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Choices, choices

Still practising

Chris Preece

Tuesday, 30 May 2017

General election_shutterstock_639557224_v2.jpgAnother year, another election, and with it there will soon be the predictable influx of people advising us to make absolutely sure that we get out there and vote. It’s a sentiment that I mostly agree with, with just one caveat. Make sure you do your homework first. Putting a cross next to a name, without really knowing what they stand for or represent is, frankly, worse than not voting at all.

Of course, wading through all the claims, counter claims, spin, publicity and outright lies can make informing yourself a pretty tricky process as well. So, in an attempt to make the process at least a little bit easier, I thought I’d pen a quick overview of the promises made by the various parties in their manifestos, with respect to health. It’s worth stating that I’ve tried my best to make this relatively balanced, rather than an all-out attack or endorsement on one party or another – and I appreciate that might be slightly disappointing for some of my readers. (Don’t worry, I dare say normal service will resume shortly.) Equally, I’m afraid I’ve limited myself to parties standing across the UK, so there’s no SNP or Plaid Cymru – I appreciate that both parties have more actual sitting MPs than the Greens and UKIP combined, but I’m miles past my allocated word count as it is. Right then, get a nice cup of tea, here it goes…

The Conservatives

In some ways, the Conservatives are the easiest to summarise – they are, after all, already in power, and as such we already know much of what to expect. In other ways, they’re the most difficult, as it’s difficult to approach their election promises as a clean slate.

Take for instance their pledge to increase NHS funding by an additional £8 billion pounds. Despite their promise that this will be a real term increase, there remains the nagging doubt that this may simply echo the previous promise of an extra £10 billion which subsequently turned out, according to their own MP (Sarah Wollaston), to only be £4.5 billion. It’s also not clear whether their stated aim for “the most ambitious programme of investment in people, technology and buildings the NHS has ever seen” will be funded from the same pot of money, or whether they plan to further fund this from elsewhere. 

Arguably, the newest thing here is also the most controversial – in order to create funding for social care provision the Conservatives plan to include the family home in all decisions relating to care, whether that be in a care home, or your own residence. (So, your home could be sold off after your death to pay for the care). They will however allow a capital floor of £100,000, but the manifesto explicitly eschews the previous Dilnot Report which advised that payments for care should be capped. This immediately lead to The Conservatives being accused of creating a “Dementia Tax”, and as a result Theresa May has stated that there will be an “absolute limit” on what has to be paid with respect to care. This apparent U-turn is apparently nothing of the sort, which is fortunate as, to date, no-one is able to explain what the cap for this “absolute limit” is likely to be.

Beyond that, this is essentially a “business as usual” manifesto. Many voters will, I suspect, be delighted to hear that the government will “expect GPs to come together to provide greater access, more innovative services, share data and offer better facilities” in much the same way that many of my colleagues will wonder whether any of that will be appropriately resourced. Equally predictable is a pledge to plough on with the Sustainability and Transformation Plans (STPs), and if necessary legislate to remove barriers to the Five Year Forward View, including a review of the “NHS’s own internal market”. Make of that what you will.

The Mental Health Act meanwhile is to be replaced with a new Mental Health Bill aiming to bring “parity of esteem” between mental and physical conditions. With respect to Public Health, the government aims to address childhood obesity by reducing unhealthy ingredients and offering clearer information on food packaging.

A final observation on the Conservative manifesto – when I first went to download a copy to peruse, I was greeted with a picture of Theresa May and the following promise which presumably was intended as a summation of their approach: “If we get Brexit right, we can use this moment of change to build a stronger, fairer, more prosperous Britain here at home.” I will leave it to you to decide whether opening your entire manifesto with a conditional clause is something that inspires confidence…

Labour

A friend recently posted an article on Facebook about what he felt were the awful things the government was doing to destroy the NHS, as evidence that we shouldn’t vote Conservative - and I had to politely point out that the article in question was from the period in which Gordon Brown was Prime Minister. All of which is a roundabout way of pointing out that judging the Conservatives based on the current state of the Health Service is to forget that much of the direction of travel was initiated by a Labour government.

Still, since then, Labour has done a remarkable job of imploding entirely as a political force, and as such it is perhaps a little easier to believe that they’re taking a new approach. Certainly, their manifesto rings the changes in that regard, announcing that they’ll repeal the Health and Social Care Act 2012 altogether, halt and review STPs, make the NHS the preferred provider for all services and introduce a new legal duty to ensure private companies do not make “excess” profits from the NHS. (It’s not clear what level of profitability they regard as appropriate.)

Like everyone else they’re offering more money – £30 billion over the course of Parliament, and have been clear where this will come from – an income tax for the highest 5% of tax payers (about £80,000 per annum if you’re wondering whether that’s you) and by increasing tax on medical insurance. (It’s not clear whether they’ve factored in an increase in NHS work resulting from people dropping their now unaffordable plans.)   

Labour also promise to create a new “National Care Service”, increasing the asset threshold for care, capping care costs, ensuring free end-of-life care for all and increasing the Care budget by £8 billion. Unlike the additional NHS funding however, it’s not clear where the funding for this will come from, with Labour saying they will seek consensus on a cross party basis.

Like the Conservatives, Labour have identified the need to act on Mental Health, albeit with an inevitably different approach. They plan to ring fence Mental Health Budgets, particularly ensuring an increase in the proportion spent on children (including access to counselling in all secondary schools). They plan to end out-of-area placements for mental health patients, and to ensure children are no longer placed on adult wards. 

