At just over £7 billion, health and social care makes up 46% of the Welsh Government’s expenditure. And over the fourth term of the National Assembly health controversy was never from the headlines. This was, in part, inflamed by the fabricated claims of David Cameron in the run up to the UK general election that Offa’s Dyke had become a line between life and death in the UK.

Since then two independent reports, by the Nuffield Trust and the OECD, has exposed Cameron’s scurrilous claims. They showed there was no substantial difference between the various health services across the UK.

Delivering quality public services is becoming ever more difficult across all of the UK at a time of austerity and a politically motivated assault to reduce the role of the state. And the problem is all the more difficult in Wales with its older, poorer, sicker and geographically dispersed population. Suprisingly none of the party manifestos have chosen to present their policies in this wider context. The hostile background for public services is taken as a given. And only the Greens have made any substantial point about the continuing health inequalities that the NHS in Wales faces.

Across the six main contesting parties (Welsh Labour, Tories, Plaid Cymru, Lib Dems, Greens & UKIP) there is a fair level of common ground on what the main issues are with many parties proposing similar solutions. But there are also substantial points of difference where the “hearts and minds” battles will be fought.

Welsh Labour has the double challenge of defending its record while still showing that it retains the vision and capacity to continue to be the main party of government. It takes comfort from the 2015 Wales National Survey which shows continuing levels of satisfaction with the Welsh NHS of over 90% for GP and hospital care. However in many parts of Wales, particularly in the west and north, service change and re-configuration has been controversial and not always welcome.

Welsh Labour’s spend on health and social care is £172 more per capita than it is in England. While waiting times are longer in some areas in others, like cancer, care is generally better than the other side of Offa’s Dyke. And in Wales there continues to be no prescription or hospital parking charges. As well new legislation has been introduced to modernise social care and organ donation.

In the earlier part of this Assembly term health & social care spending was constrained due to Westminster cut-backs and the need to meet other priorities such education. The Welsh Tories, strained “might and muscle” to contrast this with the spending on health in other parts of the UK. However Welsh Labour was always able to convincingly deflect some of this criticism onto the Conservatives and Welsh Liberal Democrats by highlighting of the overall reductions in its budget due to the Coalition and then Tory austerity programmes.

Plaid Cymru had the double luxury of being in opposition with no record to defend. They were at liberty to piggy back on any issue of their choice and to make political capital wherever difficult or controversial decisions had to be made. But this could only get them so far if they were to position themselves as being a serious party of government rather than being a mere “party of protest”. It is only in the last few years that they have begun to formulate distinctive policies which could be open to scrutiny and debate. And some of these ideas are now part of its election manifesto.

While Plaid insist that their policies have been subject to an independent economic validation, much of its programme is based on the expectation to be able to make £300m annual health savings by the end of its first term. This seems very speculative in view of the Tory Governments continuing commitment to austerity budgets. Without finding a lot of extra resources Plaid’s capacity to deliver on its most ambitious and attractive commitments will remain uncertain.

No party is offering to re-introduce a market for health care in Wales with a number of them, though not the Tories, making explicit commitments to no privatisation. Indeed the Tories do use the language of the market when they speak of local health commissioners without clarifying the status of health and social care providers. So they are keeping their options open.

In contrast to all other parties which are promising structural continuity and stability Plaid is offering a major NHS re-organisation. It promises to establish of a national board for hospital services. This will inevitably reduce local accountability for decisions on acute and hospital care which has been a lightning rod for much discontent about the Welsh NHS. It also proposes merging community health with social care in a “regional combined authority” derived from local authorities. It is not clear over what period of time this will take place but it will inevitably distract staff from service delivery. It will however, in line with UKIP and the Tories, bring an element of direct democracy to the operation of local health organisations.

Plaid also promise to abolish domiciliary care charges for the elderly within two years and dementia care charges in their first term in government with the abolition of residential social care charge for the elderly in a second term. In contrast the Tories propose a top limit of £400 / week on residential home charges and a £100k asset disregard. From April 2015 Welsh Labour have introduced a £60 cap on domicilliary social care charges and it proposes to double the Welsh asset disregard to £50k.

The Tory Manifesto is a almost a wish list. It proposes a number of ring fenced funds to deliver a range of services including a £100m cancer patients fund. In the last Assembly the Tories championed a cancer drug fund similar to one in England with little acknowledgement of the many problems and revisions of the English scheme. By way of contrast Welsh Labour is offering a new £80m “New Treatment Fund” which will target improving access for a wider range of illness to a more varied range therapies. The Tories also promise no more hospital closures as well as re-opening a number of clinical units and departments which have had to close for safety and sustainability reasons over recent years.

No more than Plaid Cymru affordability is at the heart of Tory proposals and like Plaid their “big pot of gold” is in efficiency savings with the exception of re-introducing prescription charges. They remain wedded to the UK government’s austerity programme and also propose, in the event of income tax varying powers being devolved to Wales, to reduce income tax and freeze council tax. This will inevitably increase resource pressurs on our public services including the NHS.

The Liberal Democrats have the laudable objective of seeking to create “an NHS that has time to care”. Like a number of other parties it proposes to get rid of the mandatory “15 minute” social care time slots and to increase access to GP services. This will not only involve improved provision but also a greater use of information technology.

There is a recognition across the board that achieving these objectives will demand more staff. Plaid sets the bar very high with a pledge to recruit an extra 1,000 doctors and 5,000 nurses. Apart from the cost involved such increases would be a 3-4 fold increase in current rate of medical recruitment and an even higher increase for nurses. Welsh Labour is already spending £85m on health care professional training and education and it is pledged to increase nurse training places by a further 10%.

There are many areas of shared concerns across the manifestos. All are agreed that there needs to be more integrated health and social care delivered in a community setting. While the details differ, all parties agree that there should be more community based and shared multidisciplinary units across Wales where integrated health and social care can be delivered and to where traditional hospital service, particularly in areas such as cancer, can be transferred.

All parties also recognise the need to improve the quality of care for people with mental health problems. The stigma attached to these conditions need to be challenged. Greater emphasis needs to be given to the times that patients wait for care with increased timely access to “talking treatments”. There needs to be greater equity between adult and children’s mental health services.

All parties give a clear commitment to a range of public health measures, many of which, in the words of the Green’s manifesto, seek to remove the barriers to good health. Indeed it would be fair to say that the Green give a high priority to high level public health issues while being less speciific about operational issues which take up much of the NHS debate in Wales. This is in contrast to the Tory approach which seems to be obliviouss to the public health implications of policies which are creating greater poverty and social division in our society.

So at one level in these National Assembly elections there is a suprising level of consensus on what are the big challenges. And in many areas there is consensus on the broad principles on which responses should be based. But there is also a wide choice in many areas. And even more so there is “the test of credibility” on the capacity of each of the parties to deliver on what they promise.

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