The NHS and the General Election: An Insider’s Guide The NHS and the General Election: An Insider’s Guide

Given the quasi-religious status that the The landscape in health policy will be Going into National Health Service (NHS) holds dominated by the proposals set out in in the hearts of Britons, the NHS will the Forward View and the man charged always be the one issue that continually with achieving this vision, NHS England the General stirs the electorate. Around £95 billion is Chief Executive Simon Stevens. Each of spent per year on the NHS, just over nine the three main political parties agreed Election: What per cent of the national income, but it is with NHS England on the need for more widely acknowledged that this will not funding and new models of care to cope be enough as an aging population with with extra demand in the health service, you need to greater healthcare requirements places an with Stevens seemingly convincing them increasing demand on the system. into following the NHS’s vision. What know about is needed over the coming years is for This paper provides a background to Stevens to harness this position and how health policy has been shaped ensure that politicians push ahead with health policy during the current Parliament and the tough decisions if the NHS is to maintain options on the table for the future. The a high-quality service, free at the point of NHS is struggling to cope with rising use, for another 60 years. costs – from more expensive treatments, inflation, higher expectations and a rising population. Following demands set out in NHS England’s vision for the future of the health service (the Five Year Forward View), policy-makers know they need to increase funding for the service and make efficiency savings, but all the while ensuring high quality care.

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The Conservative Party, in its 2010 election Measures in the White Paper sought to Health policy manifesto, promised to “strengthen give consortia of General Practitioners the power of GPs as patients’ expert responsibility for commissioning the guides through the health system” by majority of health services. It would background “giving them the power to hold patients’ abolish Primary Care Trusts and Strategic budgets and commission care on their Health Authorities (SHAs) and transfer – post 2010 behalf” and also “putting them in charge commissioning power to consortia of of commissioning local health services”. GPs – later called Clinical Commissioning Meanwhile, the Liberal Democrats Groups (CCGs) – providing they met election promised “elected Local Health Boards” accreditation standards overseen by the would “take over the role of Primary Care independent NHS board. Crucially, the reforms Trust boards in commissioning care for Government also sought to make the local people, working in co-operation with NHS immune from day-to-day political local councils.” considerations by establishing the independent NHS Commissioning Board When the Conservatives failed to win a – which became NHS England. These majority at the 2010 General Election reforms became the Health and Social and formed a Coalition with the Liberal Care Act 2012 (HSCA). Democrats, their ambitions for the health service coalesced into this Government’s arguably both most controversial and transformational policy.

Shortly after the formation of the Coalition, the Department of Health published the Equity & Excellence White Paper. The proposed reforms, driven by the then Health Secretary, Andrew Lansley, were to be a step change in the application of market-based principles in the health system and a radical reform of commissioning.

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The former structure of the health system:

Parliament

Arms Lenght Bodies Secreatary of State for Health

Co-operation and Department of Health Monitor Competition Panel

10 Strategic Health Authorities

152 Primary Care Trusts

Acute Trusts

116 NHS Trusts 137 Foundation Trusts

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The current structure of the health system:

Secretary of State

Department of Health

Public Health NHS Commissioning Board Health Watch England Monitor

Regional Regional Regional Regional Office Office Office Office

Primary 27 Local Offices Care

Local Hospital Council Care

Health and 211 Clinical Commissioning Groups Community Wellbeing Care Boards Mental Health

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service in a “Mandate” every year to the chance to influence these services The new NHS England, as well as the outcomes in their local area. So far, this has and corresponding indicators used to not been allowed, given the inherent hold NHS England to account through conflict of interest associated with GPs health NHS Outcomes Frameworks. commissioning their own services. landscape The NHS budget The effect of the reforms

