What did the Tory manifesto promise on health and care?

The government risks simply papering over the cracks in the system

November 26, 2019
What do his plans mean for the future of the health service? Photo: Stefan Rousseau/PA Wire/PA Images
What do his plans mean for the future of the health service? Photo: Stefan Rousseau/PA Wire/PA Images

In terms of health and social care, the Conservative manifesto published on Sunday was more notable for what it didn’t say. The biggest omission was the lack of a clear policy on social care.

In his first speech as prime minister, Boris Johnson promised to “fix the crisis in social care once and for all.” Four months on, the manifesto falls well short of solutions. There’s a commitment to seeking cross-party consensus on reform, but little detail on what the Conservatives want to achieve through it—aside from a single precondition that no one should have to sell their home to pay for care.

From a new government, that might be understandable. But the Conservatives have been in power for nearly ten years and working on a still-unpublished green paper for nearly 1,000 days. There’s even a flexible model for capping social care costs already on the statute book, awaiting implementation—a legacy of the coalition with the Liberal Democrats.

Instead, the manifesto looks to start from scratch.

The Conservatives have promised £1bn per year over the course of the parliament to prop up the existing social care system—both children’s and adults’ services. But this won’t come close to the £4.1bn needed by 2023/24 to address the costs of rising demand and match NHS pay increases. In the meantime, more people will go without the care they need.

On the NHS, the theme of the manifesto is “business as usual,” with a few new piecemeal commitments sprinkled on top.

Most eye-catching is the carefully-worded pledge to deliver an extra 50,000 nurses, including through improved retention. Our analysis with the King’s Fund and Nuffield Trust suggests that, even with a substantial boost in training, recruitment and retention, a significant portion of these nurses will need to be recruited from outside the UK.

With a global shortage of health professionals, ethically recruiting this many nurses from abroad in a way which is not detrimental to developing countries is going to be difficult. A non-restrictive migration policy—including but not limited to the government’s proposed fast-track NHS visa for migrant health workers—will be crucial, but may present a tricky balancing act with implementing wider changes to immigration controls set out elsewhere in the manifesto.

There is a new commitment to improving care for people with multiple health conditions, which is welcome despite the lack of detail. There’s also new funding to support people with autism and/or learning disabilities to move out of inpatient care. This has been a longstanding priority where progress has been painfully slow, partly due to difficulties recruiting and retaining enough nurses in learning disability and community services.

The manifesto promises that in future trade negotiations, the health service, including the prices it pays for drugs and the services it provides, will not be on the table—a response to Labour’s recent attacks that the Tories would sell off the health service to Donald Trump. The manifesto also repeats a number of the improvements promised in the NHS’ recent ten-year plan.

Despite the emphasis on the long term, the Conservatives’ overall funding commitment of around a 3.1 per cent increase over the life of the parliament falls far short of the 4.1 per cent annual increase we’ve calculated is required to deliver changes and improvements set out in the long-term plan, and below the 3.4 per cent needed to just to maintain current standards of care.

The commitments to hospital building and nurse student maintenance grants are welcome but ultimately incomplete responses to the main challenges facing the health service. The pledge to build 40 hospitals (which upon closer inspection is funding for six projects over the next five years with “seed funding” for up to 34) doesn’t address the immediate investment needed to revive the NHS’ crumbling infrastructure after a decade of austerity. This risks the NHS being trapped between high expectations of achieving specific commitments without the wider financial certainty needed to deliver meaningful improvements in care.

The same pattern of omission and “business as usual” extends to plans for improving the health of the nation.

Arguably the Conservatives’ single boldest ambition on health—extending healthy life expectancy by five years by 2035—is restated, but it’s difficult to identify what, if any, new action is planned to achieve it.

There is no commitment to go beyond the Spending Round plan, to at least provide a real-term increase in the public health grant. It will take £1bn in 2020/21 to reverse real-term per capita cuts to the public health grant since 2015/16.

While the NHS is always a strong feature in any election campaign, evidence shows that staying healthy depends on much more than health care. In fact, the strongest influences on health are the circumstances in which we are born, grow, live, work and age. So where does the manifesto leave investment in these “wider determinants of health? It does include some welcome, if limited, measures to boost adult skills and invest in public transport and cycling routes. But it is necessary to look back to the Spending Round to find more substantial, health-enhancing commitments to boost education spend and some additional financing for local councils.

The big omission on health is any acknowledgement of, or action on, the large ongoing cuts to social security expected to increase child poverty into the start of the next decade, and therefore exacerbate already widening health inequalities. The promised national insurance cuts will do little to boost the incomes of the poorest families due to their size (£32 a year for an employee on Universal Credit) and given the impact is broadly even across the income distribution.

Improvements in life expectancy are stalling, pressures on the NHS are growing, and the social care system is failing some of the most vulnerable people in society. The Conservative manifesto risks papering over the cracks—prioritising acute need over the long-term investments needed to deliver high quality health and social care and make broader improvements in the health of the population.