This is the fifth of our Pinning Down Farage articles, which scrutinise and expose the failings of UKIP policy. Click here to read the rest of the series.
The structure of pieces in this series is now well-established, so I won’t indulge in much preamble besides a reminder that as UKIP’s formal manifesto for 2015 is yet to be released we must search elsewhere to gain an insight into their view on health and the NHS. A variety of sources have been deleted or later denied, but we publish them precisely because the “people’s army” ought not to be able to evade scrutiny – particularly when they claim to hold themselves to higher standards than others.
UKIP know that the NHS is a tricky topic for them. At times, their former stance as radical libertarians left them vulnerable to suspicions among potential voters that they wanted to abolish it – and Labour have focused on the issue in their attempts to fight off purple incursions into red territory. While not the party’s official policy, the now notorious comments of Paul Nuttall MEP that “the very existence of the NHS stifles competition” haven’t helped that reputational battle.
As we will see, the awareness of this weak spot has led the party’s policy on a merry dance through a variety of positions, not all of them coherent.
As ever, the 2010 manifesto is a good starting point. Yes, it has been denied by Farage and even deleted from the UKIP website but it remains the platform on which the party and most of its current representatives fought the last General Election. To understand how they get where they are today, it merits a look. In brief, here’s the policy pitch (with UKIP policy in pink and my comments in black):
- ‘UKIP believes strongly in the principles of the NHS, which should continue to deliver care free at the point of delivery on the basis of need, not ability to pay’.
- ‘Make no cuts in NHS frontline services’. This is presumably measured in financial terms.
- ‘…substantially reduce NHS waste and bureaucracy’.
- ‘…introduce new elected County Health Boards [CHBs]. These Boards will be made up primarily of healthcare professionals’. As I noted last week when reviewing a similar proposal in their education policy, it isn’t clear how they would restrict candidacy to ‘healthcare professionals’.
- ‘…abolish overlapping layers of bureaucracy such as…Strategic Health Authorities and Primary Care Trusts. Over time UKIP will replace Hospital, Foundation, NHS Care and Ambulance Trusts with equivalent franchises’. No, I can’t quite work out what ‘equivalent franchises’ means, either – though the commitment to abolish overlapping layers of administration, and to introduce County Health Boards suggests this would mean a unitary model of health service, all run through one organisation in any one place.
- ‘…put out to tender key NHS services…by franchising key services – run on a fixed budget – to charitable associations, not-for-profit and profit-making private companies, partnerships and individuals’. In fairness, this is openly justified on the basis of bringing in ‘private sector efficiency and innovation’ – though there’s no explanation of what happens when a fixed budget is overrun.
- ‘…introduce ‘Health Credit Vouchers’, which will enable people to opt out of the NHS public healthcare system entirely if they so wish’. Impressively, this is just included in the list – with no comment on how it would interact with the county funding for a unitary NHS they’ve just proposed.
- ‘…clinically-trained Matrons to run hospitals…On-the-job nurse training and hospital-based colleges will replace most university courses’. As with education policy, UKIP’s belief in localism and private sector innovation does clash sometimes with a tendency to already know how things should be run once localised, or put out to tender.
- Require migrants to hold health insurance prior to their arrival.
- ‘Restore free eye tests and dental check-ups for all UK citizens’. No, we don’t know how much this would cost – as with much of their economic policy, it runs at odds with their declared support for austerity.
In short, a mixed-bag. Some ideas that would appeal to libertarians, some that don’t necessarily hold together and others that amount to a full-scale reorganisation of the NHS well beyond even that introduced by the Coalition.
As with education policy, the government’s record should satisfy some of UKIP’s stated aims. NHS bureaucracy in particular has been cut back, with fewer managers and resources diverted to nurses and doctors instead.
In 2012/13, UKIP carried out what appears to have been an abortive remodelling of its policy platform. Their website’s policy pages were filled with updated sets of proposals on all sorts of areas that were then taking down again only a few months later. We may never know why – perhaps there was a strategic change of direction, an internal dispute about it or increased media scrutiny meant they generated too many questions – but thanks to the Wayback Machine we do have a record of what that review said. In carrying forward some of the 2010 policies, it gives a certain sense of evolution:
- Maintain ‘a healthcare system open to all British people, regardless of their ability to pay’.
- Carry out a cost/benefit analysis of a ‘co-insurance model’ of healthcare. This is not necessarily a bad idea, but is a radical departure from the previous claim.
- Devolve the majority of NHS spending, decision-making and policy to elected County Health Boards, while keeping a slimmed-down Department of Health to address public health, staff training and research. This would involve a wholesale reorganisation of the NHS – far, far beyond that pursued by the Coalition. Such an approach hasn’t exactly proved popular – which presumably explains why UKIP never talked about it up front.
- Put CHB’s in charge of monitoring standards and acting on complaints. If recent scandals and failures have taught us anything, from Mid Staffs to Rotherham, it is that allowing a public body to police itself is unwise at best.
- Introduce on-the-job nursing training, overseen by CHBs. This sounds superficially the same as the 2010 policy, but in fact by 2013 they had abandoned the plan to abolish ‘most university courses’ for nurses, and instead propose vocational training as part of a mix.
- Renegotiate PFI contracts and reform procurement. These are good ideas in themselves – the question is how it would be done in practice.