The key result of the HSCA is that In 2013/14, the NHS was allocated a These changes mean that most NHS procurement is principally a matter budget of £95.6 billion. Of that, £65.6 decisions can no longer be controlled for local CCGs. The only services not billion was allocated to local health directly by Whitehall policy makers. Rather, commissioned by CCGs are specialised economy commissioners, and £63.4 local providers and commissioners must services, primary care services, offender billion of that sum alone was allocated take decisions led by ‘local needs’ that healthcare and services for members to CCGs. There are 211 CCGs in England also meet top-down targets. To influence of the Armed Forces. All of these are (two CCGs merged since the above commissioning decisions in the NHS, it commissioned by NHS England through map was developed), which broadly is still crucial to align a service or product its 27 nationwide Area Teams, but there have the same boundaries as local with a wider top-down policy agenda, but is an ongoing programme of work being authorities. CCGs organise the delivery even more vital to engage with the local undertaken by NHS England to move to of the majority of NHS services in commissioners and develop a bottom-up co-commissioning of specialised services England including urgent and emergency engagement strategy. The modern NHS is a and primary care services. This is due to care, elective hospital care and most system with 211 separate commissioning be completed in 2015. community health services. strategies. To sell across the NHS, the key is to align a national hook with regional and CGGs are held to account by NHS The remainder of community health local priorities. England’s 27 local area teams. These services are commissioned by local report to NHS England’s regional authorities, which were allocated offices and NHS England nationally. £0.9 billion of the NHS budget to NHS England forms a buffer between commission services, while £25.4 billion the Secretary of State and Department has been allocated for NHS England’s of Health. The Secretary of State now commissioning of specialised healthcare, merely has the power to set out the primary care and military and offender Government’s ambitions for the health services. This is in order to give GPs

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NHS England’s priorities for the NHS organising care in a locality, most likely Current debate were set out in Five Year Forward View headed up by a Foundation or NHS Trust. (FYFV) published in October 2014, which Under this model, hospitals could also has also set the agenda in health policy be allowed to open GP surgeries, offering – what will the since and is likely to continue doing so for an integrated, seamless service that is the coming years. tailored to dealing with the complex future of the health needs of an ageing population, Overall, the FYFV expects that a which seems to be the main focus of the combination of demand, funding FYFV. A similar integration is expected to NHS look like? increases and efficiencies would be take place for urgent and emergency care necessary to avoid a projected £30 billion services, through a redesign of A&E, GP shortfall by 2020, adding that annual out-of-hours, NHS 111 and ambulance uplifts of £8 billion are needed alongside services (see more below). efficiencies of two to three per cent to alleviate the shortfall. The FYFV also has a hefty focus on public health, as it acknowledges that lifestyle- The FYFV also proposes establishing new related diseases are the next big challenge primary care provision models that would to be addressed, suggesting a series of see GPs partnering with nurses, mental measures to tackle obesity, smoking and health specialists and other healthcare alcohol and to also promote employee professionals to provide “integrated out- health. Finally, the FYFV welcomes the of-hospital care, while potentially taking use of technology, calls for the fostering over the running of community hospitals of innovation in the NHS, and suggests that would further increase the range of measures on staff training, workforce services they offer (e.g. chemotherapy, numbers and the empowerment of patients. dialysis). These are called Multispeciality Community Providers (MCPs).

The Forward View additionally proposes another new care model, entitled Primary and Acute Care Systems. This would involve vertically integrated care systems

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The proposals were warmly welcomed Can the urgent and emergency care These pressures were not new in 2014/15, by all the major political parties. This system cope with demand? and had previously led to NHS England’s is vital as in order for the NHS to Medical Director, Sir Bruce Keogh, being radically overhaul the way in which There has been much debate about the asked to lead a review of urgent and care is delivered in England, there pressures on the urgent and emergency emergency care with recommendations must be a broad political and public care system following a winter in which for the future. Keogh’s subsequent vision support for such a change. This will not NHS trusts have reported the worst consists of top tier Major Emergency be possible unless such reforms are record against waiting time targets in ten Centres coordinating localised Emergency effectively communicated by politicians years. A number of reasons have been Care Networks to ensure a range of and commissioners to the wider public, cited for the unprecedented demand on urgent care provision across a locality, convincing them that whilst their the emergency care system, including: including walk-in centres, minor injury local hospital may lose out, in the long units and smaller emergency centres, run large-scale reorganisation will be • Cuts to social care services meaning which would be capable of assessing advantageous to the local area. that elderly patients cannot be sent and initiating treatment for all patients home due to a lack of care options in and safely transferring them where Most importantly Simon Stevens has the community, further hindered by a necessary. Within this, Keogh also called established himself as a leader above growing elderly population for greater integration of primary and politics with incredible influence over community care into the urgent care politicians. What Simon says really does go • Difficulty for patients accessing GP system, through better coordination of in terms of the NHS at the moment, and appointments at convenient times patient information and ensuring that he must ensure that he uses this political community services are provided outside capital to full effect if the NHS is to truly • Reduced out of hours primary care of the acute setting. see the benefits of the changes espoused services leading to patients not in the Five Year Forward View. knowing where they should head at Simon Stevens has also backed evenings and weekends approaches for more care to be delivered within the community, closer to • NHS111 operators consistently people’s homes, and more specifically referring patients to A&E regardless of in community hospital settings. Stevens their condition agreed with Keogh that the current system of care outside hospitals is “too • Staffing issues with high turnover a huge complex”, adding that “if you were problem due to the inherent pressures starting from scratch, you would not within A&E design community services like that.”

