Category Archives: Conservatives

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We will never know how many patients will have died or will die because the Prime Minister is prepared to uphold austerity measures in the face of the worst crisis to hit the NHS for many years.  Home Secretary, Mrs May forced through cuts in police budgets and she is now prepared to face out calls from many distinguished health figures warning of the consequences if the NHS does not receive an immediate emergency cash injection.

The announcement that medical students are being persuaded to assist the NHS crisis is a further indication of deteriorating health services under austerity.

Another example of the utter policy failure of the May government is to be seen in the removal of student nurse bursaries that funded their study and help with living costs.  The nursing shortfall caused by years of undersupply is at further risk of worsening if Brexit affects international recruitment.

Beyond the current NHS austerity crisis there is the advent of “Accountable Care Organisations” that would introduce new commercial non-NHS bodies to run health and social services without proper public consultation and without full parliamentary scrutiny. Currently the Courts have agreed to a Judicial Review, made possible by public funds. These ACOs would represent the breaking up of a single national health service with national terms and conditions, into 44 sub-regions with fixed restricted budgets and rationed services.  This implies a loss of all the principles behind the NHS, a loss of universalism, comprehensiveness, national terms and conditions and quality standards.  Even if they were wholly in the public centre that would be the case.  And public ACOs would still very clearly be a stepping stone towards patient selection, personal health budgets, co-payments, charges, insurance and ultimately privatisation.

In this,  the year of NHS 70,  we must be ready to celebrate but also to strongly PROTEST at the extreme threats to our beloved NHS.

As Nye Bevan, the creator of our national health service said: “Illness is neither an indulgence for which people should have to pay, nor an offence for which they should be penalised, but a misfortune , the cost of which should be shared by the community”.

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Printed in New Statesman in October 1994 in a competition asking for poems by doctors. 

 

Yet another awful day which sets me thinking glumly

That it’s time to write a letter to the dreaded Mrs Bottomley.

“Dear Sir, My frank opinion of your ‘Health Reforms’ is this:

That they do not work and never will: they’re just a load of contribution!

What seems to be the problem, and please do not say I’m lying,

Is I’ve just rung seven hospitals while patients here are likely to require only tender loving care,

And some say ‘Try Mount Vernon’ and others ‘Tooting Bec’

When I see that Trust Director I will dislocate several of his cervical vertebrae!

If you’d only seen me earlier before you drafted bills

I’d have diagnosed the problem and prescribed these special – can’t quite read what I wrote there –

Next please! “ I mean “Yours Faithfully”.  I hope I really shocked her,

“An overbudget, overworked but loyal General Practitioner, B. Chir, M.R.C.P., L.R.C.S.”

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It is tempting to join in the general hilarity of the Prime Minister’s speech to the Tory Party Conference, portrayed at large as Carry On Up the Conference!

TM: (coughs and is offered a cough drop)

Chancellor: Have one of these!

TM: Don’t mind if I do!

TM: Oh dearie me, I can’t talk and suck at the same time!

Cut to shot of conference delegates and gales of canned laughter.

But the day before the speech the headlines shrieked, ‘Up to 8,000 deaths every year may be caused by rising bed-blocking’. And the day after, we have the grim news that the Royal Cornwall Hospital has been put in special measures after delays in processing test results, cancelled appointments and increasing waiting lists are likely to have led to deaths and blindness.

According to the Guardian’s article on the Royal Cornwall, “We were informed of two patients who had died of cardiac-related causes while delayed on the waiting list,” inspectors say in the report. “While it is not possible to say the deaths were directly linked to the delay, the trust reported it was highly likely.” Hundreds of patients with cardiac problems had experienced ‘notable’ delays along with 6.503 patients with sight problems.

The research which produced the ‘8,000 deaths’ headlines, published in the BMJ Journal of Epidemiology and Community Health on 2 September 2017 stated the already known statistic that 2015 saw the largest annual increase in mortality for almost 50 years. The research was an exploratory study which shows that the increasing prevalence of delayed discharges between the NHS and social care and the increased waiting time for acute patients has a positive association with the number of deaths and mortality rate.

In short, two of the country’s key support systems designed in principle to keep people healthy are failing in their task under the auspices of Theresa May’s government, which bears the ultimate responsibility.

The tone of May’s conference speech was set by a blithe autobiographical reason why she is a Conservative, ‘at its heart a simple promise that spoke to me, my values and my aspirations that each new generation should be able to build a better future…the British dream’. As her central theme, she praised and embedded the free market system at the heart of her agenda, as the engine of progress, the great innovator and provider of opportunity and equality, effectively acceding the responsibility of government to the market as she did so. She ended with an extraordinarily condescending approach to what could be paraphrased as the ‘common folk who don’t bother about great affairs of state like this as they scurry about their little lives’ and for whom she says she has dedicated her political career, working for ‘the most vulnerable’ and ‘giving a voice to the voiceless’.

On the NHS, May talked of, ‘investing more in mental health than ever before,’ whilst Jeremy Hunt solemnly nodded his agreement from the audience. She blamed out of date legislation from 3 decades ago for any problems currently being experienced. She talked of ‘our great national achievement: our NHS’. ‘Let us not forget’, she said, ‘that it is this party that has invested in the National Health Service and upheld its founding principles through more years in government than any other’.

To hear a Conservative Party leader describe the NHS as ‘the very essence of solidarity in our United Kingdom…a symbol of our commitment to each other’, in the face of the service’s near-collapse from the top down re-dis-organisation, de-funding and privatisation is surely to have passed through The Looking Glass. She talks of year on year per-head increases in expenditure on the NHS, of the greatest investment in training of doctors and nurses ever. She says they will always support safe, high quality care.

The reality on the ground is a list of serious issues confronting the NHS as a result of constant turmoil from NHS England’s endless series of ‘new’ models and test-beds, re-shaping the service to fit the 5 Year Forward View. There is the current report on delayed discharge and increased mortality; the CQC report on the Royal Cornwall; serious difficulty in recruiting to fill the GP shortfall (Pulse magazine reported earlier this year an increase from 2.1% unfilled GP vacancies in 2011 to 12.2% this year); constant A&E crisis; scapegoating of one group of patients or another as the cause of all problems; and more.

