10-12 - ELECTION ‘24: In sickness and in health?

First of all, just how important is the NHS in general elections? Does it swing them? Is it of the most concern to voters? Does it trump the economy, the cost of living, employment, immigration and crime? Can you even win an election on what you say you will do with the health service?

I believe the answer is yes. Classically ‘the economy’ is the number one issue – although that covers a lot of ground in most people’s minds, including the cost of living, jobs, tax, wages and house prices – while the NHS is normally in second or third place.

There’s no doubt that the party most likely to win is the one that voters trust most with the pound in their pockets. But if you look at the influence of the NHS, and the state of it, in recent elections, you’ll see an interesting pattern.

First up: 2001. Tony Blair, riding high, could arguably have defeated the Tories on any front – but the strapline he went with was ‘schools and hospitals first’.

He kept his already huge majority. And true to the words of his battlebus, health investment poured in under the NHS Plan and the Agenda for Change.

The NHS reached its highest ever public satisfaction levels under New Labour – the British public fell in love with it again. Consequently, it was reset as an untouchable jewel in the national crown.

Next: 2010. In this election David Cameron made promises, soon fulfilled, to slash every area of government spending and bring the deficit under control, which he blamed on Labour. However, if you remember, he also promised one big-spending department would have its budget ring-fenced – health.

The point is, to the politicians, it is hugely important, not least perhaps, because it is the number one issue to older people – the biggest cohort of voters.

That’s surely one big reason why the NHS was put on the side of the Brexit bus in 2016, and also why in 2019, Boris Johnson made such a thing of building ‘40 new hospitals’. In politicians’ minds, the NHS does win or lose elections.

Another election is on the cards in the next 18 months. The NHS is clearly going to be front-and-centre again. So what are the two parties saying they will do, what will be the likely outcome for the health service, and what does it mean for the pharma industry?

We know that one of Rishi Sunak’s five ‘pledges’ to secure his position in the short term is to ‘cut NHS waiting lists’. That one isn’t going so well, as the NHS’ most recent data dump indicates that waiting lists are actually going up to a record 7.5m. So it’s not clear if this type of commitment will survive into the next manifes to save the Tories becoming a hostage to fortune.

Where does that leave them? One thing we are seeing is the abandoning of targets, and this may become the strategy – under the guise of ‘letting the local NHS do its thing’, ‘reducing the bureaucratic burden on frontline care’ or other such formulations.

This would also be supported by the thrust of this year’s Hewitt Review, which called for ICSs to set their own targets and priorities, and for there to be no more than ten national targets.

Steve Barclay’s tenure in the Department of Health and Social Care can be characterised by a certain aloofness in the face of, let’s face it, a huge NHS crisis – in waiting times, strikes, the elective care backlog, vacancies, finance, the lot.

His speech to NHS providers in November captured his priorities for 2023: focusing on elective recovery; tackling delayed hospital discharge; improving access to primary care; maintaining the New Hospital Programme, and investing in technology to improve patient outcomes.

The problem is, each one of those priorities is hamstrung by reality. As we’ve seen, the elective recovery numbers are going in the wrong way. Delayed hospital discharge isn’t happening because of total ‘bedlock’ – nearing maximum bed occupancy pretty much across the country, and no social care place for them to go to.

Primary care is suffering from its own morale, demand, staffing and recruitment crisis, and as for the 40 new hospitals by 2030, hardly any of them are entire hospitals. Indeed, the National Audit Office can generously count only 32.

Labour have said they only exist ‘in the health secretary’s imagination’. In conclusion, Tech is probably the only ray of sunshine – there’s been considerable investment in creating such things as digital-first primary care and secure data environments.

I predict the manifesto pledges from the Conservatives are going to revolve around damage limitation – press on with the long-term plan, which, in broad brushstrokes, has cross-party support, and develop the major conditions strategy.

This, at least, has some sensible ideas about rewiring ICSs around patients with CVD, cancer, mental health, musculoskeletal and respiratory conditions. It proposes a more flexible workforce able to move around to provide more patient-centric care, creating efficiencies through fewer touchpoints and hospital admissions.

The major conditions strategy also stresses the importance of preventative care and lifestyle interventions – although every government health policy ever does that, and nothing much has so far happened on this front.

