Uncertainties over the NHS will continue amid further Tory cuts to local government

Gone are the weeks of fog that were predicted to follow the 2015 general election. Instead the principal contours of the political landscape that lie before us for the next five years are much clearer.

But when it comes to the NHS, there are more uncertainties than certainties. And as the new Conservative government settles in, will it be that it mechanistically implements manifesto promises designed to placate fears of privatisation or cuts in spending or will the party’s new-found confidence having won an unexpected but slender majority result in new, bolder policies which may further erode the NHS’s public service ethos as its critics suspect and fear?

Prime minister David Cameron has been appointing his new team and Jeremy Hunt will stay on as secretary of state for health and if past form goes, he will be very hands on.

Inheritances

The Health and Social Care Act 2012 handed control to NHS England and abolished the health secretary’s legal duty to provide health services in England. Hunt ignored this inheritance from his predecessor, Andrew Lansley, the architect of the ill-conceived reforms.

Lansley’s changes to the act were supposed to take some of the politics out of the NHS by reducing the secretary of state’s day-to-day involvement, leaving it to the NHS chief executive. Hunt, however, proved to be a hands-on minister who took charge of events following the Mid-Staffordshire tragedy, and led the crusade for improved quality of care. He held weekly meetings with senior officials to review issues such as waiting times, and remained very much in charge and in control despite the purpose of the act being to reduce that level of interference and direct engagement.

Hunt has said he would like to stay in health but Cameron has many new MPs to keep in line and what better way to do so than to give them a challenging departmental brief to keep them out of mischief.

Whatever the uncertainties, there are some givens. The Conservatives are signed up to NHS England’s Five Year Forward View and to finding the £8 billion minimum required each year up until 2020 to enable the transformation called for to succeed. But promised further public spending cuts affecting local government, and social care in particular, are likely to have the effect of increasing pressure on already stretched and, in some cases, threadbare healthcare services compared with other wealthy countries. They can only make the realisation of integrated care more problematic.

A delicate position.Carly Lesser & Art Drauglis, CC BY-SA

Another given is that the Health and Social Care Act will remain intact. The chances of any legislation that will reinstate the NHS along the lines proposed by Lord Owen – to remove the forces of marketisation and commercialisation from legislation. In particular, removal of the controversial Section 75, which promotes outsourcing and competitive tendering and opens up a market in healthcare, must be off the agenda.

Unfettered by coalition

A major uncertainty must be over how far the government, unfettered by coalition partners, will further hollow out the NHS through the outsourcing of services to the private sector. The fear is that the NHS progressively becomes a brand on the façade while myriad private provide back-room functions to support clinical commissioning groups and frontline health and community services.

Regardless of whether using public funds in this way is efficient and in the public interest, it is inconceivable that the new government, propped up by powerful donors, lobbyists and business interests who stand to do well from lucrative NHS contracts – what the Social Market Foundation termed “institutional corruption” – will not move swiftly down this road.

Indeed, getting the controversial Transatlantic Trade and Investment Partnership Treaty (TTIP) ratified at the earliest opportunity will be a priority. Critics consider the TTIP will hasten the privatisation of public services like the NHS and further open them up to large American health companies, like United Health, where Simon Stevens, NHS Chief Executive, was former president of its global health division.

Finally, with Osborne back in charge at the Treasury and the architect of the Northern powerhouse project, developments such as DevoManc will gather pace and be accompanied by similar devolved arrangements emerging elsewhere. Whether they might be the saviour of the NHS or simply another route to dismantling it is impossible to say at this early stage. But with the next round of spending cuts expected to fall heavily on already hard-hit local authorities, it could be argued local government is being set up to fail.

For NHS-watchers in academia and elsewhere the next few years promise to be especially interesting both in terms of the devolved arrangements planned in England to run the NHS and the growing divergence between England and Scotland. The difference in approach to health policy in Scotland is often claimed to be more presentation and rhetoric, than real substance. Anglo-Scottish comparisons over the next term with Nicola Sturgeon, first minister for Scotland, having set out a very clear agenda for a publicly funded and provided NHS will allow that charge to be put to the test.

David Hunter receives funding from the NIHR and is affiliated with the Department of Health's policy research programme.