Analysis and commentary by Roy Lilley


You can download the report PDF here


What happens next is impossible to predict.

The Prime Minister is under pressure from her colleagues, appears friendless, perhaps isolated. Pressured into showing her special and closest advisers the door ( and forced into a dubious alliance with Northern Ireland’s DUP.

How enduring her tenure cannot be forecast. Measured in days? Probably, no. Measured in weeks or months… highly likely.

Whatever the machinations, one thing is true; the NHS will continue to provide services, reassurance and peace of mind during the months to come.

The backdrop will be policy commitments made in the Tory manifesto and the extent to which they might be attenuated or changed by any accommodations arrived at with the DUP ( and what can be carried in the forthcoming Queen’s Speech.

There is a lot at stake.

An even bigger question; if Prime Minister May stands down… who will follow her?



On the morning after the election of June 8th, this was my daily eLetter:

The coffee cups are still on the table and even the sofa looks tired. What a night.

John Major gambled on the EU and lost. David Cameron gambled on the EU and lost. Now Teresa May has gambled and lost. The Casino Party is in a mess.

It’s been a good night for business. The pound has lost value, making British goods cheaper, hence the stock market is on the up…

It’s an ill-wind that blows nobody any good.

That’s about it. The British people have spoken but I don’t think anyone is entirely sure what they have said. Political parties have more votes but fewer seats. That’s our democracy for you.

Two health ministers David Mowat and Nicola Blackwood, have lost their seats but as they were all but anonymous, I doubt they will be missed. Ben Gummer, former health minister, tipped as a replacement for Jeremy Hunt, has been shown the door.

An electorate; sick of austerity, by no means sure about Brexit and confused over Hokey-Cokey Tory tax-n-spend policies, have given the political classes the mother-of-all problems.

Now, there is by no means a majority for Brexit in the House of Commons. The Tories, once again, split over Europe and the prospect of another election and even another referendum looming.

Commanding confidence in the House of Commons is key. Who will discount, eventually, seeing pictures of J Corbyn in the back of the Jag’, on the way to the Palace.

What does it mean for our NHS?

Simon Stevens must be quietly chuckling. Following his spat with Downing Street, over the Prime Minister’s wilful misrepresentation of the health budget, he was briefed against and traduced. Now it looks like he will outlast The Maymite.

Ed Smith and the Jim Reaper are set to leave NHSI and Malcom Grant, the invisible chair of NHSE, is looking at the end of his tenure.

Replacing them involves a political process and it looks like, for now, at least, there will be no political process.

Keeping a minority government afloat, based on an ‘understanding’, not a formal coalition, will be a tricky balancing act.

Government by the walking wounded.

Whoever becomes the Secretary of State for Health, why not Jeremy Hunt, will be sitting in a vacuum. With confusions over Brexit and plenty of other distractions, parliamentary time for health reform, unpicking the Health and Social Care Act, is unthinkable.

The Tinkerman will be tinkering for a bit longer. Probably focussing on waiting times and dancing around the safety-and-quality handbag. Waits will pile-up on the front pages of the newspapers.

For some, a welcome delay will be to STP plans.

As the wise NHS commentator and lawyer, David Lock, highlights;

‘Labour gained Canterbury, with a swing of 20.5% in their vote… primarily over fears over the future the local hospital.’

As needed as reconfigurations are, to somehow shoehorn services into the spending envelope, the STPs have had a disastrous start, doing very little to take public opinion with them.

It will be a brave politician who will back them. Any serious realignment with social care, off the agenda.

The NHS is becalmed. Stalled. Parked.

My guess; Simon Stevens will take full advantage. A leaderless, NHSI will be vulnerable to a land-grab. HEE, dealt a bad-hand have played it badly; the chaos of staff shortages will drive a Trust-led re-profiling of the workforce.

Sam Jones’ departure from driving the Vanguard, new models of care, leaves them in limbo. Without political support for change, they could wither on the vine.

Primary care will have to muddle through. Expect GPs to get angsty.

As a Twitter-cad said, during the night; ‘June is the end of May’.




Conservative health manifesto promises are a mixture of existing policy, some new commitments and a continuing emphasis on safety, quality, access and performance.

