Comment / ElectionWatch 2024: promises, questions and practical reality

‘Good on ambition, light on detail’ was how King’s Fund chief executive Sarah Woolnough summed up the Liberal Democrats' NHS commitments within the party’s manifesto. This is hardly something unique to the Liberal Democrats, with the same criticism levelled by well-placed commentators on both the Conservative and Labour manifestos this week.

To be fair, this is pretty standard for political manifestos – more wish lists than detailed implementation plans. Even the almost obligatory accompanying costings documents tend to be an exercise in the simple adding up of numbers based on often questionable assumptions.

So, what can we learn from the NHS and social care promises of the main parties expected to contend next month’s general election?

Well, promises are plentiful. Everyone pledges to increase staffing levels – it would be difficult not to, given the analysis in last year’s NHS long-term workforce plan and existence of some 120,000 vacancies. There is commitment (or recommitment in the case of the Conservatives) to the ongoing New Hospital Programme, but not a huge amount about the need for wider capital investment, despite its importance to the improved productivity that all parties say they are targeting. The Conservatives re-spotlight the existing commitment to spend £3.4bn on technology from next year, while the other parties make similar pledges to boost scanners and digital technology.

Both the Liberal Democrats and the Conservatives would argue that their plans for increased staff and new facilities and equipment would help to address the waiting list, which currently stands at some 7.6 million. But Labour stands out in making specific commitments to throw an extra 40,000 appointments a year at the issue, with staff incentivised to work weekends and evenings and increased use of spare, independent sector capacity.

And the Liberal Democrats arguably go furthest in addressing some of the current challenges in the social care crisis with the promise to deliver free personal care and raise care workers’ salaries with a dedicated carer minimum wage.

But there is precious little on how realistic these plans are or, more to the point, how affordable they are.

Labour’s promise to return to address the waiting list and restore compliance with the 18-week referral to treatment target is laudable. But it is impossible to tell if its cost estimate of £1bn by 2028/29 is enough to realise this ambition – or how it has arrived at the number. The fact that it relies on staff working extra shifts also seems unrealistic given how tired and stressed staff are and how under-valued they feel, leading to a major withdrawal of goodwill. And how does a focus on hospital waiting times fit with its promise to shift resources to primary care and community services?

The Conservatives’ claim of record funding for the NHS seems at odds with a service that is clearly bursting at the seams. The elective waiting list is perhaps the most obvious example of the current challenges, but there are plenty of others – the number of long waits within that list, the queues for mental health services (perhaps particularly for children), ambulance handover delays and long accident and emergency waits. Its promise to increase NHS spending above inflation is practically meaningless in the face of a growing and ageing population. As the Institute for Fiscal Studies pointed out this week, in only five years between the mid-1950s and the pandemic did UK health spending fail to keep up with inflation.

The IFS also questioned the meaningfulness of the Liberal Democrats’ promise to increase day-to-day spending for health and social care by £8.4bn by 2028/29. ‘£8.4bn on top of what?’ the institute rightly asked. If this is on top of current spending, it wouldn’t be nearly enough to meet demand pressures and the party’s health and care spending commitments.

The reality is that the promises and commitments from all the main parties will cost more than they have suggested. There has been much reporting of the so-called ‘conspiracy of silence’ about the real funding difficulties facing any government in the next Parliament. Where there are commitments to extra funding, they are tied to increased delivery or new services. There is no recognition of the fact that the NHS is already running beyond its means. In reality, funding is needed just to eliminate underlying deficits, let alone ramp up service delivery.

Relatively speaking the NHS is lucky. It can at least rely on some level of protection in funding decisions as one of the government’s priority services. But the implied cuts to unprotected spending departments will also be felt in health – none of which supports promises to tackle the wider determinants of health, which is surely the long-term solution to reducing demand and creating a sustainable NHS.

There is a received wisdom that manifestos are not the place to explain radical, complex new policies. The election campaign is too short, it is argued, to convince the public about major changes. The public wants easy-to-understand messages, not hard economics. But we are left with long documents that provide only high-level commitments and promises. Perhaps at best, the manifestos signal intent or direction of travel – in which case the electorate’s decision is likely to be based on who they trust the most, rather than specific promises.