Introduction

This book considers the evolution of the Conservative Party's social policies following the 2015 general election. The period from 2015 was remarkable in a number of respects, including the Brexit process, the COVID-19 pandemic and the turnover of prime ministers, each of which had implications for the development and implementation of social policies. The 2015 election led to a Conservative government with a narrow majority in the House of Commons, and this was followed by another general election in 2017, when the Conservatives lost their majority, and subsequently by the 2019 general election, which resulted in a substantial Conservative majority of 80 seats. However, those Conservative governments were subject to significant new influences over which they had only limited control, with many of the consequences of the Brexit referendum and the COVID-19 pandemic being notable examples, while other key developments, such as ‘austerity’ and attempts at ‘levelling up’, were much more clearly driven by decisions within the Conservative Party and governments themselves. One of the ramifications of these developments was that the Conservative Party had five leaders (and the UK, five prime ministers) within seven years, with equally rapid turnover in many Cabinet positions, and each individual arguably had different preferences that would be expected to influence the shape of social policy, as is discussed later.

This chapter seeks to provide the context, and to some extent a framework, for the chapters that follow, through:

• • briefly considering the main features of policy and underlying themes in the social policies of the Conservative governments from 2015;

• • examining the extent to which the Cameron, May, Johnson, Truss and Sunak administrations of 2015 onwards had similar approaches to social policy compared with each other, and with their immediate predecessor, the Coalition government;

• • outlining the major influences on Conservative policy during the period, including in relation to both key philosophical positions and the impact of events; and

• • considering the implications of developments under the Conservatives for social policy in the UK in the post-Brexit and COVID-19 era.

Introduction

In many ways, Conservative health policy after 2015 was ‘more of the same’, continuing from the second half of Coalition health policy, which had tried to row back from the domination of the Health and Social Care Act (HSCA) 2012 in the first half of Coalition health policy (Appleby et al, 2015; Ham et al, 2015; Baggott, 2016; Powell, 2019b). It is possible to point to three broad themes: first, a continuation of the journey from ‘peak’ marketisation towards integration, initially in a series of ‘workarounds’ which gradually became formalised; second, a gradual loosening of austerity under the Conservatives compared with the Coalition, although recent increases in expenditure tend still to be below the long-term historical increases in expenditure since 1948; and third, as promised in a public health White Paper, a radical shift in the way of tackling public health challenges and a ‘new era for public health’ (Department of Health, 2010, p 4; see also Baggott, 2016). A great deal of stress has been placed on the rhetoric of prevention, but the previous emphasis by the National Health Service (NHS) on prevention has never resulted in significant action (Powell, 2009). This theme may be generalised, as it will be claimed that health policy broadly saw a large ‘implementation gap’ between policy rhetoric and action.

The journey away from the HSCA 2012 arguably began with the NHS’ Five Year Forward View (NHS England, 2014), which is generally associated with the newly appointed Chief Executive of NHS England, Simon Stevens, a former NHS manager, Blair advisor and then Executive Vice President of UnitedHealth, a US private health company. This plan claimed that it would bring about patient-centred, coordinated, integrated care focusing on prevention, out-of-hospital care and the integration of primary, secondary and community care. It argued for a ‘radical upgrade on prevention and public health’ (p 3), recognised ‘emerging models’ (p 16) and ‘radical new care delivery options’ (p 4) and stressed the importance of devolution, such as ‘Devo Manc’, in which the £6 billion health and social care budget for Greater Manchester was to be taken over by the region's councils and health groups.

Introduction

This chapter draws together the arguments presented throughout this book and relates them to the framework introduced in Chapter 1. In particular, it considers the main approaches underpinning the Conservatives’ social policies since 2015, covering five prime ministers, albeit that is particularly complicated given the impacts of Brexit (Chapter 4), the COVID-19 pandemic (Chapter 5) and the period of high inflation from 2022. It is also important to recognise that in many areas of social policy, the remit of the Conservative governments was limited to England, although the main driver of levels of public expenditure across the UK remains the decisions of central government as it largely determines the funding available to the devolved administrations.

Locating the Conservative governments, 2015– 23

As discussed in Chapter 1, this section draws on Powell's (1999) analysis of New Labour and Bochel and Powell's (2016) consideration of the Coalition government to examine social policies by setting them against the framework of alternative political approaches and drawing on the analyses provided by the contributors of each chapter for this book. It expands on Table 1.1 to look at the governments as led by David Cameron, Theresa May, Boris Johnson, Liz Truss (briefly) and Rishi Sunak, and it summarises their approaches to social policy in Table 18.1.

While there are, perhaps inevitably, some differences, our assessment is largely in line with the views of the other contributors to this book, with the Conservative governments being largely seen as having significant similarities with New Right thinking, but nevertheless having been greatly affected by ‘events’, meaning that successive prime ministers and their cabinets found it hard to clearly set out, let alone achieve, their social policy goals.

As discussed earlier, the ‘Coalition’ years cover the period with Cameron as Prime Minister in coalition with the Liberal Democrats, while the ‘Conservative’ years cover the period following the general elections of 2015, 2017 and 2019, under the leadership of Cameron (2015– 16), May (2016– 19), Johnson (2019– 22), Truss (2022) and Sunak (2022– ).