There is a plain promise to continue the ethos of the NHS, free at the point of use and an undertaking to unravel the worst of the Lansley reforms.

The foundation remains Simon Steven’s Five Year forward View.

However, there is likely to be a need to revisit it as the original document is predicated on an operational window that closes in 2020. We are now in a new cycle ending in 2022/3.

Staff renumeration is not addressed but there are some ambitious promises to enlarge the workforce.

All-told there are over 50 commitments which are listed and annotated, in italics , to highlight discussion points and issues of note.

The DUP manifesto is less crisp; more mother-hood-n-apple-pie, addressing the universal challenges of demand and resource.




The Conservative Manifesto.

Our National Health Service is the essence of solidarity in our United Kingdom

The Conservative Party believes in the founding principles of the NHS.

First, that the service should meet the needs of everyone, no matter who they are or where they live.

Second, that care should be based on clinical need, not the ability to pay.

Third, that care should be free at the point of use.

These three points are intended to address concerns that the NHS is heading for ‘privatisation’. The use of the private sector and competitive tendering is dealt with, more specifically, later in the document.

As the NHS enters its eighth decade, the Conservative government will hold fast to these principles by providing the NHS with the resources it needs and holding it accountable for delivering exceptional care to patients wherever and whenever they need it.

Accountability is a recurring theme. ‘Resources it needs’ is very controversial. Most commentators take the view the funding proposals from all of the political parties fall short of what is needed… here is what the Conservatives will do…

The next Conservative government will give the NHS the resources it needs.

1. First, we will increase NHS spending by a minimum of £8 billion in real terms over the next five years, delivering an increase in real funding per head of the population for every year of the parliament.

2. Second, we will ensure that the NHS and social care system have the nurses, midwives, doctors, carers and other health professionals that it needs.
It is difficult to see that £8bn will extricate the NHS from the present funding crisis. Given the inexorable demand, major increases in NHS productivity and savings are unlikely to fill the gap. Many commentators are saying the difference between the demand and funding will approach £40bn by 2023.

Further more; recruitment and training is highly unlikely to be accelerated to meet the manifesto promises.

3. We will make it a priority in our negotiations with the European Union that the 140,000 staff from EU countries can carry on making their vital contribution to our health and care system.

Whilst this will be welcome news for EU nationals and their families working here, it does not amount to a guarantee. Apart from the personal distress a repatriation might cause the disruption to the NHS workforce is likely to be catastrophic.

4. However, we cannot continue to rely on bringing in clinical staff instead of training sufficient numbers ourselves. Last year we announced an increase in the number of students in medical training of 1,500 a year; we will continue this investment, doing something the NHS has never done before, and train the doctors our hospitals and surgeries need.

Growing our own staff is a sensible policy. However, there is no intention to reintroduce the bursary-funding for nurses and midwives and the full impact of that policy change is yet to be felt. Training staff is one thing. Funding their employment in the workplace is another.

5. Third, we will ensure that the NHS has the buildings and technology it needs to deliver care properly and efficiently. Since its inception, the NHS has been forced to use too many inadequate and antiquated facilities, which are even more unsuitable today.

Capital expenditure is predicated on the Naylor Report ( and the sale of redundant NHS assets. The difficulty will be making sensible and timely disposals, marshalled by experts in the sector. Skills the NHS does not have.

6. We will put this right and enable more care to be delivered closer to home, by building and upgrading primary care facilities, mental health clinics and hospitals in every part of England.

Primary care is often housed in small premises that are incapable of development where planning conditions make development impossible. The likelihood is practices will close and amalgamate around bigger and more developed surgeries. Access and convenience will become a matter for public debate.

7. Over the course of the next parliament, this will amount to the most ambitious programme of investment in buildings and technology the NHS has ever seen.

The reference to technology is a familiar theme. Over time there has been little evidence that there is an appetite, among the professions, for remote technologies and call-centre style management. If it is to work the profession will have to be brought along and a major investment will be required in call centres and patient facing interconnectivity. The growth in private Apps, giving immediate access to GP consultations may point the way.

