The Guardian view on Labour and the NHS: Good plan, Mr Burnham, but now we need the detail

http://www.theguardian.com/commentisfree/2014/sep/24/guardian-view-labour-nhs-burnham-detail

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Andy Burnham, the shadow health secretary, had a happier time on the podium at the Labour conference in Manchester on Wednesday than he had had in TV and radio studios on Tuesday. Only minutes into his speech he had delegates, still tearful from the nonagenarian Harry Smith’s moving description of life and death before a free National Health Service, up on their feet roaring him on. Labour is absolutely right that the NHS must be at the centre of political debate between now and the election, for it is genuinely facing bigger challenges than at any time in its history. The party’s proposals for extra cash from taxes on tobacco and mansions that Ed Miliband set out on Tuesday are a welcome, if limited, move. A joined-up health and caring service is the right destination and a single funding body is part of the right answer. Much the same was proposed by the commission set up by the King’s Fund and chaired by Kate Barker. But there was nothing in Mr Burnham’s speech that suggested he has a policy that is worked through in enough detail to allow him to answer the challenge of the sceptical interviewer, nor any recognition that the transformation for which he rightly calls will be made in the teeth of cripplingly tight budgets.

First, the funding crisis. It is now widely predicted that NHS acute hospitals will be £1bn in debt by the end of the financial year. Even foundation trusts, whose status depends on their effective management and which have been making surpluses until this year, are starting to report serious overspends. Not only are they struggling to afford the extra nurses recommended by the Francis inquiry after the Mid-Staffordshire scandal, they are also trying to meet £4bn of efficiency savings demanded in this year’s round of the so-called Nicholson challenge, which will take £20bn out of budgets between 2011 and 2014. Key performance indicators expose the impact of the pressure. Waiting times for referral appointments, for treatment and in emergency units have all been exceeded this summer, even though the NHS budget has been ringfenced and extra cash – in total more than £12bn – has been found by the government to try to head off crisis. Yet, even if there is still room for improvement, in international comparisons, the NHS remains remarkably cost-effective. According to the OECD, in 2012 the UK spent just 9.3% of GDP on health. France and Germany, both of which have bigger economies, spent 11.3%, while in the US health expenditure is more than 17% of GDP.

While Mr Burnham’s combined health and care service is unquestionably the right direction of travel, it is not a cost-free option. The Barker report estimated that even after introducing a combined service, spending would need to rise to around 11% of GDP to meet demand. An increase on that scale would still leave our health spending trailing the highest European spenders – and it would require double the spending increase that Labour is proposing. And although Mr Burnham denies that there will be more reorganisation, it is not clear how the NHS and local councils can deliver a joint service without shared management. Unavoidably, there would be heavy transitional costs.

There are other hard choices to make. Keeping people out of hospital saves money, but it is still costly. Governments have been chary of the question of who pays, how much and when. Merging health and care will highlight the anomaly where healthcare remains free at the point of use but social care is means-tested, and increasingly hard to access.

Nor, necessarily, is the pledge that raised the biggest cheer at Labour’s conference, Mr Miliband’s commitment to create thousands more jobs in the NHS, including 20,000 more nurses, the best use of scarce resources. With Mr Burnham floundering in the face of questions about how the mansion tax will work, and when it will start to bring in the promised cash, it compounds the impression that Labour may be thinking too much about exploiting its reputation among voters as the party of the NHS at the next election, and not enough – or not hard enough – about the severity of the challenges ahead. The way health and care are provided is intensely political. But the less political the NHS itself is, the better.