A tax-funded health system will always be inseparable from politics: that’s why this column covers politics so often. And our politics is, yet again, in flux.
Ministers defenestrated PM Boris Johnson through industrial action by withdrawing their labour, so a leadership contest inevitably followed.
Former health secretaries didn't get far as candidates. Sajid Javid (whose co-resignation with Mr Sunak started the Johnsonexit snowball rolling) didn't even attract enough MPs’ support to make the first round of the ballot. Clearly, he ran a Blockbuster campaign in an age of Netflix. Jeremy Hunt failed to repeat his "last two" placing from 2019, and was eliminated at the first vote of MPs. Tragically, Matt Hancock didn't even stand again, depriving the nation of much-needed amusement.
Voting done among MPs, we now know that the Conservative and Unionist Party’s next leader will be either former chancellor Rishi Sunak or foreign secretary Liz Truss. Party members will be balloted over the summer. Their new leader – and therefore the new prime minister – will be announced on 2 September.
Rishi Sunak or Liz Truss?
In broad terms, it’s difficult to find much to choose between the two politically. Their views put them very much on what would a few years ago have been the further-right-wing of the party, and is today its mainstream.
Mr Sunak, the brand-aware Brexit-backing diminutive ex-chancellor, self-identifies as a “tax-cutting Conservative”, despite having taken UK taxation to its highest level since the Second World War.
His tax affairs and UK residency status have come under scrutiny, as have those of his wife. He was forced to reveal that he had a US green card, and had declared himself a “permanent US resident” for tax purposes for 19 months while he was chancellor and for six years as an MP.
The ex-chancellor was also fined by the police for his involvement in Downing Street’s Partygate.
Ms Truss, formerly a Liberal Democrat and Remain campaigner (as Mr Sunak helpfully reminded her in a televised leadership candidates’ debate), is famed equally for her ire about pork and cheese , and for her self-image as a Margaret Thatcher tribute act for the age of Instagram.
She is also understood by Westminster insiders to be vivacious and spirited in her personal life, which may prove interesting.
It’s too early to be sure, but polling of the partisan Conservative Home website has consistently shown Ms Truss to be that readership’s favourite cabinet minister.
And the health thing?
What have the candidates said about health and social care? Very little, at the time of writing this.
Ms Truss mentioned the dire state of the ambulance service serving her Norfolk constituency in a TV debate (nationally, all English ambulance services declared top-level emergencies this past month). She also told the BBC Today programme that she would honour NHS spending commitments, vowing to “stand by our doctors and consultants”.
She also now opposes April’s "health and social care levy" NI rise of 1.25% on employers’ and employees’ contributions, for which she voted.
Mr Sunak still supports his NHS tax rise. However, he or his team told The Times that the problems with the NHS are not about resourcing, but about a lack of output targets.
Yes, really. This Times article features claims that Mr Sunak plans "to set out details of his plans for reform of the NHS and other public services during the leadership campaign", adding: "He would focus on the need to hold them accountable for results, not to simply boast about spending."
The erstwhile chancellor reportedly "told MPs during meetings this week that the trajectory of health spending was “not sustainable”, given it would reach 44% of day-to-day government spending in 2024, up from 27% in 2000. It is understood that he does not propose to cut health spending but to "hold the NHS more firmly to account for its budget".
The piece says that "new output targets are likely to be proposed".
Ah yes: new output targets, when the system can't come close to meeting existing ones. That always works.
The Sunak diagnosis that the NHS's current problems are about not being held to financial account and its lack of output targets is... niche.
And how is the NHS doing?
Well might you ask. Not so great.
The waiting list continued its steady rise of about 100,000 a month, up now to 6.6 million.
As mentioned above, ambulance services are in crisis, all declaring the highest levels of alert. One of the main causes of this is hospitals’ inability to admit, due to their inability to
discharge medically fit patients into social care that is a) no longer funded since 1 April, as it was on an emergency basis during the pandemic, and b) scarcely available, even if there were the money.
Nor has Covid-19 disappeared. The latest ONS infection survey data shows a continuing rise in infections, with 1 in 17 people in England having been infected in the past week. The ongoing wave of infections is preventing hospitals from cutting the backlog, because infection control measures and staff absences (due to combinations of Covid infections, long Covid, stress and burnout) mean that the capacity to do more is simply not available. And for many of those staff available, pensions taxation disincentivises further work at evenings and weekends to address ever-burgeoning waiting lists.
The government is offering the NHS a pay award averaging about 5%, but has only funded a 3% increase. And the Treasury has been clear that this difference will have to be found from within existing budgets.
So, expect service cuts to achieve this.
Also, expect industrial action, because even those staff (not all, by any means) getting near to 5% are still getting about 5% below the current rate of inflation, meaning what is on offer is a real-terms pay cut.
None of this has cropped up meaningfully in the leadership debates. Shamefully, the political media has almost entirely failed to ask about it.
It’s as if truly dreadful NHS performance has become completely normalised. That is something about which we should worry.
And as and when we need to access healthcare, we will do rather more than worry about it.
Andy Cowper is the editor of Health Policy Insight