At a bare minimum it is unacceptable that Theresa May should position her party as the custodians of the NHS.

Let us assume for a moment that she does not understand the current progress of the NHS towards US-style Accountable Care; that she has been convinced that it is simply a change in the management style, not a radical undermining of the principle of universality. Then we are left with the possibility that the worst of this situation may lie in her blithe confidence in the ‘values’ of her party and her belief that only a further de-regulated free market economy can provide the strong economic background needed to support the NHS. In that case she would appear to be immunised to the truth.

Either way we are faced with the real possibility that has existed since David Cameron’s, ‘I’ll cut the deficit, not the NHS’. She either knows what is happening to our greatest public service under her government and lies about it. Or she doesn’t know in which case she and her party are not fit to govern.

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Cheered up by last week? The last few weeks have given us a respite from a seemingly endless wave of victories by populists and the right: after a miserable 2016, we have seen the radical right narrowly defeated in the Austrian presidential election, heavily defeated in the second round of the French presidential election and in the legislative vote, in decline in Germany and locked out of government in the Netherlands. And did I mention a hung parliament in the UK?

Brexit bus

It might be nice to relax and go back to critiquing neoliberalism, but we should not. The populist radical right is still a force to worry about for four reasons.

First, these electoral victories are not so impressive as they might look. In electoral terms, these votes are still scary. Only in the context of 2016 should we be glad that over forty percent of the French and Austrian electorates have voted for candidates from the darkest areas of the right.

Second, the right is directly wielding a lot of power. The radical right is in government or close to it in a number of smaller European countries. Trump is president. Despite much wishful thinking, he is likely to be president until January 2021. The UK is still likely to be governed by the Conservatives… partnering with the Democratic Unionists, a party of the radical right that has benefited until now from the refusal of the UK media to pay attention to Northern Ireland.

Third, the right shapes agendas. There is an alarming coincidence between the manifestos of UKIP and the manifesto that gave the Tories one of their highest-ever vote shares in the last election. The French even have a word for it: Droitisation, or the way the far right pulls the moderate right and even the center-left towards it, aping its arguments in an effort to get its voters. Theresa May’s whole campaign is a nice example of that. But Jeremy Corbyn, who broke with convention on so much, didn’t break with the increasingly nativist tone of politics on Brexit or immigration control.

Fourth, as the last two years have shown, politics after a decade of financial crisis isn’t easy to predict. Parties and party systems across the West have been losing stability for decades, social democratic parties have been eroding and the center-right becoming less centrist while the populist radical right parties grow.

Political scientists have written much about the populist radical right, which I review in a new article (free). The populist radical right has three characteristics. It is populist, siding with the people’s common sense over elite knowledge. It is nativist, believing there is a nation that needs defending. And it is authoritarian, expressing love and respect for authority. In the UK, that means UKIP and the DUP as well as some solid fraction of the Conservative party.

This is basically a toxic brew from the perspective of any likely reader of this blog. Populism is affirming since it relies on arguments anybody can understand. Authoritarianism is both popular in its own right and easy to trigger with, for example, scare stories about migrants.

Nativism, finally, can lead to “welfare chauvinism”, or what Alexandre Afonso calls “fake socialism”: not a neoliberal platform of cutbacks, but rather a generous and very exclusive, nativist welfare state. Think a well funded NHS that you can only use if you provide two forms of ID proving you legally reside in the UK. Trump, Le Pen, and May all campaigned on platforms with a strong element of welfare chauvninism.

Fortunately, there is not a lot of research showing that the populist radical right in office actually pursues welfare chauvinist policies. For a long time, the research found that they ran on welfare chauvinist themes and then enacted classic right-wing cutbacks (which is what you would expect of parties with a strong base in small business people who are notoriously hostile to regulation and welfare states). More recent research has found that in systems where they enter government in coalition, such as Austria or Belgium, they achieve little and what they achieve is in restricting access to benefits- more chauvinism, but not more welfare. The main reason or that is coalition government, which tempers the policy effect of any given party. The newest research seems to show that they also cut back less on welfare budgets relative to more conventional right parties. So: lots of chauvinism, not so much welfare.

In other words, the potential of welfare chauvinism is not being exploited, or at least consistently translated into policy. Trump is a particularly extreme example. After running as a welfare chauvinist candidate (whose logic pointed to a fully funded NHS for white people), he is promoting a Tea Party agenda that will be devastating to, in particular, working class rural whites above fifty who are a key part of his support. May talked a good welfare chauvinist game until people saw the Conservative manifesto, which was chauvinist without the welfare.

As the Canadian writer Jeet Heer noted of the unexpectedly good Labour result, it “looks like you can get young people, minorities, and white working class in a coalition if you offer them something.” That is a niche worth filling. Social Democratic parties exist to fill it, and collapsed after instead becoming unconvincing catch all parties. The populist radical right remains a threat, but if it empowers social democrats to actually pursue social democracy, then the long run outcome might be positive.

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The NHS is facing persistent rising costs and funding pressures. Health care needs continue to rise as a result both of an ageing population and of a changing profile of morbidity, with increasing numbers of people suffering multiple long-term conditions. Even more cost pressures arise from technology and medical advances, and the labour intensive nature of much health care means that the NHS rate of inflation is significantly higher than the general rate of inflation.

Funding pledges

Yet neither the Labour nor the Conservative manifestos promise adequate funding. While the Conservatives are promising an extra £8bn a year by 2022, and Labour an extra £12bn in comparison with current funding, this represents in both cases a further decline in the proportion of the GDP being allocated to health care (from 7.3% in 2017/18 to 7.0% and 7.2% respectively, according to the Nuffield Trust). This is likely to reflect a commitment by Conservative-led administrations to reduce the share of the national income accruing to the NHS and, perhaps, a view in Labour circles that the NHS has so far got off lightly under austerity, compared to other departments’ cuts.