Finally, they have a range of public health initiatives listed with a particular focus on child health and an ambition to break the link between poverty and ill health. In practical terms, this means a new “index of Child Health”, an investment of £250 million, a “sugar tax” and more health visitors and school nurses. The other area of public health particularly singled out is sexual health, with a push to improve HIV services, and the provision of Pre-Exposure Prophylaxis (PrEP) to high risk groups.

In short then, if the Conservatives’ plan is for us to continue doggedly down our existing path, Labour would appear to be planning to make a fairly sharp U-turn, returning to some of the NHS’s founding principles. Whilst those who don’t enjoy the current government’s approach may well take solace in this, there remains, as ever, something of a question mark about Labour’s ability to achieve all that it has promised. One could argue that this is a manifesto of ideals, rather than a clearly deliverable future.

Liberal Democrats

I’ve opened for the other two by talking of history, so it only seems fair to do the same with the Lib Dems. Of course, in their case the picture is somewhat muddied by their having been in coalition, leaving a lingering question mark over what elements of our current health landscape were actively of their creation, and which were simply things for which they were more passively responsible.

During their time in coalition, it seemed their primary push was towards Health and Social Care integration, and that’s certainly borne out by their manifesto, which states a clear aim to join up health and social care. Their other central argument is that there’s a crisis within health and social care which they claim neither Labour nor the Conservatives are prepared to admit. (Though references to precisely that are on the very first page of the Labour manifesto too.)

The Lib Dems are very clear about how they plan to fund their proposals – an additional 1p rise on income tax to raise an additional, immediate, £6 billion ring fenced for the NHS and Social Care. They explicitly state that this should go to social care, primary care, mental health and public health, and that this initial tax increase should, in the long-term, be replaced by a dedicated Health and Social Care Tax, with a long-term objective of making Health and Social Care into a single service. They would implement a cap on lifetime liability for care costs.

Like the Conservatives, the Lib Dems plan to improve access to GPs, expanding evening and weekend opening, and pushing for online and telephone consultations. They would “encourage” GPs to work in federations, and introduce a new “patient premium” to incentivise GPs to work in disadvantaged areas. Again, much of this causes me to bash my head against the desk in despair, but will doubtless be popular in the voting booth.

The Liberal Democrats (and Labour) have said that they would end the public sector pay freeze for NHS workers and reinstate student nurse bursaries, as well as supporting “innovation to empower staff and patients”.  (It’s not entirely clear what that latter statement actually means.)

From a Public Health perspective, the Lib Dems also promise to make PrEP available on the NHS. They plan to impose a new levy on tobacco companies, introduce minimum unit pricing on alcohol and introduce “mandatory sugar reduction targets”. (The use of the word “target” does somewhat imply that it’s maybe not all that mandatory.)  Finally, there is, once again, a spotlight on Mental Health. Like Labour, they’re planning to ring fence the Mental Health budget, and end out-of-area placements. They would also introduce new waiting time standards, increase access to talking therapies and “transform support for pregnant women” (again there’s no real detail as to what this entails).

So, if the Conservatives are “more of the same” and Labour are a return to the NHS of Nye Bevan’s era, then the Liberal Democrats are the inevitable “third way” – keeping a lot of the work done by the existing Conservative government, but with a clear push towards integrated care, and keeping people away from hospitals. Of course, the integration agenda is not new, and has been largely embraced as an ideology – the difficulty being that to date it has largely failed to deliver.

The Greens

With apologies to their supporters (and probably relief to exhausted readers), I’m going to go for slightly shorter summaries for the remaining two parties, not least because I suspect that health is not the primary issue that directs people towards either party.

The Greens plan to roll back privatisation of the NHS and scrap STPs. They promise to close the NHS spending gap, and offer “major investment” in social care. Care work would be publically owned, and health and social care budgets would be joined together as one.

Fundamentally, the Green approach to Health and Social Care echoes their approach to all public services – namely that they should be publically owned and run. It’s a very clear anti-privatisation agenda, with a much less clear idea of how to pay for any of it, and a distinct lack of detail all round.

UKIP

According to UKIP, the NHS is “one of the benchmarks of our civilised values” which gives you much of the tone of the manifesto. (For what it’s worth, whilst I’m a great believer in the NHS, I’m quite sure that countries without it can still possess civilised values.)

UKIP condemns the nine “arduous top-down re-organisations” of the NHS since 1973, and to that end recommends the establishment of a new Department for Health and Care that integrates health and social care – presumably this new top-down re-organisation will somehow be less arduous. They plan to tackle the GP shortage by allowing more people into Medical School and covering their tuition fees, but only if they agree to remain within the NHS for at least 10 years. They will scrap all appraisal and revalidation for doctors (but only if it “goes beyond that deemed necessary by the GMC”).

UKIP promises an extra £9 billion a year to the NHS by 2021 which they plan to accrue by redirecting the foreign aid budget and only permitting those who have paid taxes for at least five years to access all but the most urgent NHS services. There is no apparent consideration of potential public health risks from the latter, and any ethical conflicts in the former are, I suspect, unlikely to deter you if you were already considering a UKIP vote.

It’s worth noting however that even UKIP guarantees the right of foreign nationals working in health or social care to remain in the UK after Brexit, which means, of the five parties reviewed, only the Conservatives have failed to make such a promise (though they offered to prioritise them in negotiations).

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So, there you have it. The choice is yours – either change nothing, return to fundamentals, merge everything together, eschew privatisation or embrace isolationism. When it comes to health at least, you can make an informed vote, and reserve your right to moan about the outcome of the election for the next 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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