Tomorrow is the Day

I first voted in 1987, aged twenty, in the old Church Hall opposite my parents’ home. I voted at 10 o’clock in the morning, I was so excited to vote, so excited to finally get to be involved in the government of my country. Voting itself was rather an anti-climax. The voting booth was a hastily put together plywood stall, and I made my cross with a cheap, blunt pencil tied to the booth by a piece of sting. But I voted, I got involved.

I have always voted, ever since. Elections are the way we can shape our country, even if it doesn’t turn out the way we had hoped for. If we vote we are part of the political process, but this time what are the chooses for nurses? What has each party promised, in their manifesto, that they will do for nursing and the NHS?

(For the purpose of this blog I have just stuck to the three main political parties. In our political system fringe parties carry so little weight, even if some of them make the most noise)

The NHS is in crisis, to deny that is like the mythical ostrich hiding its head in the sand. NHS is seeing year on year increases in demand, we are facing an aging population with increasing healthcare needs, recruitment and retention of staff is at an all time low (last year there were 23,443 empty nursing posts in the NHS, 9% of the nursing workforce (1)), and the NHS has seen dramatic cuts to its funding in real terms since 2010 (NHS funding only increased by 0.9% each year since 2010 (2)). These are problems only a government can solve (or make worse), so what are the three main parties promising to do for the NHS?

The Conservatives

They are promising an extra £8 billion a year to the NHS, each year until 2022/23 (3). This sounds a lot of extra funding, money the NHS desperately needs, until you put it into context. The Department of Health’s budget this year was £123.7 billion (5), an £8 billion is a 6% percent rise but after seven years of 0.9% rises is this enough to repair the loss in funding. Simon Stevens, the head of NHS England, has said that the NHS needs an extra £10 billion just to keep going (6).

They will make the position of NHS staff from the EU a “priority” in the Brexit negotiations (4), but there are no guarantees or specific promises on what they will do. Previously Theresa May has refused any guarantee of a Right to Remain for any EU workers following Brexit (7).

The Conservatives have made big promises on social care (After a very public u-turn (8)). They have capped care costs at £100,000 (3), so after paying for your care needs you should be still left with a maximum of £100,000 in savings/assets. Previously if you had saving above £23,250 you paid for your own care, and any savings less than £14,250 were not counted in the means testing (9). But importantly the value of your house was not counted in these sums. This new Conservative cap of £100,000 of assets will include the value of your home. The average home in the UK is valued at £215,847 (10). A lot of people are going to be faced with having to pay for their own care.

They want to add an extra 10,000 mental health professionals to the workforce by 2020 (4), but that is their only promise on work force planning. They do not make any promises about the shortage of nurses facing the NHS, they seem to ignore that. There is no promise to end the public sector pay cap, so we will continue to see our pay fall in real terms and our colleagues leaving the NHS. There is nothing about the loss of student nurse bursaries and the low numbers of nurses being trained. The NHS is facing a workforce crisis and yet there is no mention of this either. And where will these extra 10,000 mental health professionals come from? We can’t recruit to fill the posts we already have vacant.

They want to carry on pushing ahead with the “seven day NHS” (4), but there is no mention for extra funding for it. Will the £8 billion extra funding be eaten up by this?

They also plan a “skills charge” (4) whereby any employer who recruits a foreign worker they will be charge £2,000 a year to employ them (11). The NHS currently employs about 134,000 non British staff (12), this will also eat into the £8 billion in extra funding. And the Conservatives are committed to cutting immigration to the tens of thousands each year. Where will that leave the NHS, with our reliance of on overseas staff, especially healthcare professionals?

The conservatives also want to “reform and rationalise” (13) healthcare regulation. So that means more changes to the NMC but don’t ask me what because “reform and rationalise” is the most detail they provide. After the embracement the Junior Doctors’ strike caused them, will there be no strike clauses in this new regulation?

And lastly, Jeremy Hunt is Secretary of State for Health, one of the most unpopular and patronising ones that I can remember in my life time. If the Conservatives are re-elected then the chances are he will remain in post, Theresa May didn’t move him in the re-shuffle when she became leader.

The Labour Party

They say they will give the NHS an extra £30 billion in funding over the next parliament (3). Again this looks like a big boost to NHS funding but a closer look and this is £6 billion or so a year, and the same question arises as with the Conservative funding promise, is this enough? The NHS not only needs to replace the funding lost in the last seven years but it needs to plan for the future, with increasing demand for its services. Last year there was a 3% increase in emergency admissions to hospital via A&E (14) alone. The NHS is going to have to expand services and provide new services to cope with this demand, and funding is needed for these.

They will restore the NHS treatment with 18 week guarantee (3). This is certainly needed because in March this year there were 130,000 people who had been waiting more than 6 months for treatment, after a referral to a consultant (15). That is a nearly threefold increase since 2013. With the present plan in place this is only set to get worse. Simon Stevens, the head of NHS England, has said some patients will have to wait longer for routine operations, such as hip and knee replacements, in a tread off with the increasing pressure on the acute side of the NHS (16). This promise will come as a welcome relief to many patients, if Labour achieves this, but they haven’t said how much it will cost and were the extra staff will come from. These waiting lists have increased because the NHS does not have the capacity to treat the rising demand in acutely ill people.

Labour says that NHS pay decisions to be made by an independent pay review body (4). Hopefully this will see an end to the 1% pay cap, but nurses’ pay has fallen in real terms by 14% since 2010 (17) and this has contributed to the extremely high number of empty nursing post we are now faced with, 9% of the workforce (1). On the subject of the NHS workforce, Labour will guarantee the “Right to Work” to all EU staff in the NHS. This will ensure that the NHS doesn’t suddenly face a huge staffing short-fall after Brexit.