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Policy makers also continually espouse gap and really push on with moves to as one of “pragmatism”. He has said that the benefits of integrated health and provide more care in the community. they are intended to support the NHS in social care budgets. This is in order Simon Stevens and the NHS England delivery of health services and are not the to get the most out of the funding leadership will need to make sure that only solution, noting that NHS providers and reduce the growing pressure on incentives are in place for commissioners account for around 94 per cent of all care hospitals, with the aim to keep looking and providers to be bold and lead from delivered to NHS patients. after people closer to their own homes. the front in driving service change as set With this in mind, the Department of out in the Five Year Forward View. While the Labour Party has been keen Health created the Better Care Fund to to demand changes to the competition integrate NHS and social care budgets Competition landscape, the reality is that the reforms and encourage care to be commissioned did not deliver significant change to across traditional boundaries. This has One of the most contentious reforms competition policy, which is broadly as it been funded by £3.8 billion set aside introduced as part of the Health and must be to align with EU Directives. The in last summer’s Spending Round, £2.1 Social Care Act was the introduction view of NHS England, in public at least, billion of which is intended to come from of the ‘Section 75 regulations’. These is that the independent sector should hospital budgets. Jeremy Hunt believes committed commissioners to putting continue to provide a supportive role to that joint planning of services will see all health services out to tender, unless the NHS, rather than there being any them delivered closer to people’s homes, they could prove beyond doubt that the moves for all care to be provided by the stating that “our plan is to change the current provider was the only one that independent sector. basic NHS model from one centred on could carry out the service. This led to hospital care to one that helps people many opponents of independent sector In reality, patients do not seem too stay healthy and happy at home”. provision in the NHS to argue that concerned about who delivers their care, the reforms were actively encouraging be it from the independent, voluntary or The need for a shift in care settings has “privatisation” of the health service, as social enterprise sector, as long as care been discussed for a number of years, it was difficult for CCGs to prove that remains free at the point of use. Recent but will never take place without effort services shouldn’t be put out to tender. polling by Conservative peer Lord Ashcroft being made to shift funding away from found that 79 per cent of those surveyed acute settings. While initiatives such as There has also been criticism of the agreed with the statement “it is fine for the Better Care Fund may help in this burden this has placed on CCGs, many of the NHS to provide private companies regard, there has been little to suggest whom have had to seek legal advice as to patients as long as they meet NHS that the Department of Health or to the decisions they should take when standards, the cost to the NHS is the commissioners are willing to take the tendering. Simon Stevens has described same or lower, and services remain free at steps needed to address this funding his approach to independent providers the point of use.”

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Whilst the Labour Party believes that its own While some commissioners have undoubtedly legal advice proves that competition law can be been put on the back foot by the Section 75 amended as it would like it to be, it is unlikely regulations, the signs are that there are still that the party will be able to go as far as a number of services that will be tendered wiping out independent sector interest in the over the coming months. According to a NHS altogether. But promoting state run NHS recent investigation by the Health Service services so vehemently over other strands of Journal, 24 per cent of CCGs intend to tender provision could force out specialist voluntary for contracts worth around £1 billion before and community sector organisations, which is 2017 to provide community services, with a not the Party’s intention. further 25 per cent undecided. This gives both NHS Trusts and independent sector providers In all likelihood Labour will find it is restricted plenty of chances to successfully bid for, and in how it intervenes as a result of competition run, a number of services. law, given that it broadly sits in line with EU law. But there may be some room for manoeuvre over the wording of the current regulations in order to simplify the process, making it easier for commissioners to make decisions on whether or not to tender for different contracts.

