Robert Ede argues that an ambitious programme of capital investment in the manifesto must go hand in hand with new legislation.
Since last week’s manifesto launch, the Conservative Party has faced its most challenging period of the election campaign. Controversial plans to overhaul social care – dubbed the “dementia tax” – have angered many within the party, including senior cabinet ministers who were kept in the dark, but then dispatched to defend the proposals over the weekend.
Recognising that the changes are not playing well with voters, Theresa May has rowed back, hurriedly announcing the Conservatives will introduce a cap on total care costs to protect at-risk homeowners. Alongside recent U-turns on National Insurance changes and workers on company boards, this decision demonstrates how quickly May’s top team responds to public mood.
There is a political rationale to acknowledging and resolving a perceived mistake. But numerous sudden changes tend to not make for strong and stable government. Many within the NHS will fear that the health elements of the manifesto may be vulnerable to similar backsliding after 8 June.
‘For too long, the estate has been the Cinderella of our health service – ignored in the major debates on the NHS and lacking an overarching strategy to deliver transformation’
The inevitable focus within the health sector has been on whether a minimum of £8bn extra in NHS funding by 2022-23 promised in the manifesto – effectively a two-year extension on the spending review – will be sufficient to meet the strain on the health service. But the health section also pledges to “introduce the most ambitious programme of investment in buildings and technology the NHS has ever seen”.
We received extra detail on this pledge during the prime minister’s interview with the BBC’s Andrew Neil, in which she confirmed that £10bn of funding would be made available.
For too long, the estate has been the Cinderella of our health service – ignored in the major debates on the NHS and lacking an overarching strategy to deliver transformation. The measures introduced by the Lansley reforms eroded central responsibility for the estate, and spending on capital projects has continued to decrease since the 2015 spending review, with funds redirected to prop up frontline service shortfalls. When combined with an increasingly constipated approval process, the numbers of new schemes being developed has dried up to a trickle.
However, the spotlight is returning with the recent review of NHS property and estates by Sir Robert Naylor, which sets out a compelling case for investment and system reform that will deliver better outcomes for patients. Sir Robert identified that nearly 20 per cent of hospital trust buildings predate the formation of the NHS, whereas backlog maintenance across these sites now represents a £5bn liability to the system.
‘New legislation could drive accountability into the STP process, address problems created by the internal market, and create a clear pathway for accountable care organisations’
Sir Robert argued that new premises – likely to number several hundred across England – could be financed through a combination of property disposals, matched by HM Treasury, with a final third contributed by private investors in primary care.
The Conservatives are keen to press ahead, with the Treasury already making £325m available to fund the strongest sustainability and transformation plan capital schemes. In March, this was framed by Simon Stevens as a “down payment” in advance of chancellor Philip Hammond considering a further round of proposals in the autumn.
Whilst Mrs May’s public backing for the Naylor review is therefore significant, it should not come as a complete surprise. The language in this section of the manifesto closely mirrors that in Sir Robert’s report, whilst the pledge for further detail in the autumn dangles the same carrot offered in the spring budget. But if the Conservatives are to return to government in just over a fortnight, they will be faced with several key challenges that will determine whether they are able to deliver transformation change in NHS property and estates:
To legislate or not?
Whilst Simon Stevens have been very effective in navigating around the 2012 Health and Social Care Act, there has been a growing realisation that NHS England has reached a juncture. New legislation could drive accountability into the STP process, address problems created by the internal market, and create a clear pathway for accountable care organisations. It would also turbo-charge the Naylor Review’s recommendations, creating the right incentive framework for providers to make better use of available land.
The case for legislation is therefore strong. But as we have already seen with the garbled release of the STPs, system reform must be stress-tested to avoid political backlash. A new bill introduced in mid-2019 would avoid the distraction of Brexit negotiations, and allow for sufficient consultation and buy-in with the healthcare community.
Ensuring the STP process delivers consistent care
Key Conservative figures, such as Ben Gummer within the Cabinet Office, want to reward successful STPs that offer sound financial plans and radical change. But this approach carries risk – given the potential to exacerbate variations in care and patient outcomes across England. Footprints where progress has stalled must not be left behind.
Putting the power in the new NHS property organisation
The creation of a new NHS property organisation has been disrupted by the general election. This work must recommence in earnest following 9 June, with the new government encouraged to provide clarity over its design and function provided as soon as possible.
High quality premises are the foundation of a successful healthcare system. This election is rare in bringing that debate into the public light and highlighting why good buildings matter to patients. After the election, it will be the responsibility of the estates community to ensure it does not fall off the list of priorities for the new government, whichever party is victorious.
Robert Ede is a senior political consultant at The Whitehouse Consultancy.