8. Fourth, whilst the NHS will always treat people in an emergency, no matter where they are from, we will recover the cost of medical treatment from people not resident in the UK. We will ensure that new NHS numbers are not issued to patients until their eligibility has been verified. And we will increase the Immigration Health Surcharge, to £600 for migrant workers and £450 for international students, to cover their use of the NHS. This remains competitive compared to the costs of health insurance paid by UK nationals working or studying overseas.

This is an extension of existing policy that has had little impact on NHS funding.

9. We will implement the recommendations of the Accelerated Access Review to make sure that patients get new drugs and treatments faster while the NHS gets best value for money and remains at the forefront of innovation.

Funding new drugs, as they become more complex and costly remains un-addressed by this bold statement. ‘How to pay for them…’


Holding NHS leaders to account

This is a sinister headline. The regulatory demands on NHS healthcare managers are some of the most stringent in the world and it is difficult to see how more regulation is likely to improve things. Becoming a Trust Chief Executive is no longer the attractive role it once was, witnessed by the number of Trusts with no permanent Chief Executive and the number of ‘interims’ employed at board level.

10. It is NHS England that determines how best to organise and deliver care in England, set out in its own plan to create a modern NHS – the Five Year Forward View. We support it.

This is significant insofar-as an incoming new secretary of state for health will be able to take a new direction. The prospect of stability is a good thing.

11. We will also back the implementation of the plan at a local level, through the Sustainability and Transformation Plans, providing they are clinically led and locally supported.

Locally supported… that is the issue. Few communities are ready to support closures and reconfiguration and many MPs will owe their election, in part, to supporting local lobby groups and campaigning to keep service open. STPs have largely failed in communicating their intentions.

12. We will hold NHS England’s leaders to account for delivering their plan to improve patient care. If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes.

This is coded recognition that the Lansley reforms have failed and there will be a quiet unpicking of the worst of their impact.

13. This includes the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy. So, we will review the operation of the internal market and, in time for the start of the 2018 financial year, we will make non-legislative changes to remove barriers to the integration of care.

Abandoning the internal market is a major step. It will come as bad news to private providers who are unlikely to have access to the NHS market. Integration remains the Holy-Grail. Without legislative changes very little is likely to happen.

14. We expect GPs to come together to provide greater access, more innovative services, share data and offer better facilities, while ensuring care remains personal – particularly for older and more vulnerable people – with named GPs accountable for individual patients.

This marks the end of the single-handed GP and small practices. Super surgeries will be the future

15. We will support GPs to deliver innovative services that better meet patients’ needs, including phone and on-line consultations and the use of technology to triage people better so they see the right clinician more quickly.

Many GPs are already using this model and patients, increasingly expect it.

16. We will ensure appropriate funding for GPs to meet rising costs of indemnity in the short term while working with the profession to introduce a sustainable long-term solution.

The costs of indemnity are getting unmanageable. Insurance companies are unable to carry the risk. The solution may be to revert to some form of Crown Indemnity.

17. We will introduce a new GP contract to help develop wider primary care services.

Paying GPs to do more means paying hospitals to do less. Far better would be to look at population based capitated funding for the whole of the health economy. Sharing risk.

18. We will reform the contract for hospital consultants to reflect the changed nature of hospital care over the past twenty years.

A renewed consultant contract has been on the table for three years. a conclusion is overdue. The risk is it ends in a dispute.

19. We shall support more integrated working, including ensuring community pharmacies can play a stronger role to keep people healthy outside hospital within the wider health system.

The pharmacy community have been talking abut doing more for years. Will they step-up now.

20. We will support NHS dentistry to improve coverage and reform contracts so that we pay for better outcomes, particularly for deprived children.

Recent reports ( about child dental care are very disappointing.

21. And we will legislate to reform and rationalise the current outdated system of professional regulation of healthcare professions, based on the advice of professional regulators, and ensure there is effective registration and regulation of those performing cosmetic interventions.

Merging the GMC, the NMC and other professional regulators around a simple commitment to doing what is right for patients.

22. We will also help the million and more NHS clinicians and support staff develop the skills they need and the NHS requires in the decades ahead.

Present funding plans provide nothing for the DH, responsible for training. it is difficult to see how improvements will be paid for?

23. We will encourage the development of new roles and create a diverse set of potential career paths for the NHS workforce.