While the obduracy of the government and its ideological ambivalence concerning the NHS make the Conservative proposal unsurprising, Labour’s stance must be seen as a disappointment. The impact of the financial stress endured by those working in the service, and the mounting scale of cuts and closures to services consequent upon inadequate resourcing are effectively being disregarded.

Labour promises extra capital funding but does not say by how much; the Conservatives promise £10bn of capital expenditure but do not say where the funds will come from. There is of course an irony in borrowing more expensively from the private sector when public borrowing is so cheap.

Mental health services

Commitments to funding are not a minor detail since they point to doubts as to whether the parties’ other health proposals can be achieved – and this is not just the re-pledged commitment by the Conservatives to a ‘truly seven-day NHS’. Labour promises ‘well-resourced services’, ‘safe staffing levels’ and ‘world-class quality of care’ despite the fact that inadequate funding may make these impossible to achieve. Labour will also attempt to ‘tackle’ the rationing of services and will end the ‘routine breach’ of safe bed occupancy levels but as each is likely to entail an expansion in capacity, the party’s stance on funding may impede their achievement.

This will be a source of particular anxiety to those keen to see improved mental health services. Here, Labour promise parity of esteem; ring-fence budgets; increase the proportion of the mental health budget spent on children; and end out-of-area placements. Oblivious to the consequences of their stance on funding, the Conservatives promise that those with mental health problems will get the ‘care and support they deserve’ and that medical training will ensure a deeper understanding of mental health.

Health care reorganisation

The Conservatives remain committed to the contentious Sustainability and Transformation Plans (STPs), drawn up in secret at a local level to reorganise services and simultaneously cut their costs. The privileging of financial sustainability has rather overtaken the promised transformation. But, contrary to government and NHS England assumptions, transferring services out of acute hospitals and into community settings is unlikely to achieve cheaper health care if they are to remain high quality services. Moreover, the transitional period itself requires additional funding. ‘Vanguard projects’ are currently piloting new ways of providing services and local NHS leaders are being expected to implement changes while an evidence base is still to be produced.

Labour does not promise a roll-back of STPs but instead a ‘halt and review’, with local people invited to participate in redrawing them. This feels an ambiguous passage in the manifesto which might reflect the competing pressures of cautious endorsement of STPs from some think-tanks, given the funding constraints and the perceived desirability of making more services available in community settings, on the one hand, and the fierce opposition, on the other, from local people who experience their STP as the vehicle by which large-scale cuts and closures are being implemented.

Staffing levels

Quality services also require adequate staffing levels. Labour has costed its plans to reinstate bursaries for nurses and to lift the pay cap for NHS staff – some of whom have suffered more than a 10% reduction in the real terms value of their pay since the financial crash. Its commitments on NHS staffing – recruitment and retention – differ somewhat from those in the Conservative manifesto. Labour promises an immediate guarantee of the rights of EU staff, lifelong education and development for doctors, and reinstating the role of the independent pay review body. The Conservative Party promises 10,000 extra staff in mental health service, an extra 1500 doctors a year in training, stronger staff entitlement to work flexibly, and the development of new roles in health care. This is perhaps to facilitate the shift to more generic roles heralded in some STPs, and the greater use of unregistered nurse associates and physician associates to supplement (or supplant) the registered professionals. Where all these staff will come from remains unclear. The Conservatives offer EU nationals working in the NHS only the promise that they will do their best for them in the Brexit negotiations.

Privatisation

Those who have been campaigning against privatisation and the use of market forces in the NHS will welcome Labour’s commitment to reversing the privatisation of the NHS. They will also hope that this is compatible with Labour’s promise to introduce a new legal duty on the Secretary of State to ensure ‘excess private profits are not made out of the NHS at the expense of patient care’. They will certainly welcome the repeal of the infamous 2012 Health and Social Care Act.

The Conservative manifesto also points to the prospect of legislative change and indicates that the provisions of the Health and Social Care Act – a highly unpopular piece of legislation among both campaigners and professional associations – may not be sacrosanct where they interfere with the implementation of STPs. This hints at the fact that much STP activity has occurred outside statutory provision and is an implicit acknowledgment by the Conservatives that Accountable Care Organisations (ACOs) offer a better route to commercialisation than a model based on a competitive provider market in a time of financial constraint. Anti-privatisation campaigners, aware that ACOs can be contracted out to non-public organisations and always suspicious of Conservative intentions, will take little comfort from this.

This was first published on the British Politics and Policy blog.

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And does it matter if I still get treatment free at the point of use?

The short answer is yes, not just plans but plenty of private contracts have been issued taking the NHS down the privatisation route. And yes, it will matter to you when you have to pay for your treatment from medical insurance and risk bankruptcy if you require multiple or long-term care. Here is the ‘blueprint’ for privatisation laid nearly 30 years ago by Letwin and Redwood – see for yourself how close we are to the end game.

In 1988 Letwin and Redwood (conservative) laid down the blueprint for the privatisation of the NHS.  It is worth reading this document in full as it will explain both our current position and give insight into the next steps.

Letwin and Redwood

Starting with a negative analysis of the use of waiting times to ration resources they swiftly moved into the reasons why the NHS needs a fundamental overhaul:

At the end of 1986 (the latest date for which figures are available), there were almost 700,000 people on NHS waiting lists; of these, half were destined to wait more than two months for treatment and one in fifty for more than a year.

When compared to today’s figures of 3.66 million waiting for routine treatment, up 11% from Dec 15 – Dec 16 and a target time now of 18 weeks (nearly 5 months) with 92% waiting significantly longer than that, House of Commons/Feb/2017  we can see the figures used by Letwin and Redwood actually reflected an efficient NHS service.   But then the premise for privatisation must start from the basis that the current system is broken.  

By chapter 2 they confirm;  [note the italics]

The need for change is now widely accepted.

The first step is to restructure at management level and make the NHS bodies independent to ‘give clear lines of responsibility’ which do not reach back to government.