Introduction

Like many other health systems, the NHS has been regarded as more like a sickness than a health service, failing to place health before healthcare, and to focus ‘upstream’ on the ‘social determinants of health’ (SDH) (for example, Wanless 2002; Marmot and Wilkinson, 2005; Hunter 2016a). This has implications for both aggregate health and health inequalities. First, while life expectancy in the UK in the twentieth century increased 38 years for men and women, equivalent to an increase of 4½ months per year (ONS, 2015), much of this improvement in life expectancy and health status more generally, is associated with the SDH (Marmot, 2010). It has been estimated that only 10–25 per cent of the health of a developed population is attributable to the healthcare system (McGinnis, Williams-Russo and Knickman, 2002: 83; Harrison and McDonald, 2008: 165). However, only ‘around 5% of the total UK government healthcare expenditure’ is devoted to preventive healthcare, with about half of NHS staff not regarding prevention as a core part of the work of their organisation (Faculty of Public Health, 2019; see also Exworthy and Morcillo, 2019).

Second, the temporal pattern for health inequalities is more complex. There has long been a recognition of health inequalities in terms of geographical and social class differences in life expectancy since at least the Chadwick Report 1842 (for example, Bambra, 2016). However, while overall health, in terms of life expectancy, broadly increased for much of the twentieth and early twenty first century before stalling or reversing in recent years (Marmot et al 2020a), health inequalities have increased at some times and reduced at others. For example, according to Robinson et al (2019), absolute inequalities in the infant mortality rate (IMR) increased between the most deprived local authorities and the rest of England between 1983–1998, decreased during the period of the English health inequalities strategy (1999–2010), but increased again in the period 2011–2017.

This chapter will thus examine the ways in which the NHS has addressed the issue of health and health inequalities. First, it focuses on four chronological periods of policies on health and health inequalities in the 75 years of the NHS. Then, it explores health and health inequalities through the four analytical lenses introduced in Chapter 1, before moving to evaluate policies concerned with health and health inequalities.

Introduction

We opened this book (Chapter 1) by observing that the NHS was in a parlous and unprecedented position. Now that the contributors have surveyed the period across a range of domains, there seems to be very little evidence to revise that verdict. Over its 75 years, the NHS has seen a number of ‘big bang’ reforms and many more, smaller incremental reforms (Tuohy, 2018). While there has been a great deal of analysis on the former (Robinson and Le Grand, 1994; Le Grand, Mays and Mulligan, 1998; Thorlby and Maybin, 2010; Exworthy Mannion, 2016), there is a danger that the smaller but cumulative changes of the latter may be missed (Powell, 2016).

Cumulative incremental changes are harder to detect and assess and receive less publicity than large-scale (big bang) reforms which are often heralded with much fanfare and public debate. Large-scale reforms of health systems such as the NHS may be somewhat constrained by its own logics (Tuohy, 1999) but they might also have a negative impact on the resilience of the NHS. Individual reforms (or a programme of them) may not necessarily lead to a loss of resilience at that time but repeated reforms may undermine the cohesion of its structures and processes. The rapidity of such change might only serve to weaken such cohesion further (Thorlby and Maybin, 2010; Exworthy and Mannion, 2016: 8; Timmins, 2012; Exworthy and Mannion, 2016: 8). Without a comprehensive and longitudinal evaluation programme, the cumulative impact of healthcare reforms will remain uncertain or unknown.

In this book, we have sought to offer a comprehensive analysis of the state of the NHS in its 75th year. The four analytical axes (governance; public/private, central/local, and profession/state; introduced in Chapter 1 and reprised next) provided an overarching framework which applied, more or less, to the individual chapters. The subjects of these chapters enabled, we argue, a comprehensive coverage of the main dimensions of the NHS in its first 75 years. We note, however, the absence of topics, such as workforce wellbeing and diversity, and environmental sustainability (among others), from our analysis but we urge others to engage with these topics in future research.

Introduction

In its 75th year, despite the hallowed role that the NHS plays in the UK national psyche, the NHS found itself in a parlous position. Across a range of measures, the NHS was facing unprecedented pressures in 2023. First, public satisfaction with the NHS had fallen to its lowest recorded level – 29 per cent, falling 7 percentage points from 2021. Equally significant was the level of dissatisfaction with the NHS, at 51 per cent (Morris et al, 2023). Second, waiting lists were at an all-time high of 7.2 million (as of December 2022). Much of this can be explained by delayed care due to COVID-19 (a rise of 2 million since the start of the pandemic). This was despite the ‘elective recovery plan’ published in 2022 (NHS England, 2022). Third, there were 133,000 (full-time equivalent) vacancies in the NHS in September 2022, a vacancy rate of 9.7 per cent (Health Foundation, 2022). Vacancies in social care stood at 165,000, a vacancy rate of 10.7 per cent (King’s Fund, 2023). Fourth, there was a wave of strikes among NHS staff. Members of the Royal College of Nursing went on strike for the first time in their history. They were joined by ambulance staff and junior doctors. NHS consultants had also voted for strike action. Fifth, while pay can explain some of the causes of these strikes, it is likely that high levels of stress and burnout were also significant factors. The 2022 NHS Staff Survey (published in March 2023) indicated that 45 per cent of staff were unwell due to work-related stress and 57 per cent had come to work despite feeling unwell. Overall, 34 per cent of staff felt burnout, with ambulance staff being especially prone (49 per cent) (Nuffield Trust, 2023).

The conditions prevailing in 2023 were the confluence of factors in the previous several years – financial austerity from 2010, the Brexit referendum vote in 2016 (and the consequent impact upon recruitment and retention of staff and pharmaceuticals) and COVID-19 pandemic (from March 2020). Arguably, the conditions were also the result of the NHS’ politics, policies and organisational structure over the previous 75 years. So it is timely to reassess the contribution and state of the NHS in the past, in the present and in the future.