Are we ready for a grown-up election debate on the NHS and social care? | Niall Dickson

In an age when experts are no longer de rigeur, it may be asking too much for the political debate about the future of health and social care to be nuanced, balanced and informed. Were it to be so, it would surely be the first time we had achieved such dizzy heights in the bare knuckled fight of an election campaign.

So what would be good to hear? First, an acknowledgement that all the main parties are culpable for severe underfunding of social care – arguably both at national and local level. The additional sums announced in the budget are welcome but not sufficient. The government has promised fundamental reform but again all parties, including the Conservatives, have made such promises before and then failed to deliver.

Second, a commitment to health and social care funding linked to GDP over the next parliament. We can only afford what the country can afford so it is right to link it to the size and success of the economy, but we can do much better than the current 10% well below the levels seen in the comparable economies of France and Germany. Allied to this, it would be refreshing to hear an admission that we can only afford what we pay for and that it is inevitable that care will be rationed when priorities have to be made.

Third, can we acknowledge that there is no evidence that the health service is over managed? Compared with other systems worldwide we have fewer managers and lower administrations costs. In January the Organisation for Economic Cooperation and Development reported UK spending on health administration at 2%, was below the 3% average and well below the 6% spent by France and 10% in the US.

This is not to argue that the system does not need reform. Far from it, but again some honest reflection on this would not go amiss. It would also be good to hear candidates support the drive for a major transformation of health services, which is occurring in different ways across the four services of the UK.

In England organisations that have in the past struggled to collaborate are starting to come together to create more integrated systems. The sustainability and transformation partnerships (STPs) are at very different stages of development and in some ways are an attempt to make the best of the rather messy reorganisation of 2012; but they are the only show in town and their intentions are honourable.

STPs present an enormous challenge. We have an unsustainable system, with institutions, incentives and patient flows designed for a different era. Creating systems where treatment and support are given at the most appropriate time and in the most appropriate place is far from easy. In part this is because we are asking leaders to sacrifice their own institutional interests in favour of the wider system. We are also doing this at a time of severe financial constraint, unprecedented levels of demand and when pressures from the centre are as great if not greater than ever.

It is not easy because the political class in all its colours either does not understand – or chooses not to understand – what is at stake. It is possible to have some sympathy for what has become the default political position, which is simply to defend buildings and organisations as if they were sacrosanct. But we need to reduce demand for acute services and the only way we know how to do that is to invest in alternative services in the community. A debate about how this can be achieved, recognising that it will mean difficult choices, would be a significant advance in the political discourse.

It is clear there will be claims and counter claims about impending privatisation and it is of course a legitimate view that all healthcare should be publicly provided. It is not one shared by the NHS Confederation – we believe our members from the voluntary and independent sectors make a vital contribution to the NHS. We know that the public consistently reports being relaxed about who provides their care – what matters to them is that it is high quality and free at the point of use. Here too though we could at least clarify the debate. Private or plural provision has been part of the NHS since its inception and is clearly compatible with a service free at the point of delivery. That is quite different from advocating a service based on charges or co-payments.

So are we ready for a grown-up debate? Election campaigns are always hard to read – they often have a mind of their own and can easily divert away from the messages the parties are desperate to push, (readers may recall Jennifer’s ear in 1992 or Sharron Storer ambushing Tony Blair in 2001). This time though we may struggle to secure the necessary time or space to facilitate a more mature debate.

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