  1. Establishment of the NHS as an independent trust.
  2. Increased use of joint ventures between the NHS and the private sector.
  3. Extending the principle of charging.
  4. A system of  ‘health credits’.
  5. A national health insurance scheme.

It would appear that we are currently moving between point 2 and 3 of this agenda.

By chapter 3,  Letwin and Redwood introduce the notion of charging – an idea fundamentally at odds with the ethos of the NHS – free at the point of delivery.

Another avenue which has been tentatively explored by the Government is charging. In principle, this could be extended to the point of universality – a charge for every service. That could permanently solve the problems of waiting lists and of basic attitudes towards patients – since the NHS could charge enough for each service to ensure that demand matched supply, every patient would become a valuable customer, bringing  funds to the system. If combined with the establishment of the NHS as an independent trust, this would in effect turn the NHS into a nationalised non-profit service competing on level terms with the private sector, and at arms-length  from the Government.

The NHS was already a nationalised non-profit service, so what is new here is the idea that it should ‘compete on level terms with the private sector’ and be ‘arms-length’ from the Government.  ‘Charge enough for each service to ensure that demand matched supply’ indicates hiking prices on treatments in demand – in the same way that airfares rise in school holidays.  Aware that charging would preclude sections of the population from accessing health care the pair put forward the idea of ‘credit notes’ which would create a two-tier system.

Each individual patient would receive, from his GP, a ‘credit note’, entitling him to treatment for a specific complaint. This credit note would cover the charge ·levied by the NHS for the treatment in question. If the patient chose instead to go to a private sector hospital he would be entitled to carry the credit with him making up any difference in cost out of his own resources or through private insurance.        

In order to bring in the ‘benefits of marketisation it is suggested that;

In short, increased competition would be created not only between the NHS and the private sector but also between one NHS hospital and another. Under such an arrangement, it might be possible to go even further than the establishment of the entire NHS as an independent trust or company: each major hospital or district could be separately established with only a national funding authority left at the centre to administer the payment of credits.

And finally, we reach the end goal – a fragmented NHS service, competing with itself and private providers, funded by individual payments into a National Health Insurance Scheme. 

A method of overcoming the drawback of a pure ‘credits’  scheme is to ally it to a national health insurance system. Under such a system, every adult would contribute a fixed insurance premium each year to a national health insurance fund.

Having established that under this scheme the NHS would charge the full cost of each treatment to be reclaimed by insurance, Letwin and Redwood confirm;

The existence of a national health insurance scheme would not, of course, be to the detriment of the private sector. Indeed, under any of the variants, contributors to the national scheme could be given rights to carry some or all of the insurance cover to the private sector, either in the form of rebates for private insurance or in the form of ‘credits’ usable in private sector hospitals.

The insurance premium could be actuarially adjusted, like car insurance to reflect the varying risks associated with different categories of contributor though this would need to be balanced by subsidies to those who were not well off, and were either already ill or in a high – risk category.

Before concluding;

To a great degree, the divisions between the public and private sector would fade.

Indeed, given that we would all be paying the full cost of treatment from our own insurance policies.  If you have recently taken a pet for treatment at your local vet you will know the eye-watering cost of a single blood test, let alone the management of a long-term condition.  Although apparently convinced by their own arguments, they realised that moving from a universal system of free treatment to one where we individually cover our own care through differentiated insurance, would take time.

A system of this sort would be fraught with transitional difficulties. And it would be foolhardy to move so far from the present one in a single leap. But need there be just one leap? Might it not, rather, be possible to work slowly from the  present system towards a national insurance scheme? One could begin, for example, with the establishment of the NHS as an independent trust, with increased joint ventures between the NHS and the private sector; move on next to the use of  credits’ to meet standard charges set by a central NHS funding. administration for independently managed hospitals or districts; and only at the last stage create a national health insurance scheme separate from the tax system.

‘…and only at the last stage create a national health insurance scheme separate from the tax system.’   The last stage is presumably when the entire reorganisation is complete and we have no option but to take out our own insurance policies.

Read more of this story by following the link below and find out how talks between Jeremy Hunt and Kaiser Permanente are sealing the deal with the big US health insurance companies waiting to step in.

This is an editted version of a post by socialistinsurrey.com.

 

 

 

 

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Extracted from the Conservative Manifesto

The mental health gap

It was Conservatives in government that gave parity of esteem to the treatment of mental health in the National Health Service. We have backed this with a significant increase in 57 funding: since 2010 we have increased spending on mental health each year to a record £11.4 billion in 2016/17, with a further investment of £1 billion by 20/21, so that we can deliver the mental health services people deserve. We will now build on this commitment.

First, we will address the need for better treatments across the whole spectrum of mental health conditions. We will make the UK the leading research and technology economy in the world for mental health, bringing together public, private and charitable investment.

Improving treatment services will not be sufficient, however. We will also reform outdated laws to ensure that those with mental illness are treated fairly and employers fulfil their responsibilities effectively.

The current Mental Health Act does not operate as it should: if you are put on a community treatment order it is very difficult to be discharged; sectioning is too often used to detain rather than treat; families’ information about their loved ones is severely curtailed – parents can be the last to learn that their son or daughter has been sectioned. So we will introduce the first new Mental Health Bill for thirty-five years, putting parity of esteem at the heart of treatment.

We will transform how mental health is regarded in the workplace. We will amend health and safety regulations so that employers provide appropriate first aid training and needsassessment for mental health, as they currently do for risks to physical health, and extend Equalities Act protections against discrimination to mental health conditions that are episodic and fluctuating. We will consider the findings of the Stevenson-Farmer Review into workplace mental health support, working with employers to encourage new products and incentives to improve the mental health and wellbeing support available to their employees. And, as we did with Dementia Friends, we will train one million members of the public in basic mental health awareness and first aid to break the stigma of mental illness.

The disability gap

We will build on the proud Conservative record in supporting those with disabilities, including the landmark Disability Discrimination Act of 1995. We want to see attitudes to disability shift as they have for race, gender and sexuality in recent years: it should be completely unacceptable for people with disabilities to be treated negatively.