Labour will also bring back the bursary for nursing training and abolish tuition fees (4). This will certainly ease some of the pressures on student nurses and hopefully should reverse the 23% fall we saw this year in the number of people applying to train as a nurse (18), the first year student nurse didn’t receive a bursary. But Labour do not say that they will ring fence money dedicated for nurse training. Since 2010, we have seen a 15% fall in the number of student nurse training places (19), as funding was used to make-up funding shortfalls elsewhere in the NHS.

They say they will “reverse” NHS privatisation (4). We have seen many examples of private companies failing to meet their NHS contracts and actually handing those contracts back because they were not profitable (Circle Holdings withdrawing from operating Hinchingbrooke Hospital (20), Bupa withdrawing from a musculoskeletal contact in West Sussex (21), and Coperforma losing Sussex non-urgent ambulance contract because their extremely poor performance (22)). How will this be achieved though, again Labour don’t say. Will it phrased in, as each contract comes up for re-newel it will be cancelled and the service returned to the NHS? Or will all the contacts be cancelled at once? This could leave the NHS open millions of pounds in compensation claims by the private companies. And remember, Labour did encourage private companies to take on NHS contracts when they were last in government.

Labour’s Shadow Secretary of State for Health is Jonathan Ashworth. He’s only been an MP since 2011 (23). Before being Shadow Secretary of State for Health he was Shadow Minister without Portfolio, and before that he was an Opposition Whip. He has never serviced in Government, never held a ministerial post, or even a Junior Ministerial post. He has only ever been an MP in an opposition party. How would he cope with the very high profile and high pressured role as Secretary of State for Health?

The Liberal Democrats

Their big, flagship policy on health is a 1p rise in income tax to fund the NHS, and long term a dedicated health and care tax (4). This would be a 1p raise to all rates of income tax, not just the basic rate. It sounds very impressive and sounds like it would raise the most funding for the NHS out of all the parties. But in reality a 1p raise would generate about £6 billion in increased funding (24), roughly the same as the other two parties. Of course if our economy goes into recession after Brexit then this could raise a lot less money.

They also promise that mental health care waiting time standards will match those in physical health care (3). Again this is a very needed aim, mental health services have always been the poor relation compared to acute physical health services, not receiving the funding or resources that physical health does. But this aim falls at the first hurdle, there are not enough mental health nurses to support this increase in service. Since 2010, the number of nurses working in mental health has fallen by 15% (25), in some places 20% of posts are standing empty. Also, there’s an aging population of mental health nurses, with 32% of them being aged over 50 (25), many of whom will be looking to retire within the time span of the next parliament. To have such an increase in a service there needs the workforce to support it, mental health services simply don’t have that.

They want to ensure that there are more nurses on hospital wards and in the community (3). Some of their other policies do seem to support this, such as: guaranteeing EU staff can remain in Britain after Brexit (4), ending the pay freeze (4), a premium for staff who work in deprived areas (4), though they don’t say how much, and bringing back student nurse bursaries (4), but they won’t end tuition fees for nurse training, will student nurses be faced with most of their bursary going on tuition fees? But is this enough to fill the 23,443 empty nursing posts (1)? Surely there needs to be more dedicated funding and strategies in place to do this?

None of the parties’ manifestoes seem to tackle head-on the problem of the 23,443 empty nursing posts. Is this just too big a problem for their manifestoes or do none of them actually know what to do about it?

The Liberal Democrats’ spokesman on health does seem to be someone with some experience of holding a ministerial post in the Department of Health. Norman Lamb was the Minister of State for Care and Support during the coalition government (26). But the coalition government did not have a fine record on health and the NHS, they were the government that first cut NHS funding in real terms.

Brexit

This is the huge problem that hangs over this election and a huge potential problem facing the NHS. There are tens of thousands of ex-pat British pensioners living in Europe. If we do leave the EU with a hard Brexit they could be forced to return to Britain. It is estimated that their return could cost the NHS an extra £120 billion a year (27). None of the parties have made any proposals to deal with this, and this large increase in demand could swamp or even break the NHS. All the parties’ increases in funding combined would just be a drop compared to what is needed.

12% of NHS employees are non British and 5.5% (About 60,000 people) are from the EU (12). If we are hit with a hard Brexit and EU nationals are forced to return to their home countries, where will that leave the NHS? Losing 60,000 staff almost overnight could break us, it would certainly make many NHS services dangerously under staffed. Since the Brexit Referendum we have seen a 92% fall in EU nurses coming to work here (28), and that has hit us hard. Could we cope with an even smaller pool of people to recruit from?

And what if the economy crashes into a recession following Brexit? The three main parties have all promised increases to NHS funding, but NHS funding is reliant on the government raising enough revenue through taxation. If our economy falls into recession that revenue could be seriously hit and there would be a knock-on effect on NHS funding. NHS funding was cut to only a 0.9% yearly increase in 2010 (2) as part of the then government’s austerity policy, cutting public expenditure to fund a cut in the deficit. How much more would NHS funding fall by if our economy tanked?

The NHS presents many and often unique problems, complicated problems that require a multilevel approach, and yet to me these three manifestoes just seem to be tinkering around the edges of the problems. Is it because our politicians do not have the political will to tackle them, saying politically unpopular things and facing politically unpopular choices? Or is it because our politicians simply do not know what to do about the NHS or just don’t understand its problems?

I’m going to vote tomorrow, and the NHS is a big deciding factor in who I vote for.

Drew Payne

PS. My special thanks goes to the Nursing Standard magazine, especially the Election 2017: Party policies and the future of the NHS article (4), and the BBC’s General election 2017: Manifesto guide on where the parties stand webpage (29), because they have done the work so we don’t have to. They read the party manifestoes.