Comment / ElectionWatch 2024: reading between the lines

The penultimate week of the general election campaign started with a brutal pulling apart of the various parties’ published manifestos. Well, as brutal as the level-headed economic experts at the Institute for Fiscal Studies (IFS) ever get.

The think tank has been making the case for a number of weeks now that it is not what is in the manifestos that is of most importance, but what is missing. It is not the money that the parties are promising to spend to deliver specific proposals – such as weekend waiting list initiative sessions (Labour) or an expansion of pharmacy first and more community diagnostic centres (Conservatives) that we should be looking at – but the failure to address the baseline level of NHS spending.

Current plans, as confirmed in the spring Budget, are for public spending to grow by 1% in real terms over the next Parliament. With an expectation that certain ‘protected’ departments, including health and defence, would see higher rises, the implications for other departments are significant cuts. The choices for whoever is in government are: make these cuts (in which case where would they fall?); raise taxes (despite ruling out most options to do this in their manifestos); or borrow more and break their fiscal rule to have borrowing falling by the fifth year of the Parliament.

At the risk of repeating earlier articles, it is worth highlighting one comment the IFS made this week that really backs its ‘conspiracy of silence' argument. Current spending on health is around £180bn. Providing enough money to deliver the NHS long-term workforce plan would need an estimated 3.6% growth a year in real terms over the next Parliament – that would take spending to around £220bn in today’s money, according to the IFS. That is a £40bn difference between a flat, real-terms settlement and the money need to implement a plan that both parties have committed to.

Indicating roughly where that figure might land would be a real indicator of the parties’ intent in relation to the NHS and makes the £1bn or £2bn that has been thrown at manifesto commitments look insignificant by comparison.

It may be naïve to expect such pragmatic openness. Nobody could expect a spending review-type assessment to support manifesto promises. And being so frank clearly opens parties up to all sorts of questions that they don’t want to get into. But simply ignoring the issue makes a mockery of ‘fully costed’ claims. Another good example is the basic commitment from the main parties to deal with the waiting list. Maybe funding the workforce plan would deliver this, but there is no guarantee that this would provide all the promised improvements – and we don’t even have that level of funding promised.

The Health Foundation this week highlighted the actions it believes are needed to tackle the current waiting list crisis. It won’t be easy and it won’t be quick. It will require action on several fronts and both revenue and capital investment, including some double running costs. It includes expanding existing hospital capacity and making better use of it, while also investing in primary and community services and focusing more on prevention – fixing the problem for the future not just the present. And then there is the elephant in the room that is social care. Everyone accepts it is broken – adding pressure to the NHS – but there is little sign of where the money would come from to fix it.

Whatever the future settlement for the NHS, the Health Foundation’s action plan provides a useful framework for addressing the waiting list.

The IFS is quick to acknowledge that better-than-predicted growth in the economy could make everything a little easier. But having a plan for what happens if this growth doesn’t come – or if the economy underperforms against predictions – would seem sensible.

The reality is that all we have to go on in terms of how the main parties would tackle the significant financial challenges facing all public services, including the NHS, are the manifestos. (The IFS is perhaps even more disparaging about some of the other parties’ manifestos – describing Reform UK and Green Party proposals as ‘wholly unattainable’.) The manifestos are (deliberately) high level. There is no small print to check the detail. We are just left reading between the lines.

Big decisions will have to be taken, and quickly, following next week’s result. And then perhaps we can start to see a way forward and plan for long-term improvement.