The 15-month gap between the Queen’s Speech today and this Government’s first in December 2019 feels like looking back to a different era. Since then, COVID-19 has changed almost everything about the way we live our lives, and the roles of Government, Parliament and the NHS have all changed dramatically.
Amidst the change, it’s instructive to look back at the underlying political priorities that drove the 2019 Queen’s Speech. With a majority newly won from the ‘Red Wall’, Boris Johnson’s Government recognised that delivering tangible change for these voters would be crucial to retaining them. The Conservatives needed health services, as well as high streets, across their new seats to ‘feel’ better by the next election. There needed to be new hospitals, easier access to GPs, and shorter waiting lists for treatment. As we’ve recently seen in Hartlepool, a feeling that local hospital services have got worse can drive changes in voting patterns like almost nothing else (although who voters blame is not always predictable).
For health, the 2019 Speech promised to enshrine record funding up to 2023/24 – meaning an expanded workforce was possible – deliver 40 new hospitals, and bring forward pre-legislative proposals for NHS and mental health reforms. Clear gestures such as revenue funding and bricks and mortar came first; meeting NHS England’s legislative requests second. Social care, as so often is the case, was left with promises of cross-party consensus building – the unfortunate lesson of the 2017 manifesto debacle appearing to be that the issue was too hot for any electorally-focussed party to handle.
The 2021 Speech continues these themes, although the changes are instructive.
The focus on delivery has been there in recent days. Boris’s desire to give the NHS the money it needs to tackle waiting times has been widely briefed (although additional funding may need to wait for the Spending Review). Whether any new money will be enough to actually make a dent is another question… 2020 was HMT’s worst ever year in its long-running battle to contain NHS spending, albeit with understandable – and hopefully not repeatable – causes. Despite the rhetoric, we do not appear to be on the cusp of another era of 7% annual budget rises that drove waiting times down in the early- to-mid- 2000s.
Sadly, warm words remain the only gift for social care. Despite bearing the brunt of the ravages of COVID-19, securing cross-government agreement on a credible plan that will be acceptable to both the Government’s political needs and HMT’s spreadsheets is still some way down the road. A plan has been promised this year. Time will tell if this promise means more than the now annual pledges made by successive Governments since 2017.
The life sciences is one area where the Queen’s Speech demonstrates a changing focus for Government during the pandemic. The early reference to both the sector and leading the world in discovering new treatments, albeit without any promised legislation, is an indication of the changed level of political priority given to the life sciences, which will now be eager to see how this rhetoric is translated into reality.
The big change, however, is the focus on legislation.
The reforms for mental health services have been widely welcomed – although whilst improved legislation is important, it is far from a panacea for either improving services or clearing the growing backlog of mental health need. With the reforms entering pre-legislative scrutiny, they’re unlikely to make much noise this year at all.
The same can’t be said for NHS reform. Following the White Paper, the Government is committing to delivering the changes that NHS England has been requesting since the launch of the Long Term Plan. As we said when the White Paper was released, the question of why the Government is choosing now to invest so much political capital in a technocratic NHS reform needed to be answered. With the Government seemingly increasingly aware of the waiting times challenge, it is perhaps unsurprising that this is the political need that the Queen’s Speech claims the legislation will help solve. Given the White Paper mentions waiting times a grand total of once, whether this retrofitted rationale will hold water is an open question.
As the Bill begins its long passage through Parliament (no COVID-19 regulation short-cuts for Matt Hancock here!), whether the Government can win that framing battle will go a long way to determining how smooth the Bill’s journey will be. The Government will have got 90% of the way there if the case can be won that ICSs, ministerial directions, and everything else the Bill contains are ultimately about reducing waiting times.
However, history suggests that moving health legislation through Parliament is never easy, and, at points, this Government have shown remarkably little tact in Parliamentary management. Parliament has been sidelined through much of the COVID-19 legislation. We’d be surprised if there aren’t points where Parliament – particularly the Lords – wants to assert its will during the passage.
If the Bill does descend into the kind of political problem that David Cameron faced in 2011/12, Boris Johnson – with both eyes on the next election – will have to answer the question, how much political capital am I willing to commit? Do I need to protect every aspect of these reforms to make to health services ‘feel’ better in 2024? Or can I take the path of least resistance and compromise on controversial aspects? Given the main architects and advocates for the legislation are in Skipton House rather than Number 10, we wouldn’t bet against it.