Comment / ElectionWatch 2024: manifestos, funding and avoiding the baseline

General election manifestos are odd things. Mostly high-level commitments. Flimsy cost assumptions. Modest spending commitments attached to specific initiatives. But parties that are specific to UK nations other than England take this to a different level.

Plaid Cymru or the Scottish National Party (SNP), for example, can have a big impact on who is in power in Westminster. But for many aspects of their manifestos, they are really offering influence over decisions taken on a UK-wide basis, rather than a promise of what would actually be delivered.

If elected, SNP MPs would ‘demand’ extra funding for the NHS across the UK of £16bn a year, which would generate some £1.6bn annually for Scotland’s NHS. They wouldn’t be in a position to actually deliver this. This is the nature of the devolved government system, with the Holyrood government able to determine how funds are spent across the various devolved programmes, but not to dictate the overall level of funding. The SNP styles this arrangement as working with ‘one hand tied behind our back by Westminster’. It is also a helpful fact of life for devolved governments in general – take credit for the things that go well, blame Westminster for everything else.

Plaid Cymru similarly sets out the issues it would be looking to influence within a Westminster Parliament. And much of this influence would be about trying to get a better financial deal. It states that it would ‘work to ensure that our NHS is properly funded through a new fairer and needs-based funding model for Wales’ – although the Institute for Fiscal Studies (IFS) has pointed out that a needs-based system wouldn’t necessarily boost funding. Many of the party’s other promises show its stance on outsourcing (against), wage restoration for staff (for) and increasing GP numbers (for), interestingly recognising that this would be a two-term pledge.

Perhaps what the SNP manifesto does do is provide a benchmark against which funding commitments of the main UK parties can be measured. And, arguably, its £16bn is a more realistic figure for addressing the very real challenges facing the NHS across all four UK nations.

The problem with the manifestos of the Conservatives, Labour and the Liberal Democrats is that they all talk about extra funding without explaining what this is on top of. Put simply, what is the baseline spending on healthcare that they are planning for? We have a high-level total envelope, but no actual departmental budgets beyond the current year. The Nuffield Trust has tried to fill this gaping hole by making some assumptions for that NHS baseline, based on figures from the Office for Budget Responsibility, and then adding the different parties’ extra funding to this. 

This suggests an underwhelming 0.9% real terms increase for the Conservatives, 1.1% for Labour and 1.5% for the Liberal Democrats. The Nuffield Trust rightly points out that ‘none of these [spending] pledges are plausible’ – and way beyond the means of improved productivity to pick up the slack. Just take one area. All the parties, overtly or otherwise, appear to back the NHS long-term workforce plan, which could increase NHS staffing in England from 1.5 million in 2021/22 to as much as 2.4 million in 2036/37. As well as simply paying the salaries of those extra staff, pay in general will most likely have to be increased to attract and retain staff. The IFS has suggested that overall this will require 3.6% real-terms increases a year, adding billions to NHS costs.

The most recent concern about current investment plans came from the Health Foundation, which has published analysis this week claiming that the NHS could be facing a £38bn-a-year funding gap by the end of the next Parliament (see News). 

Of course, manifestos don’t provide all the detail of what parties would do in government and they are really exercises in providing scripts for party candidates in the run up to the election. Parties don’t want to corner themselves into commitments they can’t deliver and don’t want to have their high-level promises undermined by practical realities and detail. 

The real expectation is that while the future government will stick with the existing high-level spending plans, health will be awarded higher real-terms increases at the expense of cuts for unprotected departments (such as prisons, courts and local government). But we just don’t know.

And without that context, the spending promises are relatively meaningless. As I have argued before, the manifestos’ key asset is in spotlighting the different parties’ diagnosis of the current challenges and suggesting their priorities for how they might go about addressing these issues. The financial detail – disappointingly – will come later.