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Polling throughout the winter of 2014/15 the NHS is to both parties on a scale of What do the has consistently placed the NHS in the zero to 10, voters had Labour at 6.69 and most important two or three issues for the Conservatives at 5.30. David Cameron voters in the UK. This is unsurprising can take heart from the results showing parties have given that the HSCA has been one of the that he was the only leader of the three most contentious issues of the current major Westminster parties to outscore his planned post- parliament and also the amount of media own party, coming in at 5.34. coverage given to A&E demand pressures over the Christmas period. Each party has looked to outbid the election? others over recent months with promises Whether voters like it or not, there of funding increases for the service and is no doubt the service has already promises to patients. David Cameron become a ‘political football’ with both announced that the Conservatives would the Conservatives and Labour looking to continue to ring-fence the NHS budget, pin current problems on the other party. with real terms increases in line with Much of the arguments in the House of inflation, and link health spending to Commons and on voters’ television sets balancing the budget, a point echoed are around historical issues as opposed by Health Secretary Jeremy Hunt. The to looking forward at options for future Conservatives have continually pointed out reform. What is more, arguments centre that any increases to the NHS budget will on language and tone taken on the NHS be dependent on a “strong economy” but with David Cameron looking to neutralise have noted that they would be prepared to Labour’s lead on the issue by accusing meet the asks in the Forward View should opposition leader Ed Miliband of trying to the economy recover sufficiently. ‘weaponise’ the NHS.

A more important question for party strategists is: who do the voters trust to put in charge of this service that they hold so dear? The answer to that question is categorically the Labour Party. When asked as part of Lord Ashcroft’s poll in January 2014 how important voters think

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The Government also used the 2014 The Party has also been quick to Priorities for 2015 Autumn Statement as an opportunity challenge NHS providers on their ability to provide a pre-election funding boost to provide high quality patient care, The Coalition Government and current for the service, with around £3 billion to through a more stringent inspections Health Secretary, Jeremy Hunt, will be spent on upgrading GP infrastructure regime and heightened enforcement continue to attempt to cool all talk of and helping providers along the way to powers for the Care Quality Commission the health reforms and focus on friendly meeting the new care models set out in (CQC). Meanwhile, it has introduced issues, such as improving how patients are the Five Year Forward View. The money measures to increase accountability cared for, not the structure in which care was described as a “downpayment” on among individuals involved in the takes place. The Conservatives will also the Forward View vision by Chancellor health service. This includes a new Fit point towards recent funding injections George Osborne. and Proper Persons Test for members as proof that they are committed to of boards of health providers, the improving the NHS, despite objections to The Conservatives have also pledged to introduction of Fundamental Standards this assertion from the Opposition. increase access for patients, one of the of Care, which providers must adhere to main issues cited by the public when or face prosecution, and legislating for By concentrating on patient safety polled on their priorities for the NHS, a new ‘Duty of Candour’ which states initiatives, the Conservatives are looking with a commitment that all patients that health providers must always to champion themselves as sticking would have access to seven day GP report on incidents where patients have up for patients, although they risk services by 2020. suffered moderate harm in their care. aggravating NHS staff by suggesting that The Government also plans to introduce tougher enforcement is needed to ensure The Conservative Party has not set out a new law that will see “deliberate or quality care. The Prime Minister has also an extensive vision for the future of the reckless behaviour” towards patients championed a return to old-fashioned NHS, aside from hoping recent reforms punishable by up to five years in jail. nursing, including the return of matrons to beef up patient safety and inspections on hospital wards, while Jeremy Hunt has regimes drive up standards across the made patient dignity a key part of his NHS. This focus came as a response to agenda as Health Secretary. Sir Robert Francis’s review into care failings at Mid Staffordshire NHS Trust, The Conservatives will also continue where it was identified that regulatory attack the Labour Party’s record in Wales, and oversight systems had failed to where the party is responsible for the address the Trust’s many problems in NHS, and have attacked Labour’s record providing the highest possible quality on waiting times and care failures. care to patients.