We will get 1 million more people with disabilities into employment over the next ten years. We will harness the opportunities of flexible working and the digital economy to generate jobs for those whose disabilities make traditional work difficult. We will give employers the advice and support they need to hire and retain disabled people and those with health conditions. We will continue to ensure a sustainable welfare system, with help targeted at those who need it most. We will legislate to give unemployed disabled claimants or those with a health condition personalised and tailored employment support.

We believe that where you live, shop, go out, travel or park your car should not be determined by your disability. So we will review disabled people’s access and amend regulations if necessary to improve disabled access to licensed premises, parking and housing. We will work with providers of everyday essential services, like energy and telecoms, to reduce the extra costs that disability can incur.

A long-term plan for elderly care

Our system of care for the elderly is not working for the hundreds of thousands currently not getting the dignified and careful attention they deserve, nor for the people and organisations providing that care, nor is it sustainable for today’s younger people who will potentially one day face care costs themselves. It is not fair that the quality of care you receive and how much you pay for it depends in large part on where you live and whether you own your own home.  Where others have failed to lead, we will act. We have already taken immediate action, putting £2 billion into the social care system and allowing councils to raise more money for care themselves from Council Tax. We are now proposing medium and long-term solutions to put elderly care in our country on a strong and stable footing.

Under the current system, care costs deplete an individual’s assets, including in some cases the family home, down to £23,250 or even less. These costs can be catastrophic for those with modest or medium wealth. One purpose of long-term saving is to cover needs in old age; those who can should rightly contribute to their care from savings and accumulated wealth, rather than expecting current and future taxpayers to carry the cost on their behalf. Moreover, many older people have built considerable property assets due to rising property prices. Reconciling these competing pressures fairly and in a sustainable way has challenged many governments of the past. We intend to tackle this with three connected measures.

First, we will align the future basis for means-testing for domiciliary care with that for residential care, so that people are looked after in the place that is best for them. This will mean that the value of the family home will be taken into account along with other assets and income, whether care is provided at home, or in a residential or nursing care home.

Second, to ensure this is fair, we will introduce a single capital floor, set at £100,000, more than four times the current means test threshold. This will ensure that, no matter how large the cost of care turns out to be, people will always retain at least £100,000 of their savings and assets, including value in the family home.

Third, we will extend the current freedom to defer payments for residential care to those receiving care at home, so no-one will have to sell their home in their lifetime to pay for care.

We believe this powerful combination maximises protection for pensioner households with modest assets, often invested in the family home, while remaining affordable for taxpayers. We consider it more equitable, within and across the generations, than the proposals following the Dilnot Report, which mostly benefited a small number of wealthier people.

An efficient elderly care system which provides dignity is not merely a function of money. So our forthcoming green paper will also address system-wide issues to improve the quality of care and reduce variation in practice. This will ensure the care system works better with the NHS to reduce unnecessary and unhealthy hospital stays and delayed transfers of care, and provide better quality assurance within the care sector. We will reduce loneliness and promote technological solutions to prolong independent living, and invest in dementia research. As the majority of care is informally provided, mainly by families, we will give workers a new statutory entitlement to carer’s leave, as enjoyed in other countries.

Creating a sustainable elderly care system means making decisions about how the rising budget devoted to pensioners is spent, so we will target help where it is needed most. So we will look at Winter Fuel Payments, the largest benefit paid to pensioners, in this context. The benefit is paid regardless of need, giving money to wealthier pensioners when working people on lower incomes do not get similar support. So we will meanstest Winter Fuel Payments, focusing assistance on the least well-off pensioners, who are most at risk of fuel poverty. The money released will be transferred directly to health and social care, helping to provide dignity and care to the most vulnerable pensioners and reassurance to their families. We will maintain all other pensioner benefits, including free bus passes, eye tests, prescriptions and TV licences, for the duration of this parliament.

OUR NATIONAL HEALTH SERVICE

Our National Health Service is the essence of solidarity in our United Kingdom – our commitment to each other, between young and old, those who have and those who do not, and the healthy and the sick. The Conservative Party believes in the founding principles of the NHS. First, that the service should meet the needs of everyone, no matter who they are or where they live. Second, that care should be based on clinical need, not the ability to pay. Third, that care should be free at the point of use. As the NHS enters its eighth decade, the next Conservative government will hold fast to these principles by providing the NHS with the resources it needs and holding it accountable for delivering exceptional care to patients wherever and whenever they need it.

The money and people the NHS needs

In five ways, the next Conservative government will give the NHS the resources it needs.

First, we will increase NHS spending by a minimum of £8 billion in real terms over the next five years, delivering an increase in real funding per head of the population for every year of the parliament.

Second, we will ensure that the NHS and social care system have the nurses, midwives, doctors, carers and other health professionals that it needs. We will make it a priority in our negotiations with the European Union that the 140,000 staff from EU countries can carry on making their vital contribution to our health and care system. However, we cannot continue to rely on bringing in clinical staff instead of training sufficient numbers ourselves. Last year we announced an increase in the number of students in medical training of 1,500 a year; we will continue this investment, doing something the NHS has never done before, and train the doctors our hospitals and surgeries need.

Third, we will ensure that the NHS has the buildings and technology it needs to deliver care properly and efficiently. Since its inception, the NHS has been forced to use too many inadequate and antiquated facilities, which are even more unsuitable today. We will put this right and enable more care to be delivered closer to home, by building and upgrading primary care facilities, mental health clinics and hospitals in every part of England. Over the course of the next parliament, this will amount to the most ambitious programme of investment in buildings and technology the NHS has ever seen.

Fourth, whilst the NHS will always treat people in an emergency, no matter where they are from, we will recover the cost of medical treatment from people not resident in the UK. We will ensure that new NHS numbers are not issued to patients until their eligibility has been verified. And we will increase the Immigration Health Surcharge, to £600 for migrant workers and £450 for international students, to cover their use of the NHS. This remains competitive compared to the costs of health insurance paid by UK nationals working or studying overseas.