What is the future of nursing and care staff. Will new models emerge?

24. We will reform medical education, including helping universities and local health systems work closer together to develop the roles and skills needed to serve patients.

We want the NHS to become a better employer.

25. We will strengthen the entitlement to flexible working to help those with caring responsibilities for young children or older relatives.

These are matters for Trusts. With a tightening labour market it makes sense to be a better employer. The reality may dictate something quite different.

26. We will introduce new services for employees to give them the support they need, including quicker access to mental health and musculoskeletal services.

Does this mean NHS employees will jump the queue?

27. We will act to reduce bullying rates in the NHS, which are far too high. We will take vigorous and immediate action against those who abuse or attack the people who work for and make our NHS.

Outcomes in the NHS for most major conditions are considerably better than three, five or ten years ago. However, the founding intention for the NHS was to provide good levels of care to everyone, wherever they live. This has not yet been achieved: there remain significant variations in outcomes and quality across services and across the country. We will act to put this right.

28. To help the NHS provide exceptional care in all parts of England, we will make clinical outcomes more transparent so that clinicians and frontline staff can learn more easily from the best units and practices, and where there is clear evidence of poor patient outcomes, we will take rapid corrective action.

A continuation in the direction of travel and welcomed by patient organisations.

29. We will ensure patients have the information they need to understand local services and hold them to account.

30. We will empower patients, giving them a greater role in their own treatment and use technology to put care at their convenience.

Who knows what this really means!

31. In addition to the digital tools patients already have, we will give patients, via digital means or over the phone, the ability to book appointments, contact the 111 service, order repeat prescriptions, and access and update aspects of their care records, as well as control how their personal data is used.

Thus far investments in this type of technology have yielded little in the way of sustained improvement.

32. We will continue to expand the number of NHS approved apps that can help monitor care and provide support for physical and mental health conditions.

Approving Apps will be a huge job… given the number that are coming onto the market.

33. We will pilot the live publication of waiting times data for A&Es and other urgent care services.

This is an exciting development. The technology exists and could help to spread demand.

34. We will further expand the use of personal budgets.

35. We will also continue to take action to reduce obesity and support our National Diabetes Prevention Programme.

This is a huge challenge for public health services.

Our ambition is also to provide exceptional care to patients whenever they need it. That is why we want England to be the first nation in the world to provide a truly seven-day healthcare service. That ambition starts with primary care. Already 17 million people can get routine weekend or evening appointments at either their own GP surgery or one nearby, and this will expand to the whole population by 2019.

36. In hospitals, we will make sure patients receive proper consultant supervision every day of the week with weekend access to the key diagnostic tests needed to support urgent care.

This is a watered down version of the original ambition to prove 24-7 care.

37. We will also ensure hospitals can discharge emergency admissions at a similar rate at weekends as on weekdays, so that when someone is medically fit to leave hospital they can, whichever day of the week it is.

Fundamentally this is a challenge for social services and local government.

38. We will retain the 95% A&E target and the 18-week elective care standard so that those needing care receive it in a timely fashion.

If the NHS can overcome the present hiatus, this is achievable.

39. We will extend the scope of the CQC to cover the health-related services commissioned by local authorities.

The prospect of the CQC taking on more inspections is laughable.

40. We will legislate for an independent healthcare safety investigations body in the NHS.

41. We will require the NHS to continue to reduce infant and maternal deaths, which remain too high.

Requiring and delivering are two very different things!

42. Our commitment to consistent high quality care for everyone applies to all conditions.

43. We will set new standards in some priority areas and also improve our response to historically underfunded and poorly understood disease groups.

Probably means more targets.

44. In cancer services, we will deliver the new promise to give patients a definitive diagnosis within 28 days by 2020.

45. Expanded screening and a major radiotherapy equipment upgrade will help ensure many more people survive cancer.

46. We will continue to rectify the injustice suffered by those with mental health problems, by ensuring that they get the care and support they deserve.


47. We will recruit up to 10,000 more mental health professionals.

From where, how will they be trained and paid for?

48. We shall require all our medical staff to have a deeper understanding of mental health and all trainees will get a chance to experience working in mental health disciplines; we shall ensure medical exams better reflect the importance of this area.