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preferred provider of NHS services. Priorities in 2015 Labour Party Labour has consistently argued that commissioners are not able to do their job • Ed Miliband has signalled his intention to attack Looking to capitalise on its lead in the polls effectively as they are too preoccupied the Government’s record on the NHS, in order on the NHS, the Labour Party has sought to with how best to adhere to competition to shore up the Labour Party’s lead on the issue make the Government’s record on the NHS regulations. Burnham has subsequently in the polls. The Party will claim that the recent personal for the Prime Minister, launching noted that, in practice, this is most likely reforms have led to the NHS being fixated on its election campaign by publishing a to mean that a failing NHS service is given competition law rather than service to dossier entitled “The NHS as you know it more time to turn itself around before the the patient. cannot survive another five years of David service is put out to tender to evaluate Cameron”. Led by Ed Miliband and Andy whether alternative provision would see • More specifically, Labour has pledged to repeal Burnham, Labour is looking to position an improvement in delivery. parts of the Health and Social Care Act should itself as the ‘saviour of the NHS’ by it win this year’s election, scrapping the Section claiming it is standing up for staff and also At Labour’s party conference in October, 75 regulations and other market orientated for the NHS against the private sector. Ed Miliband announced a number of NHS reforms brought in under the Act. measures to help stimulate extra funding Labour has set out its stall ahead of the for the NHS should the Party win the next • The Labour Party has looked to take on a General Election with the release of its election. The introduction of a £2.5 billion distinctly pro-NHS agenda, portraying the 10 year vision for the NHS. In the Time to Care fund would be funded by a Party as the “defender of the NHS” against document the Party lays out the how ‘mansion tax’ on properties worth more what it sees as policies introduced by the it will integrate the health and social than £2 million, the closing of tax loopholes coalition Government, which have led to the care systems with a single pooled and tackling tax avoidance (focused on City “privatisation and fragmentation” of the commissioning budget. Under the system hedge funds) and by levying a windfall tax health service. the party has said it will place on tobacco companies. full commissioning responsibility at the • The Party is also likely to push its own local level, which will likely lead to Health Building on Ed Miliband’s announcement integration agenda and “whole person care” and Wellbeing Boards assuming control of that a Labour Government would increase mantra as the debate intensifies over how both health and social care budgets. NHS funding by £2.5 billion, Andy Burnham the NHS will cope with an aging population. added that this would be repeated for A key pledge made in the 10 year plan every year of the next Parliament. • Increased focus on public health, including is the repealing of parts of the HSCA, plain packaging for tobacco and legislating including the Section 75 regulations, against high levels of fat, salt and sugar in and legislating to make the NHS the children’s food.

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made by the independent Office for Priorities in 2015 Budget Responsibility. Liberal The Lib Dems are unlikely to offer much Seemingly agreeing with Labour’s in the way of radical health proposals Democrats proposals, Health Minister Norman Lamb in the run up to the 2015 election, and has also pledged support for legislation will be keen to keep their involvement in The HSCA was another moment in this that would make it a legal obligation for the HSCA shielded as much as possible. Government when the Lib Dems had health and social care commissioners to However, given that Norman Lamb is to just hold their noses and hope the pool their entire budgets. He has stated considered one of the brightest and most smell would go away. With many Lib that “it doesn’t make sense to have effective Ministers currently serving in Dem supporters natural allies of Labour, two separate budgets in a local area”. Government, it would be a disservice rather than the Conservatives, some However, in looking to distance himself if they did not build on some of his believed that the HSCA went too far in from Burnham’s stance, he cautioned achievements, particularly in promoting encouraging a plurality of providers. his comments by stating that Burnham mental health issues. As such, the party’s is talking about a national health and focus on mental health at October’s At the Autumn Party Conference in care service, whereas he favours a more Party Conference was not too much of October 2014, Deputy Prime Minister “permissive approach”. Lamb commented a surprise. Nick Clegg announced a focus on mental that: “I would envisage that one may health for the Lib Dems, including want to set a date when you would encouraging a “parity of esteem for say by this date we will pool the whole mental health with physical health”, and budget … set an end point but then allow the introduction of waiting time targets different models to develop locally.” for mental health patients. It has been further reported that the focus on mental health is likely to become a core part of the Lib Dems manifesto for 2014.

On funding, Clegg has pledged to meet the full £8 billion requested annually by NHS England from 2020, with the Lib Dems plan based on the economy recovering in line with current projections

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