Fifth, we will implement the recommendations of the Accelerated Access Review to make sure that patients get new drugs and treatments faster while the NHS gets best value for money and remains at the forefront of innovation.

Holding NHS leaders to account

It is NHS England that determines how best to organise and deliver care in England, set out in its own plan to create a modern NHS – the Five Year Forward View. We support it. We will also back the implementation of the plan at a local level, through the Sustainability and Transformation Plans, providing they are clinically led and locally supported.

We will hold NHS England’s leaders to account for delivering their plan to improve patient care. If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes. This includes the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy. So we will review the operation of the internal market and, in time for the start of the 2018 financial year, we will make non-legislative changes to remove barriers to the integration of care.

We expect GPs to come together to provide greater access, more innovative services, share data and offer better facilities, while ensuring care remains personal – particularly for older and more vulnerable people – with named GPs accountable for individual patients. We will support GPs to deliver innovative services that better meet patients’ needs, including phone and on-line consultations and the use of technology to triage people better so they see the right clinician more quickly. We will ensure appropriate funding for GPs to meet rising costs of indemnity in the short term while working with the profession to introduce a sustainable long-term solution.

We will introduce a new GP contract to help develop wider primary care services. We will reform the contract for hospital consultants to reflect the changed nature of hospital care over the past twenty years. We shall support more integrated working, including ensuring community pharmacies can play a stronger role to keep people healthy outside hospital within the wider health system. We will support NHS dentistry to improve coverage and reform contracts so that we pay for better outcomes, particularly for deprived children. And we will legislate to reform and rationalise the current outdated system of professional regulation of healthcare professions, based on the advice of professional regulators, and ensure there is effective registration and regulation of those performing cosmetic interventions.

We will also help the million and more NHS clinicians and support staff develop the skills they need and the NHS requires in the decades ahead. We will encourage the development of new roles and create a diverse set of potential career paths for the NHS workforce. And we will reform medical education, including helping universities and local health systems work closer together to develop the roles and skills needed to serve patients.

We want the NHS to become a better employer. We will strengthen the entitlement to flexible working to help those with caring responsibilities for young children or older relatives. We will introduce new services for employees to give them the support they need, including quicker access to mental health and musculoskeletal services. We will act to reduce bullying rates in the NHS, which are far too high. We will take vigorous and immediate action against those who abuse or attack the people who work for and make our NHS.

Exceptional standards of care, wherever, whenever

Outcomes in the NHS for most major conditions are considerably better than three, five or ten years ago. However, the founding intention for the NHS was to provide good levels of care to everyone, wherever they live. This has not yet been achieved: there remain significant variations in outcomes and quality across services and across the country. We will act to put this right.

To help the NHS provide exceptional care in all parts of England, we will make clinical outcomes more transparent so that clinicians and frontline staff can learn more easily from the best units and practices, and where there is clear evidence of poor patient outcomes, we will take rapid corrective action. We will ensure patients have the information they need to understand local services and hold them to account.

We will empower patients, giving them a greater role in their own treatment and use technology to put care at their convenience. In addition to the digital tools patients already have, we will give patients, via digital means or over the phone, the ability to book appointments, contact the 111 service, order repeat prescriptions, and access and update aspects of their care records, as well as control how their personal data is used. We will continue to expand the number of NHS approved apps that can help monitor care and provide support for physical and mental health conditions. We will pilot the live publication of waiting times data for A&Es and other urgent care services. We will further expand the use of personal budgets. We will also continue to take action to reduce obesity and support our National Diabetes Prevention Programme.

Our ambition is also to provide exceptional care to patients whenever they need it. That is why we want England to be the first nation in the world to provide a truly seven-day healthcare service. That ambition starts with primary care. Already 17 million people can get routine weekend or evening appointments at either their own GP surgery or one nearby, and this will expand to the whole population by 2019.

In hospitals, we will make sure patients receive proper consultant supervision every day of the week with weekend access to the key diagnostic tests needed to support urgent care. We will also ensure hospitals can discharge emergency admissions at a similar rate at weekends as on weekdays, so that when someone is medically fit to leave hospital they can, whichever day of the week it is.

We will retain the 95 per cent A&E target and the 18-week elective care standard so that those needing care receive it in a timely fashion. We will continue to help the NHS on its journey to being the safest healthcare system in the world. We will extend the scope of the CQC to cover the health-related services commissioned by local authorities. We will legislate for an independent healthcare safety investigations body in the NHS. We will require the NHS to continue to reduce infant and maternal deaths, which remain too high.

Our commitment to consistent high quality care for everyone applies to all conditions. We will set new standards in some priority areas and also improve our response to historically underfunded and poorly understood disease groups.

In cancer services, we will deliver the new promise to give patients a definitive diagnosis within 28 days by 2020, while expanded screening and a major radiotherapy equipment upgrade will help ensure many more people survive cancer.

We will continue to rectify the injustice suffered by those with mental health problems, by ensuring that they get the care and support they deserve. So we will make sure there is more support in every part of the country by recruiting up to 10,000 more mental health professionals. We shall require all our medical staff to have a deeper understanding of mental health and all trainees will get a chance to experience working in mental health disciplines; we shall ensure medical exams better reflect the importance of this area. And we will improve the co-ordination of mental health services with other local services, including police forces and drug and alcohol rehabilitation services.

We have a specific task to improve standards of care for those with learning disabilities and autism. We will work to reduce stigma and discrimination and implement in full the Transforming Care Programme.

We will improve the care we give people at the end of life. We will fulfil the commitment we made that every person should receive attentive, high quality, compassionate care, so that their pain is eased, their spiritual needs met and their wishes for their closing weeks, days and hours respected. We will ensure all families who lose a baby are given the bereavement support they need, including a new entitlement to child bereavement leave.

