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Election 2024: Whoever wins, the reset that is required is fundamental
Dr Naru Narayanan

HCSA President

Health services are the number two priority for the public going into this election, according to pollsters Yougov, ranking narrowly behind the economy. If current rosier economic projections are to be believed then health is likely to regain the top spot.

Little wonder then that the NHS features prominently in election manifestos. But are the pledges worth the paper they are written on? Do they give confidence to hospital doctors that the future may be better than the present?

It is welcome that both Labour and the Conservatives have pledged action to regulate NHS managers – a step which would chime with one of HCSA’s own calls on the culture preventing doctors from speaking up on safety, punishing many who do. This would be a step forward, though not in itself a solution.

Both parties also maintain that they will not reintroduce the lifetime allowance for pensions, which previously left many senior hospital doctors in a tax trap. So far, so good.

From the Conservatives we have the Prime Minister’s vow to “serve citizens not vested interests” in the NHS – a line hard not to interpret as a veiled criticism of doctors. Their manifesto promises to lead us to the sunny uplands of technological transformation through the NHS app, AI and new computers.

They vow to “cut waste and bureaucracy” by culling 5,500 NHS managers to free up half a billion pounds. At the same time we are told there will be 92,000 more nurses and 28,000 more doctors by the end of the next parliament, and services will be brought closer to patients through investment in GP surgeries and community diagnostics. We see the return of the pledge of 40 “new” hospitals.

For individual hospital doctors there are slim pickings. The Conservatives vow that they “will improve working conditions for all NHS staff” – precisely how, they do not say – while pursuing their policy of forcing through the flawed plan for minimum service levels to undermine industrial action.

There is little on funding, aside from a commitment to stick to spending plans but to “unlock” over the next parliament £35 billion which is apparently hiding down the back of the health service sofa, by increasing “productivity” by 1.9 percent a year. Wishful thinking?

There is little here that hospital doctors have not heard before – and as ever the detail is scant. But if polling is to be believed, all this may be academic. So, what of Labour’s plans?

Amid the heavy rhetoric of “change” and “fundamental reform” – words which mean little in themselves and which may elicit a weary groan from those who have heard it all before – there are some solid aspirations.

In truth the underlying thrust of Labour’s 10-year “big vision” is little different from the Conservatives – the laudable aim of better primary and preventative care to avoid patients overloading our hospitals. Labour maintains that in government it will transform the NHS into a “Neighbourhood Health Service”.

It does though make more tangible pledges to double the number of CT and MRI scanners, and deliver 40,000 additional appointments every week to tackle waiting lists “by incentivising staff to carry out additional appointments out of hours” and using “spare capacity in the independent sector” for diagnostics and treatment. Labour states that referral pathways will be reformed to reduce pressure on GPs.

Labour also pledges it will “reset relations with NHS staff”.

The elephant in the room, however, is how all this will be paid for – how we move on from a model of patching up NHS finances in moments of crisis, against a backdrop of historic underfunding and an aging and growing population.

Transformation of the kind that Labour has pledged will not come cheap. It will not be covered by levying VAT on private schools, catching tax dodgers and other tweaks. The thousands of additional staff hours required to deliver 40,000 more appointments a week will alone run to £1.1 billion per year, according to the party’s estimates.

Independent analysts have made clear the scale of the gap between commitment and cost. The Nuffield Trust warns that under any of the main parties’ “the period 2022/23 to 2028/29 would see the tightest and most sustained NHS funding squeeze” since 1979/80. It estimates, based on Office for Budgetary Responsibility figures, that a Conservative would oversee annual real-terms increases of 0.4 percent, and Labour 0.5 percent – leaving the NHS, by 2028-29, around £23bn per year short of what is required to implement its workforce plan.

This compares to a historical average of 3.6 percent yearly real-terms funding growth, a figure which dropped to 1.8 percent across the 2010s – coinciding perhaps unsurprisingly with rising pressures which predate the covid pandemic.

The Health Foundation states that 3.8 percent is the minimum required per year to deliver sustained improvement in health services, while 2.9 percent represents standing still in the face of rising demand. Current spending plans will leave the NHS £38bn per year short of its “sustained improvement scenario” by 2029/30, it warns.

Aside from funding, what is clear is that if any government is to have a chance of addressing the challenges currently facing the NHS, it must understand and resolve the issues deeply felt by medical staff in our hospitals. Hospital doctors have a crucial part to play in delivering stability in the health service and bringing down the waiting lists. That means more than simply “resetting” the relationship between trade unions and government. It means listening and solving the problems on the ground which are driving low morale and recruitment and retention issues.

The NHS Staff survey this year again revealed the scale of this crisis – over 4 in 10 hospital doctors reported burnout, and over half were thinking of leaving their employer.

All too often we have seen a patronising, top-down attitude towards medical staff from employers and government, who it feels sees us as chess pieces to be moved around the board rather than equal partners vital to solving issues in the NHS. We are forced to haggle for the slightest crumb of improvement nationally while seeing our terms and conditions, and even the buildings we work in, erode ever further locally.

There has long been a sense within the profession that hospital doctors are taken for granted and their concerns, whether that be consultants seeing SPA time slashed or junior doctors struggling to even take time off for their wedding, dismissed as unimportant in the grander scheme of things. There is a sense that things rarely improve, but incrementally get worse. When the hint of slight improvements do emerge, they are generally as a result of an enforced trade-off somewhere else, or disappear into a porridge of powerpoints paying lip service to change.

And when we challenge the degradation of terms and conditions, or threats to patient care such as the misuse of associate professionals, we are too often treated like children who do not know their place. But this isn’t kindergarten and this isn’t a chess game. It cuts to the very heart of the future NHS.

Whoever wins this election, the reset that is required is fundamental – it is about not just establishing sufficient funding but reshaping the working lives of hospital doctors, who are vital if we are to have any chance of turning our health services’ fortunes around.

The next government fails to recognise this at its peril.