49. We will improve the co-ordination of mental health services with other local services, including police forces and drug and alcohol rehabilitation services.

50. We have a specific task to improve standards of care for those with learning disabilities and autism.

Task or target?

51. We will work to reduce stigma and discrimination and implement in full the Transforming Care Programme.

52. We will improve the care we give people at the end of life. We will fulfil the commitment we made that every person should receive high quality, compassionate care, so that their pain is eased, their spiritual needs met and their wishes for their closing weeks, days and hours respected.

53. We will ensure all families who lose a baby are given the bereavement support they need, including a new entitlement to child bereavement leave.

…. you will have your own views. Be sure to share them on Facebook and Twitter.



The DUP Manifesto.

People are living longer. Key mortality rates like cancer mortality in under 75s and avoidable mortality are falling;

​•​We have invested over half a billion pounds more in Health;
​•​We have employed 275 more consultants, 1,200 more nurses and midwives, and 500 more allied health professionals;
​•​We have delivered over £800 million in efficiency savings to reinvest in the frontline;
​•​We have built new, state of the art health and social care facilities such as the new Critical Care Building at the Royal Victoria Hospital, new Health and Care Centres in Ballymena and Banbridge, the Radiotherapy Unit at Altnagelvin and large scale redevelopment of the Ulster Hospital and
​•​We have developed new services like a HEMS air ambulance and a world leading mental trauma service.

We recognise that our NHS in Northern Ireland is under pressure and faces a range of tough challenges now and into the future. Yet, the focus of some on what isn’t perfect within the system distracts us away from what is working well and the many improvements that have been made. Ours is a Health and Social Care system which, in spite of the many issues it must contend with, has improved performance and increased productivity over the past 5 years.

Under DUP leadership:

​•​the number of people admitted to hospitals in Northern Ireland has increased by over 25,000 between 2010/11 and 2014/15;
​•​the average length of stay in hospital has fallen from 6.7 days in 2011/12 to 6.0 days in 2014/15;
​•​the number of domiciliary care contact hours has increased by 12% from 2011 to 2014 and
​•​the Ambulance Service has responded to 13,000 more Category A emergency calls between 2010/11 and 2014/15.

However, we must continue to improve. For example, much needed guidance for our health professionals dealing with terminations has been provided. An expert panel on the issue of pregnancies with severe life limiting conditions has been established.

The extent to which terminations might feature in any policy bargains is unclear. As health is a devolved issue, it does not have to be but will still be a talking point across Westminister and probably in relations with Scotland.

The DUP has a vision for a sustainably financed Health and Social Care system that puts quality, safety and the patient at its centre by providing world class outcomes for our population. This is our Plan to achieve it.


The DUP pledges to seek to increase spending on Health by at least £1 billion by the end of the next Assembly term to specifically help in tackling waiting lists and investment in innovation and reform. We will continue to invest in the transformation of Health and Social Care services by ensuring that a Transformation Fund of at least £30 million remains in place for each year of the next Assembly term.

Perhaps the price of support from the DUP might be an uplift in funding.

The DUP will invest more resources in increasing frontline staff numbers and will employ at least 1,500 more Nurses and Midwives and 200 more Consultants by the end of the next Assembly term.

This is probably unachievable. If EU nationals are evicted that will include nurses from the Republic of Ireland. There are nearly 1,000 vacancies of nurses and 250 doctors.


We will continue to increase spending on mental health each and every year of the next Assembly term.

We will appoint mental health champions across the public sector and establish a world leading mental trauma service.


The DUP will reduce bureaucracy and encourage innovation by passing legislation through the Assembly to close the Health and Social Care Board, moving responsibility for commissioning services primarily to the Department with more autonomy for the Trusts in certain areas. We will support the work of the Expert Panel led by Professor Rafael Bengoa as they seek to remodel Northern Ireland’s Health Service to overcome looming challenges like our growing and ageing population, the rise in the number of chronic conditions and the impact of unhealthy lifestyles.

If this makes any sense to anyone, tell me! An end to commissioning but more bureaucracy? Another reorganisation?


