Labour appears poised to win a historic election victory on 4 July. In the series Life under Labour, we look at Keir Starmer’s five key political missions and ask what is at stake and whether he can deliver the change the country is crying out for. “If they came into power, the Labour party would inherit a really terrible set of problems in the NHS that are both broader and deeper than the ones they faced in 1997. This feels a lot worse,” says Siva Anandaciva, the chief analyst at the King’s Fund thinktank. “After years of rising pressure, declining performance, a pandemic and cost of living crisis, a wider range of health and care services are now under pressure and the pressures they are experiencing are more severe.” If Labour does take power next week the NHS it will inherit on Friday 5 July will be in much worse shape than the one John Major bequeathed to Tony Blair in 1997. Public satisfaction with the health service is at the lowest since records began 40 years ago, after 14 years in which it has been neglected, endured serial underinvestment and routine staff shortages, and been hit hard by Covid-19. Just under one in four people are satisfied with the NHS, down from 70% in 2010. People can no longer rely on getting an ambulance quickly when they dial 999, which has forced more who are in serious ill-health to get themselves to A&E under their own steam. Getting dental care on the NHS has become impossible for millions, with “dental deserts” common. Mental health services have not expanded to keep pace with the huge rise in demand linked to Covid, austerity and the cost of living crisis, leaving significant unmet need. Care around childbirth is so variable that two-thirds of maternity units in England are now deemed unsafe and a fourth major inquiry into a maternity scandal is ongoing.
Long waits for key forms of care – to see a GP, be treated in A&E, have surgery, undergo cancer treatment, go to hospital in an ambulance or receive support for mental ill-health – are now routine for the first time in a generation. “Trolley waits” and “corridor care”, both alarming illustrations of a system that cannot meet the demand on it, are common phenomena even in the summer. The waiting list in England for hospital treatment has ballooned from 2.6 million in 2010 to 7.6 million. Care waits mean patients are being put in danger. A&E doctors warn that an average of 268 patients a week die as a direct result of not receiving urgent and emergency care quickly enough. Ambulance bosses have voiced similar concerns about the risk from delays.
In addition, staff morale is poor as a result of Covid, persistently low pay, poor working conditions and the huge pressures created by the relentlessly rising demand for care. Strikes by NHS personnel including doctors and nurses, previously uncommon, have occurred across the UK over the last 18 months, prompted by deep dissatisfaction at years of below-inflation pay rises. Labour’s detailed plans to tackle all this occupy 12 pages of its manifesto, with an overall ambition to “build an NHS fit for the future”. Pledges include “the return of the family doctor” and a “dentistry recovery plan”. But with treatment delays such a huge concern to the public, the party’s key promise, repeated endlessly by Keir Starmer and the shadow health secretary, Wes Streeting, is to “cut NHS waiting times with 40,000 more appointments every week”. Boldly, given how far off-track waiting times are now, Labour insists that “we will return to meeting NHS performance standards”, such as the four-hour A&E target and 18-week target for hospital care.
So can Labour banish treatment delays and get the NHS back on its feet? Experts are surprisingly upbeat about how realistic that goal is. Labour’s key tactic for fulfilling its signature NHS pledge is ensuring the delivery of 2m extra scans, operations and outpatient appointments a year, at a cost of £1.3bn from closing the non-dom tax loophole. But, as Kathryn Marszalek, a senior analytical manager at the Health Foundation, points out, not every one of those extra bits of NHS activity results in the waiting list reducing by one. If it takes five such appointments to shorten it by one then that would cut it by 400,000 a year beyond the fall that the NHS’s already strenuous efforts would achieve. But if it takes only three appointments then the waiting list would shrink by 667,000. “Over a period of five years this additional activity could reduce the waiting list by between 2 million and 3.3 million,” in Marszalek’s view. While this extra activity would cut the headline total, it would not be enough on its own to necessarily help the NHS back to treating 92% of those awaiting hospital care within 18 weeks, she cautions. She raises other practical questions, too. Would the £1.3bn be enough? Are already overstretched and exhausted staff going to volunteer for the evening and weekend extra sessions of surgery that Labour envisages? “People might be tempted to see Labour’s plan as a silver bullet. However, reality is inevitably more complicated,” Marszalek says. Dr Rob Findlay, a waiting list expert, believes Labour’s hope to hit the 92% mark again by the end of a five-year parliament is “quite feasible” and could even happen within three years. The key, he says, is the willingness of staff – who would be paid overtime – to do, and keep doing, extra shifts.
Anandaciva does not share Findlay’s optimism. He was a civil servant at the Department of Health in the early 2000s when Blair’s government got waiting times under control, and recalls how much effort, money and focus was needed over a number of years to do that. “I’m sceptical that restoration of all the key waiting time standards is doable in five years,” he says. For that to happen, he adds, Streeting would have to not just resolve the junior doctors’ dispute, which has led to 1.4m appointments being postponed, but ensure that other staff do not strike again, too. However, industrial peace will only reign in the health service if they receive pay rises they see as decent enough to not return to the picket lines. Given that the NHS in England alone employs 1.5 million people, the price tag for doing that would be billions of pounds. And it is not obvious where the money needed would come from, given Labour’s insistence that it would stick to Conservative-set spending plans for the next few years. If, as chancellor, Rachel Reeves does give Streeting, as health secretary, some extra money, which of the NHS’s daunting array of problems would he spend it on? Raising salaries to avoid strikes? Tackling the £11.6bn backlog of repairs in hospitals, some of which are falling down? Or funding the new hospitals programme or NHS long-term workforce plan, both of which are desperately needed but – as pledges go – less voter-friendly than fixing waiting times? The economic situation and state of the UK’s public finances mean a Labour government will have much less financial “room to manoeuvre” – and thus spend on the NHS – than Blair and Gordon Brown did. During their tenures annual budget rises averaged 6%, which is unthinkable now. Labour’s NHS plans are “hugely ambitious”, Anandaciva believes. That is partly because of the waiting times promise but also because the party is also intent on changing the NHS radically “so that it becomes not just a sickness service, but also able to prevent ill-health in the first place”. There is little detail on what that means or how it would be pursued. But doing so would involve a major expansion of NHS care and advice outside hospitals, delivered by GP surgery staff, district nurses and health visitors, potentially through new “one-stop shops” offering preventive help, he explains. Labour in power will benefit from a surge of goodwill from staff who know that it is the party that created the NHS in 1948 and always seeks to improve it. But the sheer number of issues at hand – including strikes, avoiding a winter crisis, making rapid progress on waiting times – may mean that the day-to-day challenges of being in charge of such a vital and complex service force a rethink of the scale of ambition in the plan to repair what they say is a broken NHS.