The context of this year's UK party conferences, just seven months before the general election, was unusually challenging. Voters in both Scotland (who voted in the Referendum) and in Clacton-on-Sea (who earlier this month voted in Ukip's first MP to Westminster) have delivered newsworthy 'we're-fed- up-with-the-usual-Westminster-politics' votes. International developments are worrying. The domestic agenda is tough. The economy, since 2008, has been characterised by recession, then years of anaemic growth. The current government's public sector cuts have been deep, unpopular, and controversial, especially to welfare.
But through all this, the budget for the National Health Service (NHS) in England has been protected. Why? The latest Guardian/ICM poll show that it is the single most important issue to voters, way ahead of the economy, deficit reduction, immigration and jobs. Despite this, things are far from tranquil in the NHS.
First, the money. Yes the budget has been protected, but real-terms growth has been a slim 0.8% a year since 2009-10, compared with the long run historic average of between 3-4%, and 6-7% between 1998-2008. 0.8% is short of meeting demand - an estimated £30bn short by 2020. The immediate result is more than two-thirds of hospitals are in deficit, with the NHS heading for a £2bn hole in its finances by the end of 2015-16.
Second, productivity. The trend over the last decade has been to devolve power to the front line, encourage competition and not run everything from Whitehall. But the policy cocktail is not increasing productivity fast enough to offset budgetary shortfalls.
Third, quality of care. Despite recent scandals including the failings at Mid-Staffordshire NHS Trust, the last decade has seen the quality of care steadily improve across the UK and public satisfaction is consistently good. But cracks are now appearing. As shown in a recent report from QualityWatch (a joint Health Foundation and Nuffield Trust research programme), the huge progress in reducing waiting times is slowly reversing, particularly for those with mental health problems. Last week the Care Quality Commission (CQC), as the national regulator for quality in health and social care, released a report which showed that of the 38 Trusts inspected, that safety was of biggest concern: four out of five ratings were inadequate or required improvement.
Small wonder that the NHS was central to this year's crop of speeches by Conservative, Labour and Liberal Democrat party leaders and health ministers. Reading between the lines, what clues have they provided as to the agenda for the next parliament?
Party lines
The main pledge from Labour was an extra £2.5bn per year fund to help pay for 3,000 more midwives, 5,000 care workers, 8,000 GPs and 20,000 nurses, with the extra funding to come from closing tax loopholes, proceeds from a mansion tax on homes valued over £2m and increasing tobacco tax. A further pledge was to repeal the Health and Social Care Act 2012.
While welcome, it was not obvious what the £2.5bn would be additional to, the timescales and whether the funds would be earmarked for the NHS or the wider care system, including social care.
The Health and Social Care Act 2012 resulted in the most profound set of changes in the NHS's history. Apart from repealing the Act, few more details about their plans are forthcoming. The spectre remains of another large scale and distracting reorganisation in future.
In his speech, shadow health secretary Andy Burnham, underlined the need for more integrated care. But he continues to see the NHS as the preferred provider of services, turning away from what could be valuable innovation and productivity from other providers.
For the Conservatives, like Labour, the central message was that the NHS is safe in their hands. Similar to Labour, there were pledges to maintain real-terms growth.
On increasing productivity, little was said. Health secretary Jeremy Hunt was quick to point out the value of using the independent sector and charities to provide NHS-funded services, suggesting this policy will be maintained at least. But most of Hunt's comments focused on the quality of care. He, like Burnham, stressed the need for better care coordination, pointing out initiatives such as the Better Care Fund, which is being set up with £3.8bn to drive this agenda.
Improved access to care also featured, with the promise of GPs providing "8am-to-8pm care" seven days a week by the end of the next parliament. But health chiefs are arguing the system is already at breaking point - the risk is that greater access will fuel even more demand.
Liberal Democrat leader Nick Clegg pledged to improve the state of care for people with mental health problems - a welcome and overdue development. The promise to increase the NHS budget above inflation by £1bn a year (about 0.9% real growth compared to the current 0.8%) was also welcome, but its parsimony will not be enough to meet rising needs. Coalition health minister Norman Lamb wanted to see the entire NHS (about £110bn) and social care (around £17bn) budgets pooled to encourage integrated health and social care. Other pledges to support the implementation of personal health budgets to give users more control, and extra financial support to carers, are all along the right lines.
Omissions tell us something too
The elephant in the room is that none of the funding pledges are nearly enough to meet current demand, and the NHS is heading for a financial crisis and soon. On this the politicians were silent, as well as on how the productivity of NHS staff could be increased to offset budget shortfalls.
Why? Cynics will point to the proximity of the election and how those in power need to keep awkward stories on the NHS out of the press. Opposition politicians fear upsetting the public with talk of cuts, and unions and staff with talk of the new working practices needed to increase productivity.
Another plausible reason is that politicians simply don't know what to do. Real change happens far away, at the front line of which politicians have little experience. Boosting such change that is initiated from Whitehall is the task at hand, but all parties are a long way off.
Dr Jennifer Dixon, Chief Executive, The Health Foundation