Too big to bail out

BRITONS will not hear a bad word said about the National Health Service, but its problems are becoming hard to ignore. A combination of austerity and an increasingly needy population has left it short of money. It also suffers from a kind of developmental disease. The NHS was built in the 1940s, when health care was mostly about treating broken legs and infections in hospital. Its biggest task now is to improve the quality of life of chronically ill old people. The NHS needs to change profoundly while running flat out. Managing that will be a mighty challenge for the next government.

In 2010 the Conservative Party put up posters promising the party would “cut the deficit, not the NHS”. The Tory-Liberal Democrat coalition stuck to that promise, yet the health service is feeling the pinch. Although NHS spending has risen by an average of 0.7% a year in real terms, spending per person has been falling in England since 2013.

Many hospitals are struggling. Large accident-and-emergency wards often fail to see 95% of patients within four hours, as a government target suggests they should—and they are missing by bigger margins. In 2014 fully 3m people, the highest number in six years, were waiting for treatment. It does not help that money is being frittered away. Unnecessary drugs and X-rays cost £2 billion a year, according to the Academy of Medical Royal Colleges; the Cancer Drugs Fund, which pays over the odds for new medicines, drained £280m last year.

The Conservative Party is again pledging to protect the NHS budget if it returns to power, with up to £2 billion extra a year until 2019-2020. Labour has promised to shell out £2.5 billion more than the Conservatives, spending it on new doctors and nurses, although the cash might not be available until 2017-18. The Liberal Democrats plan to spend £8 billion more a year by 2020, the sum NHS executives say is needed, increasing yearly spending after tackling the deficit in 2017/18.

If the Tories have a plan to reform the NHS, they will probably keep quiet about it: after all, they spent the second half of the 2010-15 parliament rowing back from an immense reorganisation that they had launched in the first half. This reform, which aimed to stimulate competition and enabled groups of local doctors to purchase services, was unpopular with voters, caused much upheaval and delivered few obvious benefits. The Tory health secretary, Andrew Lansley, was replaced by Jeremy Hunt, who has mostly tried to keep the NHS out of the news.

Much of the private provision in the NHS was introduced by Labour

Still, many think structural reform is overdue. Healthcare is currently separate from “social care”—a catch-all category encompassing mental-health services, nursing homes and the like, which are often run by local councils. Fusing the two seems sensible. And it would probably save money, if hospital beds could be emptied of people who could manage at home with a bit of extra help. Labour has claimed the idea as its own, dubbing it “Whole Person Care”; the Tories quietly back a similar plan by Simon Stevens, the head of NHS England. But no party will be drawn into discussing specifics. Moving care into the community might mean closing hospitals, which would be desperately unpopular. And it would not be easy to keep the current service ticking along while the new one is built.

The Conservatives’ election campaign will focus on increased transparency and inspection—the most successful part of their record (if the classic last resort of a beleaguered health ministry). Putting outcomes online—especially those of surgeons—has led to improvements and vigorous patrolling has driven up standards, albeit mostly by increasing staff levels. The Tories made hay out of an inquiry into the awful neglect of patients in Mid Stafford hospital, which had happened on Labour’s watch.

Labour will accuse the Tories of plans to shrink and privatise the NHS. In fact, by signing up to Simon Stevens’ plan Labour has committed to stepping up privatisation, and in any case much of the private provision in the system appeared as a result of reforms launched by the last, Labour, government. Under the coalition, on the other hand, competition has not grown much. The Tories retort that Labour’s line is mere “political posturing”. Polls suggest most people do not much care about how NHS services are delivered, as long as they are good and free at the point of access.

The Liberal Democrats are likely to talk about their Better Care Fund, which has managed to shift small amounts of money from the NHS to social care. Nick Clegg is also keen to prioritise mental health. Both ideas, of course, could starve other NHS services of money.

Conservatives were outraged when it was suggested that Ed Miliband, Labour’s leader, wanted to “weaponise” the NHS as a political issue in the election. But it is already so. Scottish separatists claimed last year that the country must break away to protect its health service from free-market Tories in London. David Cameron has attacked Labour’s management of the NHS in Wales. Every party will wield health care as a weapon, regardless of the strength of its arguments.