should be able to access evidence-based mental health treatments within 28 days. (A move which arguably prioritises mental health over physical, within the NHS.)

The Greens say they will focus additional funding on community health centres, and there is a general move towards more locally tailored services, with private sector involvement replaced with “community leadership”, and more power handed to Health and Wellbeing Boards.

The Greens acknowledge the Social Care burden, with a promise of an additional £4.5 billion a year for free social care to people over 65, as per the Scottish model. Like Labour they state they will “explore” moving this provision to all ages in the future.

As for where the money for this is coming from? If I’m honest it’s not entirely clear from the manifesto - there’s additional corporation tax of 24%, and some savings from adopting a single Consolidated Income Tax, but none of this would cover the cost. Instead it seems fairly clear that this funding, like the £100 billion they’ve pledged to tackle the climate crisis, would be achieved through borrowing.

  • Change-o-meter: 8/10 – Similar to Labour, but without the explicit increase in taxes to fund it.
  • Underpant Gnomes: 2/10 – by virtue of a relatively small number of explicit policies, the Greens are fairly clear about what they plan to achieve and how (barring the financial element).
  • Magical Money Trees: 9/10 – No real mechanism for raising funds other than borrowing, and hoping for benefits further down the line. Still, if anyone can nurture a money tree, I guess it’s The Green Party

Brexit Party:

Let’s face it, if you’re thinking about voting for the Brexit Party, it’s probably not because of interest in their attitude to the NHS. Nonetheless, it’s probably sensible to know what they’re proposing…

First of all, the Brexit Party are keen that you know that theirs isn’t a manifesto, but a “contract with the people”, with “a targeted set of deliverable pledges”. In reality, this results in what reads pretty much exactly like a manifesto, albeit with less detail than some of the other parties.

The Brexit Party is clear that they believe that the NHS should remain publically owned and free at the point of use, with “no privatisation” and a commitment to return to public ownership any private initiatives that have failed to deliver.

They say they support medical research and will “stop the taxpayer being ripped off by pharmaceutical companies” (there is no explanation as to how they intend to achieve this). The Brexit Party also promises to introduce 24-hour GP surgeries which, it says, will relieve the strain on A&E Departments. Again, I can see nothing to indicate how this is intended to happen, or a recognition of the current shortage of GPs. There is, however, a commitment to remove the degree requirement from nursing training, and to introduce a new nursing qualification in social care.

Finally, they promise a “national debate on our NHS” and will “discuss” ring-fencing the NHS budget. The only reference to social care (bar nurse training) is a promise to “invest in the NHS and Social Care”, but no indication of how much this would be, or what this would entail.

  • Change-o-meter: 1/10 – This is a manifesto contract more interested in reassuring you about what they’re not going to do, than in actually saying what they will.
  • Underpant Gnomes: 7/10 – The few solid commitments are pretty Gnomey (24-hour GPs, not being “ripped off”), whilst others are so broad as to be ultimately meaningless (“invest in the NHS”).
  • Magical Money Trees: ???/10 – Who knows? With no actual financial commitments, it’s difficult to see whether they’re deliverable or not.

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So what have we learnt? That however you vote, we are at least going to have the nursing bursary reinstated. That the Conservatives and Lib Dems aren’t planning on changing very much, whilst Labour and the Greens are planning on changing everything. That Underpant Gnomes have invaded pretty much every political party, and that I really, really don’t want to have to do this again for at least five years.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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