Comment / ElectionWatch 2024: social care, new hospitals and the inevitable manager bashing

The NHS has become used to being front and centre in general election battlegrounds over the years. But social care is less accustomed to the limelight. This is despite the fact that fixing adult social care may just be one of the best ways to reduce pressure on the health service. 

The Health Foundation has described the current system as a ‘threadbare safety net’, with historic cuts in funding having limited services and with ‘chronic staff shortages’, in part linked to low levels of pay. As well as improving pay and conditions, there is an urgent requirement to stablilise the provider market – paying them enough to cover costs and invest in services – and address unmet need.

Successive governments have paid lip service to reform. And even when change was actually on the cards, with a cap on care costs planned to be introduced last year, the Conservative government delayed the change for two years, channelling the money into more care packages instead.

The Liberal Democrats attempted to get the election debate to focus on this key public service this week, with its plan to offer free personal care to all those that need it – mirroring the model introduced in Scotland in 2002. Free personal care covers support with personal hygiene, mealtimes, immobility problems, medication and general wellbeing (but stops short of help with housework, shopping or services outside the home). It would also still leave those needing care having to pay for their accommodation.

The party said its plan to deliver free personal care would cost £2.7bn by 2028/29 above existing plans, with the change potentially saving the NHS up to £3bn. The policy would be paid for by reversing tax cuts for big banks – raising £4.3bn a year, the party said. It added that, if elected, it would also introduce a carers’ minimum wage, set £2 above the minimum wage, to tackle the huge shortage of care workers.

The costings almost certainly deserve far more scrutiny. The Health Foundation, for example, has estimated that a Scottish-style model of free personal care could cost around £6bn extra in 2026/27, rising to £7bn by 2035/36. But how refreshing would it be to see the parties actually stand up and talk realistically about what they would do in social care and how they have arrived at their costings? At least the Liberal Democrats are attempting to put the issues under the spotlight.

The reality is that ‘fixing social care’ – as numerous parties have previously promised – will require a range of interventions, from freeing up access to services (or changing access thresholds) to raising pay and conditions and increasing local authority support so that councils can pay providers fees that cover these higher wages and the appropriate level of service. That is an expensive fix, at a time of unprecedented pressure on public resources from all public services.

The devil is inevitably in the detail. And the detail surrounding social care is copious and complex. But it is a major issue that needs a comprehensive solution – especially as the population gets older and the demands on social care are set to increase.

Manager bashing

If social care has charted for nearly the first time in an election campaign, we haven’t had to wait very long for another old classic to be re-released. Cutting NHS managers was not the headline of the Conservatives’ latest healthcare policy, but it is how they plan to pay for their promise to build 100 new GP surgeries and modernise a further 150, if they are returned to office. The party is also targeting an expansion of the Pharmacy First initiative – with enhanced roles for pharmacists helping to free up a total of 20 million GP appointments – and would build a further 50 community diagnostic centres.

Pharmacy First was launched in January, enabling community pharmacists to diagnose and prescribe for seven clinical conditions without patients first seeing a GP. If returned to power, a new Conservative government would expand the scheme by including further conditions and treatments. The community diagnostic centres (CDCs), which aim to ease the diagnostic bottleneck in treatment pathways, would build on the existing network of CDCs. The Conservative government announced last year that it would deliver its initial target of 160 CDCs a year early – by March this year.

Although the party appears to be happily mixing ongoing revenue costs with one-off capital, it said that, in total, this would cost £1bn per year. This would be paid for by cutting the number of NHS managers by 5,500 to pre-pandemic levels – saving £550m a year by 2029/30 – and halving management consultancy spend across government.

The King’s Fund acknowledged that boosting community services was a ‘welcome direction of travel’, but could only be a first step if a government was serious about realising the shift to primary and community health services. However, it described the cut in management as a ‘considerable sting in the tail’. 

While managers are used to having their value questioned, especially during election campaigns, the think tank said that cutting headcount would risk ‘sabotaging’ the goals of the policy. ‘The NHS already has a lower ratio of managers compared to other industries and a smaller administrative spend compared to other health systems globally,’ its chief executive Sarah Woolnough pointed out. ‘Achieving an efficient and productive health service requires experts who can streamline processes, align incentives, and create the environments for clinicians to focus on what they do best – delivering patient care.'

There are inevitably areas where technology can take some of the weight in administrative areas, taking over transactional processes. But if the NHS is to really become sustainable, it faces a major change agenda, which will require a collaboration between management and the clinical workforce.

It is not as though there isn’t already downward pressure on workforce size. Integrated care boards face specific requirements to reduce running costs by 30%, which effectively means major reductions in headcount. And trusts’ difficult financial positions mean that they are looking at all options to reduce costs, including headcount reductions. But they will also be reliant on managerial support to achieve eye-watering levels of efficiency this year and in the future. It would be nice to hear politicians recognising managers – appropriately skilled and in the right numbers – as value adders, rather than just an overhead.

New hospitals

Labour this week committed to progressing the New Hospital Programme (NHP) in the NHS, if it is elected as the next government. The programme, which started under former Conservative prime minister Boris Johnson back in 2020, aims to build 40 new hospitals by 2030 and to develop a standard hospital design and building approach based on modern methods of construction. The programme has been through a reset, with a redefinition of the hospitals included, and been subject to significant delays. At the end of last year the Public Accounts Committee said it was ‘extremely concerned by the lack of progress’.

But what a Labour government would do with the programme has been another concern for those trusts involved, fearful of further delays. This week the party confirmed it was committed to the rebuilding scheme. This was widely welcomed, boosting confidence for those currently involved with planning and business cases.

So, even if the programme faces a rebrand, which appears to be widely expected, there is recognition of the need for the new facilities. However, think tanks were quick to point out this week that the NHP really is only scratching the surface of the service’s capital needs. The NHS needs to spend £11.6bn to address its backlog maintenance and the NHP doesn’t even address all the capital needs of the lucky few to have been selected.

Anita Charlesworth, respected economist and director of research at the Health Foundation, said that an additional £33bn would need to have been invested over the last decade in buildings, equipment and infrastructure to match European levels of investment. And the NHS Confederation has called for a £6.4bn increase in NHS capital funding for the next three years – almost doubling current levels of investment.

Labour’s commitment to the NHP is welcome, but it begs lots of further questions – such as how it will be funded, especially as it is already clear that many of the projects are exceeding their initial capital envelopes.

Green investment

Increased investment is exactly what the Green party have promised in a preview of its full manifesto. It promised £30bn extra for the English NHS by 2030, alongside an additional £20bn for social care. The NHS funds would be spent on increasing frontline workers’ salaries, improving access to GPs, and giving everyone access to an NHS dentist. This party said that the £50bn boost to day-to-day costs would sit alongside a £20bn capital investment to ‘bring crumbling hospitals and outdated equipment up to modern standards’. 

The party’s co-leader Adrian Ramsay said the Greens were the only party being honest with the public that ‘its going to cost money to nurse the NHS back to health’. This would all be paid for by a tax on the ‘very richest’ people, along with adjustments to capital gains and windfall taxes for oil and gas companies.