The DUP will support the additional investment of a minimum of £80 million to tackle waiting lists in each year of the next Assembly term. This extra money will be focused on increasing capacity inside the Health Service in Northern Ireland but will utilise the independent sector where and when appropriate. It will help people to get close to 200,000 appointments, treatments and procedures each year with the target of getting waiting lists well below 2013 levels by 2021.

Greater use of the private sector? It is underdeveloped in NI and what ‘help people to get close to 200,000 appointments means… I have no idea!


The DUP will establish a Commission on Adult Care and Support to provide expert, independent analysis of the challenges facing the system and to think radically about what changes must be made to safeguard it for future generations. The Commission on Adult Care and Support will be tasked with producing a set of recommendations to reform the system and its funding structures to ensure its future sustainability. We will pay particular attention to ‘best practice’ examples like the acclaimed Buurtzorg community care model in the Netherlands and Italy’s new models of care in managing the chronic conditions of its ageing population and we will actively examine the opportunity for rolling out similar models in Northern Ireland.

A commission is usually code for kicking a problem into the long grass. ‘Examining’ the Buurtzorg model? What is there to examine? Why not just do it?


The DUP will further support primary care by working progressively towards having 110 GPs a year in training by 2020, continuing to support the development of GP Federations, implementing the recommendations of the GP Working Group and maintaining a Financial Transactions Capital funded GP Modernisation Scheme. The DUP will support the Northern Ireland wide roll out of the physiotherapy direct access scheme and will develop similar projects in other specialisms.

Persuading GPs to stay in NI, in a competitive market, will be the big challenge. Physiotherapy direct… yes, like the sound of that!


The DUP will develop a new Electronic Health and Care Record for Northern Ireland to help revolutionise the delivery of health and social care for patients. This would provide accurate, up-to-date and complete information about patients at every point of care, reduce discharge delays and enable safer and more reliable prescribing of medication as well as increase the time that doctors, nurses, therapists and social workers have to spend with patients – allowing the use of data analytics to improve population health and care planning and it will help our Health and Social Care system to become ‘paperless.’

Well, good luck with this. It’s not costed and is a huge undertaking.


The DUP supports a continuation and amplification of the cross-Departmental approach to tackling health inequalities in Northern Ireland, building on the progress made by the Making Life Better public health strategy, as part of the next Programme for Government.

We will also consider the success of initiatives like South Australia’s Health in All Policies (HiAP) and examine if a similar approach could work in Northern Ireland.

More ‘consideration’ and no action…


The DUP will provide support for further investment in improving healthcare facilities across Northern Ireland. This includes the new regional mother and children’s hospital at the Royal Victoria Hospital, further redevelopment of the Ulster Hospital and redevelopment of Craigavon Area Hospital. We will also take forward the development of more Health and Care Centres in Lisburn and Newry and examine the scope for places like Newtownards, Bangor, Armagh, Dungannon, Lisnaskea, Carrickfergus and Larne.

On the lists of trade-offs might well be more capital investment. Good for building companies and employment. Very Keynesian.


Public debate has focused on the needs of women who are pregnant with a child diagnosed with a severe life limiting condition. The DUP believes that women who find themselves in these most difficult of situations need the best medical and emotional support. The DUP is committed to establishing a perinatal hospice care service or facility in Northern Ireland.

This is a key issue. Health is devolved so it need not be a deal breaker unless Westminister MPs want to make it so.


The DUP will continue increasing investment in cancer care by at least an additional 10% and introduce a new comprehensive cancer care plan for the next decade.

We will endeavour to improve 5 year cancer survival rates by 20 percentage points from the establishment of devolved government, continue to promote awareness and prevention, establish further innovative new services and provide more nurse specialists.

If they don’t have a cancer plan by now… where have they been?

The DUP recognises that the contribution made by nurses and midwives is invaluable to the functioning of Northern Ireland’s Health Service. Equally, we acknowledge the pressures facing the profession especially around staff numbers.

We are proud to have worked closely with the Royal College of Nursing to address a range of challenges facing nurses. During the next Assembly term, the DUP will support nursing by implementing the recommendations of the newly created Nursing Task Group, retain Nursing Bursaries in Northern Ireland and continue to increase the number of nurses and midwives in training and practice.

If you want to become a nurse… go to NI for a bursary!