Expert Health Commentary: Nuffield Trust

The Nuffield Trust's full analysis of the manifestos can be found here.The Nuffield Trust is an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK. The commentary that follows has been produced independently of Full Fact.

The political parties have published their manifestos, with leaders taking to the airwaves soon afterwards to defend their policies and attack those of their opponents. What conclusions can we draw from the Labour, Liberal Democrat and Conservative manifestos about how health and social care might fare after May 8th?

Unanswered questions on funding

A notable feature of this campaign is the NHS bidding war between the parties. Keen to emphasise that they have got the message that the NHS needs more funding to survive, the parties have each made great play of their own proposals. The Conservatives and Liberal Democrats have both promised at least £8 billion for the NHS by 2020 - the minimum amount NHS England has said is necessary to maintain services. Labour have pledged a more modest £2.5bn over a shorter timeframe.

Much of the debate has centred on the extent to which these promises are funded. The Conservatives and Liberal Democrats have insisted that their reliability in delivering past economic growth will guarantee their promises in the future. Labour have said their pledge can be paid for by a combination of a mansion tax and a tax on tobacco companies. Evaluating the prospects for growth and future tax receipts is beyond the Nuffield Trust's remit, but for us, three unanswered questions remain on these pledges.

First, it is not clear when any of this additional funding will kick in. NHS England has said that above- inflation increases must come in smoothly over the course of the parliament, but the Conservatives have not set out any detail about when their extra money comes on-stream. Labour's increase is supposed to take effect from 2016/17, but they have offered little information about how they plan to collect and process their new taxes within this timeframe. The Liberal Democrats have been most explicit, saying the bulk of their £8bn will come after they've balanced the books in 2018/19. But the NHS is under severe pressure today: any increases need to happen quickly.

Second, £8bn is the bare minimum to maintain existing standards of care for a growing and ageing population. But all the manifestos contain ambitious plans for enhanced services—from seven- day working to large increases in staffing or new initiatives on mental health.

Third, the overlooked flipside of the £8bn figure is that it depends on the NHS making £22bn in productivity gains by 2020. But improving productivity on this scale would be unprecedented and no party appears to acknowledge the degree of financial distress already being felt in the system.

Joined up care but with a glaring omission

All three manifestos promote the importance of joined-up care, particularly for older people and those with chronic ill-health. Detail is light from the Conservatives, who reiterate their existing policies. Labour speaks about a seamless system of 'whole- person care'". The Liberal Democrats promise to "encourage the development of joined-up health providers, which cover hospital and community services, including GPs".

Labour promises all people with complex needs a care plan and single point of contact, and both Labour and the Liberal Democrats promise more personal budgets, changes to payment systems, and some structural changes. Both parties commit to pooling budgets, with the Liberal Democrats making an extremely ambitious pledge to fully pool health and social care budgets by 2018. No party acknowledges that integration takes time to deliver or that evidence on its short-term financial benefits is patchy.

The glaring omission from all three parties is any discussion on social care funding, despite a 16% cut in funding for social care for older adults since 2010. The only whisper on this comes from the Liberal Democrats, who suggest a non-partisan fundamental review' of NHS and social care finances this year—something that would be welcome if it led to a concrete change.

Competition falls out of favour

With the role of the private sector in healthcare a key concern for the public, both Labour and the Liberal Democrats propose to roll back competition and market forces in the NHS.

Labour's plans are the most radical. They intend to repeal the Health and Social Care Act, limit the role of the private sector, limit NHS Trusts' ability to raise private income, and restrict the tendering of NHS services. The Liberal Democrats offer vague commitments on removing legislation that might make NHS services "vulnerable to privatisation though international agreements". Both plans would take time and political will to implement.

The Conservatives are silent on the role of the market, promising only to increase patient choice.

It is striking that the role of choice and competition as a driver for improvement has vanished from the manifestos this time round—explicitly from Labour, but also implicitly from their rivals. While the jury is still out on whether competition improves quality and efficiency, there is a long history of non-NHS provision in services like end-of-life care and mental health services. This needs to be factored into any departure from the market.

A welcome focus on mental health but a lack of vision on public health

All three manifestos promise to improve mental health provision. The Liberal Democrats are the most ambitious, outlining a specific funding pledge, new waiting time targets and better crisis care. Labour promise action on waiting times, but stop short of promising extra money. The Conservatives state they are increasing funding, but offer no further detail.

The focus on mental health from all parties is welcome. But promises have been made before. Driving up standards cannot succeed without adequate funding and support for those delivering services.

On public health, while there is a long shopping list of ideas from Labour and the Liberal Democrats, none of the three parties have a compelling vision for this important issue.

There can be no doubting the scale of the challenge facing the next government. The message that NHS needs additional funding seems to have got through, but it will be a pyrrhic victory if it comes too late or is at the expense of investment in the kind of large- scale changes needed in social care and health services. It is not clear from any of the manifestos that this challenge has been fully understood.

The Nuffield Trust's full analysis of the manifestos can be found here.