Children’s and young people’s health

We believe government has a role to play in helping young people get the best possible start in life. We are seeing progress: smoking rates are now lower than France or Germany, drinking rates have fallen below the European average and teenage pregnancies are at record lows. We will continue to take action to reduce childhood obesity. We will promote efforts to reduce unhealthy ingredients and provide clearer food information for consumers, as our decision to leave the European Union will give us greater flexibility over the presentation of information on packaged food. We shall continue to support school sport, delivering on our commitment to double support for sports in primary schools.

We understand the massively increased pressures on young people’s mental health. We will take focused action to provide the support needed by children and young people. Half of all mental health conditions become established in people before the age of fourteen. So we will ensure better access to care for children and young people. A Conservative government will publish a green paper on young people’s mental health before the end of this year. We will introduce mental health first aid training for teachers in every primary and secondary school by the end of the parliament and ensure that every school has a 73 single point of contact with mental health services. Every child will learn about mental wellbeing and the mental health risks of internet harms in the curriculum. And we will reform Child and Adolescent Mental Health Services so that children with serious conditions are seen within an appropriate timeframe and no child has to leave their local area and their family to receive normal treatment.

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The Conservative Party is riding high in the polls despite widespread gloom over the prospects for public services. The Party’s electoral vulnerability on the health service creates an interest on the part of the NHS and its political opponents to declare a “crisis” at every opportunity and during every election. Even during periods of sustained austerity, as now and as in the 1970s, the NHS operates on the well-founded belief that bust will be followed by boom. It is hardly surprising that the intrinsic urge to innovate is weak. The promise of “reform” is taken as a threat, not an opportunity. The political debate reverts time and again to funding. The inevitable result is a disastrous financial rollercoaster. It is time to bring an end to this nonsense and recognise the reality of health spending.

The Guillebaud Report of 1956 nailed the myth that demand on health services would decline as population health improved. In 1985 Nick Bosanquet produced a substantive study on health funding showing that an increase of 2% a year was needed just to keep pace with technical advance and demographic change. Nothing has changed. Life expectancy continues to improve and technology continues to expand the range of what is possible to improve quality of life.  Meanwhile health spending has defied this logic.

Health spending


Source: HM Treasury, ONS see here

The consequences of this erratic path are plain.

Firstly, the boom-bust cycle stokes NHS inflation, making many of the declared crises very real. Booms inflate costs as the service tries to catch up on the recent past. This is most evident in the workforce, which is the majority cost of a health system. There is an inevitable and urgent attempt to boost pay after periods of freezes and to boost staff numbers after recruitment clamps. The tragedy of Mid-Staffordshire bears human testimony to this awful cycle. The inflated workforce costs, that are essential to repair damage done, are carried for many years to come – not just in the active workforce but also in pension costs.

Secondly, the rollercoaster makes real innovation almost impossible. No organisation can invest the time and energy in reform if it expects its resources to randomly boom or bust. It will simply survive in anticipation of the next bail-out. This bias against change is made worse by the stark divide between health and social care. Their funding cycles are unsynchronised, leading to institutionalised distrust and protectionism.

Debates about funding systems and structural reform are simply a diversion from recognition of the fundamental truth of health and social care spending. As a pragmatist rather than an ideologue, Theresa May should be capable of confronting the core problem facing our care system.

Since the creation of the NHS the average annual real-terms increase in spending has been 3.7%, but with erratic and dramatic variation around this average. As in the 1970s, the current average is closer to 1%. One simple but effective policy change would be to amend the NHS Constitution to create a firm commitment to a target range for health and social care annual spending growth. This should be based around Bosanquet’s 2% doctrine. Just as the Bank of England is set a clear 2% target for inflation, so the Treasury itself should face significant hurdles if its plans break firm upper and lower limits for NHS inflation around the target.

Of course, such special treatment for the NHS can generate, quite illogically, spending cuts for social care. The Government must continue with its existing commitment to reform social care funding. A cap on the individual costs of social care for the unfortunate few in this lottery, would enable a clear commitment to stable state funding for the future and create a foundation for private innovation in financing and care delivery.

Every General Election is about the NHS. It is simply an area in which there is a clear divide of party perceptions. In 2017 the election takes place at a time when NHS providers are reporting unprecedented deficits, and the social care system is in a real crisis. The Conservative manifesto will need to address these head on. Replacing the “triple lock” with a constitutional pledge to health and social care would demonstrate a real commitment to fairness over political games.

This first appeared on the  British Politics and Policy blog

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I have written before about Jeremy Hunt’s opaque and secretive reorganisation of the NHS, which is being drawn up behind closed doors at this very moment through Sustainability and Transformation Plans (STPs).

Despite my best efforts, there still seems little appetite among the media to talk about STPs, but I think that will change when the outcome of this project becomes clear. Following the publication of the NHS “reset” (otherwise known as NHS Improvement: Strengthening Financial Performance & Accountability in 2016/17), we can finally be a lot clearer about what is in store for local health services and it doesn’t look good.

The “reset” sets out three areas where action will be required to improve the financial position of the NHS. The first two; tackling excessive paybill growth and implementation of Lord Carter’s recommendations on back office efficiency savings are discussed in my last post about the “reset.”

But it is the third that should cause us most concern. It tells us that “by the end of July, STPs should have reviewed services which are unsustainable” and proposes “the consolidation of unsustainable services… with a view to take early decisions to re-provide at nearby units.” This in other words means that some “units” or hospitals will be closed and that it will happen sooner rather than later.

Whatever the rationale behind these closures or mergers might be, it is completely unacceptable that these plans are being drawn up without any scrutiny. There can be no explanation for such an abject failure to provide any kind of transparency, other than a fear from Ministers about what the reaction of the public will be. My concern is that once the plans are published, any changes will be presented as a fait accompli.

The STP plans were initially due for submission by the end of June, but after I probed Ministers as the deadline began to approach, I was told that “the degree of detail that will be provided by 30th June will vary” and promised that sign off of the plans would occur “in a series of waves over the coming weeks and months.” When the plans are finally be published any drafts submitted to Ministers should be open to public scrutiny and consultation.