- Put the Department of Health in charge of ‘co-ordinating R&D in health care to ensure duplication is avoided’. Leaving aside the fact the most healthcare research takes place outside the UK, I’d be wary of centralising control of research to avoid duplication - free enterprise and academic innovation are routinely ahead of Whitehall bureaucrats in finding out what works.
- Allow CHBs ‘to introduce a small charge (e.g. £1) for everyone’ to reduce abuse of free prescriptions. [This is an outright departure from the supposed commitment to the current model of free at the point of use NHS provision.]
- Restore free eye tests and dental checks.
There were some signs of a more subtle approach – for example, opening an additional vocational route into nursing rather than the 2010 policy of abolishing the university education of nurses. The wholesale reorganisation of the NHS on a county basis persisted, though, along with new signs of serious risks posed by allowing CHB’s to police themselves. Remarkably, while that policy was in place the BBC reported that “UKIP says it has no plans to fundamentally change the NHS”.
We rejoin the story in the modern day. The 2010 manifesto has been scrapped, denied and deleted – the 2013 policy update has vanished down the same memory hole. Instead, we have available a patchwork quilt of speeches, statements and webpages.
Policies for People, which seeks to summarise the announcements at the UKIP conference, proposes the following:
- ‘UKIP will ensure the NHS is free at the point of delivery and time of need for all UK residents’.
- ‘…ensure that visitors to the UK, and migrants until they have paid NI for five years, have NHS-approved private health insurance as a condition of entry’. So in fact the NHS won’t be ‘free at the point of delivery for all UK residents’.
- ‘…stop further use of PFI in the NHS and encourage local authorities to buy out their PFI contracts early where this is affordable’. As with the 2013 policy, the instinct is laudable but the absence of costings for buying out such vastly expensive contracts is totally absent.
- ‘…ensure foreign health service professionals coming to work in the NHS are properly qualified and can speak English’. This is already NHS policy.
- ‘There will be a duty on all health service staff to report low standards of care’. Thanks to Jeremy Hunt, this is also already NHS policy.
- ‘…replace Monitor and the Care Quality Commission with elected county health boards to be more responsive scrutineers of local health services’. This is a drastic departure from the previous UKIP policy of County Health Boards – which were going to be the main seat of budgeting and decision-making in the NHS. Now it seems they would only hold a scrutiny role.
- ‘…ensure that GPs’ surgeries are open at least one evening per week, where there is demand for it’. Quite how, who knows – writing evening services into the GPs’ contracts would be wise, but a vague statement of ‘where there is demand’ is hard to imagine pinning down in practice.
It’s a notable set of changes. CHBs are suddenly watchdogs, not administrators – a bulwark against new Mid Staffs-type scandals, without the acknowledgement that UKIP’s previous policy would have made them a potential source of such failures. Similarly, they promise to introduce some policies (such as a requirement for foreign doctors to speak English or a duty to report poor care) which are already in place – it’s hard to imagine UKIP don’t know that’s the case, which suggests an opportunistic dishonesty.
Then we have the conference speech of the party’s health spokesman, Louise Bours MEP (video here) – one of their more outspoken representatives, if not perhaps the smartest. The party’s own press release on her speech makes the focus of its NHS policy all too clear: after “NHS”, the most common word was “Labour”.
As such, much of it was spent denying Labour’s criticisms of UKIP, but we can glean a little more policy, too:
- “A two tier national health system, where those with money can opt to pay for enhanced services will never be acceptable”. She neglects to mention – or perhaps has forgotten - that it was her own party’s policy in 2010 to allow people to do exactly that by opting out of the NHS with Health vouchers.
- Ally with Unite to oppose TTIP. Brandishing a letter from Len McCluskey (Red UKIP, anyone?), Bours describes the mooted free trade deal with the US as a “serious threat” to the NHS, in order to serve “big business”. There are various reasons to be concerned about TTIP - I’m concerned its implementation without democratic consent will harm the standing of free trade, for example – but teaming up with Unite, who oppose any and all free trade, on the basis of flimsy scare stories about the NHS is a Faustian pact. Yet again in this series we see UKIP trade their principles (they still describe themselves as a party of free trade) for party advantage.
- “Bureaucrats now outnumber clinicians and nurses” and that money should be diverted to the frontline. This is a misreading of the numbers at best. The latest House of Commons Library note on NHS workforce statistics found “qualified clinical staff accounted for 51 per cent of the NHS workforce in England in 2013, with 20 per cent as support to clinical staff.” That 20 per cent includes a variety of trainee therapeutic staff and all sorts of others directly involved in front line care, so the figure is well over a majority. Even leaving the figures aside, Bours ought to know that the Coalition has been drastically reducing the number of managers – in short, doing exactly what she proposes.
- UKIP propose a licensing system for NHS bureaucrats. This is, at best, a gimmick – you don’t need a licence to prove you are a competent administrator, you need a recruitment system that properly scrutinises applicants and checks references. Awkwardly, establishing and running a licensing system for administration staff would require, er, more bureaucrats in the NHS.
In short, UKIP’s health policy is distinctly patchy. Demands for policies that are already in place. Denunciations of principles that were proposed in their own General Election manifesto. Calls for fewer bureaucrats while proposing a centralised licensing system for hundreds of thousands of staff.
But then, being practical or consistent isn’t the point. As Louise Bours’ own press release said, the policy is “designed to make Labour squirm; UKIP stand ready in the wings, waiting to replace them as the party who will fight for NHS.” That, it seems, is the real priority – and they don’t intend to let honesty or practicality stand in the way.