The late Mayor of New York, Mario Cuomo once said “You campaign in poetry. You govern in prose.” If the last few years of UK politics have suggested that our governing classes have lost the plot, then there has been little poetic about this election campaign.
The 2019 election campaign is unlikely to live long in the memory, but it will have a lasting impact on the politics of health. We don’t yet know the result or composition of the next Government (let alone the strength or nature of its mandate), but here are six lessons that we can draw from the campaign on the nature of the debate on health in the coming Parliament.
1. Money talks
The NHS will get money and will continue to do so. Spending commitments on the NHS may not have cut through, but this is precisely because all parties made, at least on the face of it, vast commitments. Once you get into the billions, it is difficult for voters to distinguish between the figures on the various cheques being waved at them. Nonetheless, it is difficult to envisage a situation in the near future where politicians would risk being seen as denying the health service additional funding.
2. Workforce and capital can no longer be ignored
For well over five years, the debate on NHS funding has led to headline-grabbing revenue commitments while at best ignoring and at worst exacerbating shortages in workforce, as well as problems with decaying buildings and equipment. Rows over pledges on the number of new hospitals and nurses have generated more heat than light, but voters have heard that there will be new hospitals and many more nurses. These are issues which no government will be able to ignore in the next parliament.
3. Trade talk is unlikely to Trump access to medicines
We have heard a lot about trade talks and we will continue to do so. Getting Brexit done is of course not something that ends with the passage of the EU Withdrawal Bill and we can expect to hear a lot about ‘sinister’ (real or imagined) threats to different aspects of the NHS. The concept of the NHS ‘under threat’ does resonate with voters in leave-voting constituencies that now appear to form the main battleground of British politics. The quest to find examples of this threat will be a prominent feature of the political discourse on health for years to come.
Debate on drug pricing systems and development processes has taken a populist turn and this will endure. However, much of this is fuelled by public antipathy to Donald Trump. Should 2020 see him replaced by a Democratic President (who much of the UK left would be in thrall to), some of the heat will be taken out of the issue. Should the Conservatives win, then their pledge to create an Innovative Medicines Fund may also reduce the flashpoints where patients are denied access to high profile new treatments on the grounds of cost. Without these human examples to demonstrate the ‘threat,’ debates about pricing policy will become ever more abstract.
Pharmaceuticals have been one of the flashpoints of the election. Big politics in the USA and detailed policy in the UK could defuse the issue or, if the US election goes the other way and the Innovative Medicines Fund stalls, further inflame it.
4. Is addiction this year’s surprise theme?
Public health issues rarely feature prominently in campaigns (mainly because parties are wary of making a case to the public about preventing something that voters didn’t think they were at risk of). Yet addiction services have proved an exception in 2019. Perhaps because of the link to mental health (now firmly established as a priority) or perhaps because of the family experiences of some of those leading health policy, addiction has received more political airtime than ever before. Given this, as well as the evidence of rising need, it is hard to see the issue slipping back into relative anonymity.
5. Social care remains the poor relation
The election has also proven that social care remains a poor relation. Pledges (or lack of follow through on previously made commitments) have received little scrutiny. Talk of reaching a cross-party consensus is not progress, it is a red herring. Discussion about future talks is just that.
For progress to be made on the issue, campaigners need to ensure that the next government ‘owns’ social care and feels an imperative to deliver on it. This means focusing less on technocratic solutions and endless discussion of systems and instead focusing on the very human impact of a broken system. We can all visualise an NHS winter crisis. Similar ‘scandals’ are common in social care, but somehow the issue feels less visceral to voters and therefore politicians. This needs to change.
6. Performance matters
The NHS is already struggling, with signs that flu and norovirus are having an impact. Although the dissolution of Parliament coincided with the publication of the latest set of dire waiting times, there has been relatively little focus on actual NHS performance. Those planning reforms to waiting times standards will no doubt breathe a sigh of relief that the campaign has not led to political commitments on waiting which will prevent change.
Traditionally performance issues have cut-through far more with voters than arcane policy issues which might exercise experts or activists. Even the most rigid messaging can be disrupted by real examples of a service under pressure, as the Prime Minister found out yesterday. Yet curiously, notwithstanding events in Leeds, Labour has not sought to focus its campaign on the challenges facing the NHS today, instead focusing on future threats and policy pledges, both of which are somewhat less tangible than the reality of the services people experience. Perhaps there is a lesson here for future campaigns.
Whatever the result on Thursday, we can expect a further shakeout in UK politics. The result could herald further instability on the right, left or centre of British politics (or all three). However, the parameters of the debate on health in coming years are becoming clearer.