The media mood music around ‘what Labour will actually do’ is: they currently say nothing of note, refuse to tie their colours to any particular mast, are being ultra-cautious fiscally, and are terrified of stepping out of line.

But actually, there is a fair amount of messaging coming from Labour on Health, both from Keir Starmer himself and shadow health secretary Wes Streeting,
Labour has said it will pay for ‘the biggest workforce expansion in NHS history’ by scrapping non-dom tax status, which it says could raise £3.2bn a year.

And people would be treated closer to home wherever possible with under a new ten-year plan with the NHS to shift the focus of healthcare out of the hospital and into the community.

Starmer has said the health service was ‘on its knees’ and ‘at the next election, the NHS is on the line’. He promised to ensure the health service meets targets that are being missed, including a seven-minute response time for cardiac arrests, a four-hour wait to be seen in A&E and planned treatment within 18 weeks.

Streeting, having survived the latest shadow cabinet reshuffle, will most likely be the next person in charge of the NHS. What do we know about him? He’s a Blairite. He has absolutely no problem with more private sector involvement (if you remember from the noughties, Blair said his biggest regret was not going further with public service reform).

1. Private sector involvement
This will principally be to reduce the backlog. Barclay would do it because he believes in it anyway. Streeting would do it believing under the last Labour government it was this policy that finally shifted waiting lists.

Both will have to do it because frankly there is no alternative – the NHS needs a massive injection of capacity in the face of ever-increasing demand. For industry, this will mean new customers in the healthcare market under NHS contracts, and more NHS patients managed in private settings. You may have to redraw your stakeholder map.

2. Big investment in digital
Both parties are committed to digital investment and reform, they’ve seen how such initiatives as online triage are helping to manage demand, and virtual wards to monitor LTC patients at home are becoming more popular.

AI tools – particularly in diagnostics, with software helping to stratify and risk assess patients, will be the next boom area, along with sharing systems where, for example, imaging can be transferred and accessed immediately by all the relevant clinicians in a patient’s pathway.

Industry can get involved in collaboration with clinicians about diagnostics for their therapy area – few pathways are perfect and pharma can and has successfully influenced the NHS to adapt their diagnostic guidelines to more evidence-based models.

3. A shift to prevention
Always promised, but perhaps more likely to arrive under Labour via investment. Pharma should recognise this desire in the NHS in its overall value proposition.

Primary prevention – lifestyle change promotion, social prescribing, sugar taxes and so on – may well become more of a ‘thing’, but industry should also explore supporting the NHS on so-called ‘secondary prevention’.

This involves preventing patients from developing late-stage disease by getting them to come forward earlier, and also managing emergencies and exacerbations with medicines so as to prevent unnecessary hospital admissions. Care closer to home will continue to be the overall aim whoever wins.

4. Focus on health inequalities
Action on healthcare equity – improving access and outcomes for deprived communities and minorities – is being driven by such policies as CORE20PLUS5, which both parties can see is working well, and has the broad support of the local NHS and bodies like the NHS Confederation.

It’s striking that these inequalities are often at play in key ‘red wall’ marginal seats – particularly in the midlands and north-west – so Labour would probably invest more in these areas.

Most sensible commentators agree that addressing health inequalities is a good idea economically – it’ll bring in more patients that need to be on pathway sooner and will reduce costs overall. The controversy will come if it’s perceived that this investment comes at a cost to middle England – the blue wall.

For pharma, addressing these inequalities should be absolutely paramount – it can collaborate with the NHS on finding patients, improving access to information, and providing data and cost models to support streamlining pathways to make them more accessible.

5. A long road back
The NHS has faced multiple shocks. Austerity-driven funding freezes, a staff exodus – owing to insufficient recruitment, poor pay, stress and conditions, exacerbated by Brexit – two years of pandemic, swelling a backlog that was already bad.

Add to that, political chaos – with four health secretaries last year – and an ever-increasing, ongoing demand from an ageing population.

Industry should take note that, whether it’s Barclay or Streeting in charge, the NHS is in for a rough ride – regardless of who is at the wheel.

In sickness and in health?

Conservative estimates

The Blair pitch project

Five alive – what will happen next?