The third priority of the “reset” goes on to state that STPs should also have “developed plans to re-provide these services in collaboration with other providers.” And if that isn’t a euphemistic enough reference to privatisation for you, theBusiness Plan of NHS Improvement goes on to outline a priority to “explore” and “facilitate” new private sector partnerships.

CCGs that have been placed in special measures are to be subject to a series of potential interventions including being disbanded altogether. However it is the reference to “Accountable Care Organisations” (ACOs) as a potential replacement for CCGs that will set alarm bells ringing. ACOs are commonplace in the USA and whilst the official language over here is about them looking at “place based” working, the fact that on the other side of the Atlantic they are intimately connected to the private insurance system is bound to raise questions about where this is heading.

As the respected Health Service Journal has reported, NHS Improvement also said the NHS sometimes “underutilised” the private sector and that “a new work programme” would examine the “most promising” areas for greater collaboration. It plans to look at “outsourcing of new, novel or restructured clinical services” and “independent sector management models.”

Further issues arise with NHS Improvement’s powers to intervene in failing regimes such as the removal of autonomy over key spending decisions. The Department of Health will also reserve the right to exchange surplus assets for cash for any providers under a programme of financial special measures.

Be in no doubt the Government have amassed a huge range of tools to reshape the NHS by hook or by crook but because they have passed responsibility onto the 44 STP footprint areas, you won’t see Jeremy Hunt or Theresa May standing up in Parliament to announce or even to defend hospital closures or the further creeping privatisation of health services. However we should be under no illusion that it is their policies that are responsible and we should do everything possible to hold them to account.

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We found out in July that Jeremy Hunt will continue to be the Secretary of State for Health in Theresa May’s Cabinet.

Since I had the honour of becoming Labour’s shadow health secretary, I have pressed Hunt on the problems facing our NHS, but he has had few answers from the barrage of cross-bench concern at various parliamentary debates on NHS funding and the impact of Brexit on the NHS.

When asked what he was doing to ensure that the NHS gets the £350 million a week that it was promised during the Leave referendum campaign, Hunt said: “I am a little stumped, because I was never really sure whether we would see that money.”

The government’s health policy is increasingly incoherent. The Leave half of the government has been promising millions of extra pounds to the health service while the Remain side knows full well that that money will be unavailable as it responds to the economic concerns regarding Brexit by steadfastly carrying on with austerity.Clearly this does little for morale in the NHS, which is already near rock bottom due to Tory cuts to the service.

Yet for the last six years the Conservative Party had sold the myth of austerity, promising that that cutting public services would “save money,” rather than choke off a sustainable economic recovery, squeeze the living stands of the majority and put our poorest citizens through unnecessary misery. The NHS is a big casualty of austerity. The public accounts committee said in May that nationally the NHS is short of 50,000 front-line staff and the government is driving through £22 billion in cuts by 2020, which has pushed hospitals and A&E departments to the brink of failure.

Last week’s junior doctors’ rejection of the government’s contract is just the tip of the iceberg. Anger at the government’s neglect of NHS staff and patients goes deep among both NHS workers and the public.
In that dispute, it has not helped that the government is treating junior doctors like the enemy within. It has not helped their morale to imply that the only barrier to a seven-day NHS is their reluctance to work weekends, when so many of them are already working unsocial hours, sacrificing their family lives in the process.

To mark the anniversary of the NHS as Labour’s proudest creation, I recently visited my local hospital, the Homerton University Hospital, and met some of the wonderful nurses. One of their main concerns was the abolition of the bursary, but they were also genuinely worried that NHS staff were no longer valued. Take, for example, the area of nursing. Indeed, an early 2016 report showed that one in 10 nursing positions are not filled, and low staff morale can only make this worse.

To make this worse, from next year, the government plans to scrap bursaries. It will fund nurse training through loans instead of grants to create an “open market” that will remove the NHS’s ability to place nurses where there is demand.

This government’s actions are the complete opposite what is needed to address the current recruitment crisis. And with one in three nurses over 50 and set to retire in coming years, the NHS has no long-term plan.But the Jeremy Corbyn-led Labour Party is not just about opposing the Tories’ failed policies of austerity. It’s also about setting our sights higher about the type of society we want.

We can do this with an economic policy that is not based on cuts, but instead invests to grow our economy.This will enable us to create good jobs and pay, build homes, provide public transport and provide quality public services for all, including our NHS.

For this reason I have been delighted to support for the Ten Minute Rule Bill introduced by my colleague Margaret Greenwood MP.

The central proposition of the NHS Reinstatement Bill is self-explanatory. It will have the effect of restoring parliamentary and ministerial accountability for the NHS. Amazingly, the Secretary of State for Health has no statutory responsibility for the NHS under current legislation.

This is not simply because the Tories, and Hunt in particular, find it more convenient to not be held accountable for the growing problems of the NHS — although that is probably regarded by them as a happy spin-off. The main Tory rationale is that undermining the NHS makes it more chaotic and more susceptible to denationalisation and privatisation. After all, this was the government that promised to protect the NHS, yet waiting times have soared. This is the government that talked about putting clinicians and staff first, yet provoked the first all-out strike by junior doctors in the history of the NHS.

In contrast to this approach, it is extremely important to restore parliamentary accountability and in effect to renationalise the NHS.Of course no-one wants yet another top-down reorganisation. NHS professionals and staff who I speak to hold up their hands in horror at the prospect. The NHS has already had more than one reorganisation too many. But at the same time it is, or ought to be, a fundamental principle that the political oversight of any public service must itself be accountable and subject to scrutiny from the elected representatives of the population. This is no less true for the NHS, which is one of our most vital services, and which commands such large public resources.Under the Tories, there has been top-down reorganisation, services have not been not protected, staff morale is at rock-bottom and measured performance continues to deteriorate. This is the chaos they have introduced.

Labour stands for the opposite. Under Jeremy Corbyn, Labour will have no truck with Tory plans for break-up and privatisation of the NHS. Instead, we will develop plans to strengthen and improve the NHS and oppose all damaging cuts.

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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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