Being asked to choose a Prime Minister between Boris Johnson and Jeremy Corbyn is like being asked whether you'd prefer constipation or diarrhoea. The obvious answer is 'neither, thanks'.

It's not quite a Hobson's Choice of a General Election, but it's not far off.

As I wrote for The Guardian recently, the poker game of NHS funding pledges hasn't cast much light on the issue. The iridescent Professor John Appleby has had a go at making the numbers comparable.

I've been writing a series of columns for the BMJ on the general election, and the following is the uncut version of my assessment of the main three Westminster parties' manifestos on health and care.

As the 12 December 2019 polling date hoves into view, this general election feels challenging to predict.

While opinion polls in aggregate suggest that the Conservative and Unionist Party has a decent lead, it doesn't feel like a solid one. The duplicity and negativity of the Tory campaigning to date is not the action of a confident party.

The week and a bit until the vote offers plenty of time for events to intervene.

My last column considered how the personalities of the two main party leaders may impact voting intentions. One longstanding view of Westminster politics has been that the party with whom the public see as the best leader wins elections: this may not still stand when Mr Johnson’s net favourability rating is -48 and Mr Corbyn’s is -60.

The 2019 Nicholson Challenge: more Viv than David
This means that turning to their manifestos may offer us clearer ideas based on what is on written offer to the voting public.

On the NHS and social care, the question seems to be ‘how much?’ For all three main parties, austerity is very clearly something that previous governments used to do.

The fiscal mood music is less what former health secretary Stephen Dorrell dubbed ‘The Nicholson Challenge’ (after the then-NHS chief executive Sir David Nicholson’s plan of £15-20 billion of NHS efficiency and productivity savings in the wake of the global financial crisis), and more the ‘spend, spend, spend!’ of football pools winner Viv Nicholson.

Liberal Democrats
The Liberal Democrats’ return from the political Liverpool Care Pathway has largely been on the back of discontented Remain voters watching both Tories and Labour tacking to the extreme wings of their parties on the country’s post-Brexit relationship with the EU.

But as a centre party, they still face the UK’s ‘first-past-the-post’ system’s classic problem: the Lib Dems are likely to have too many votes in the ‘wrong’ (i.e. over-concentrated metropolitan liberal) places to make serious numerical headway in the House of Commons.

Their manifesto is prominently branded ‘Jo’s Plan’, in an effort to cash in on the perceived popularity of their relatively new leader Jo Swinson. They propose that part of their spending plans will come from a ‘Remain Bonus’ of £50 billion of economic growth that would result from their pledge to revoke Article 50 and not leave the EU. Fiscally, their plan also aims to fund spending increases from taxation, borrowing more only for investment projects.

The Lib Dems plan to increase the basic rate of income tax by 1 pence, to fund increased spending of £7 billion a year on health and social care. They would also “use £10 billion of our capital fund to make necessary investments in equipment, hospitals, community, ambulance and mental health services buildings, to bring them into the 21st century”.

Hypothecated taxes are a big theme, with their plan for a longer-term dedicated health and social care tax: “a dedicated, progressive Health and Care Tax, offset by other tax reductions … to bring together spending on both services into a collective budget and set out transparently, on people’s payslips, what the Government is spending on health and social care”.

This seems to sit curiously with a pledge to depoliticise funding decisions by creating “a statutory independent budget monitoring body for health and care, similar to the Office for Budget Responsibility. This would report every three years on how much money the system needs to deliver safe and sustainable treatment and care, and how much is needed to meet the costs of projected increases in demand and any new initiatives – to ensure any changes in services are properly costed and affordable”.

It proposed full integration of health and social care, but fails to seriously address how to fund what is currently means-tested social care. On social care, they hide behind the magical realist solution of a “cross-party health and social care convention that builds on the existing body of work from previous conventions, select committees and the 2018 citizens’ assembly to reach agreement on the long-term sustainable funding of a joined-up system of health and social care”.

Whooppee. Previous commissions on funding of social care have all proved brilliantly effective, be they Royal (1999), Dilnot (2011) or Barker (2014).

There are also pledges to train more GPs and increase primary care access, in person and virtually; improve workforce planning; and ring-fence funding to give mental healthcare parity with physical (including on national waiting times); greater emphasis on public health and a new national wellbeing strategy, to affect all government policies.

Labour
Perhaps thanks to a subversive graphic designer, Labour’s ‘Time For Real Change’ manifesto is laid out in a font called ‘LotaGrotesque’. An inevitable introduction by Labour’s Dear Leader Jeremy Corbyn promises “Labour will give the NHS the funding it needs, end privatisation, and never let our health service be up for grabs in any trade negotiation. We’ll expand our NHS to offer free prescriptions for all and free basic dentistry, building on its founding principles.

“We will end the social care crisis that has left 1.5 million elderly people without the care they need. Labour will fund free personal care for older people and extra care packages”.

Funding, pay and capital
There are significant promises on funding and public sector pay: to return the latter “to at least pre-financial crisis levels (in real terms), by delivering year-on-year above-inflation pay rises, starting with a 5% increase”.

On NHS funding, Labour finally quantifies its longstanding ‘whatever it takes’ approach, promising to “increase expenditure across the health sector by an average 4.3% a year. This investment enables us to end patient charges, guarantee the standards of healthcare patients are entitled to receive from NHS England, invest in education for the health workforce and restore public health grants”.

There are sensible words on capital and infrastructure, with the announcement of “an infrastructure plan to return NHS England to the international average level of capital investment … we will complete the confirmed hospital rebuilds and invest more in primary care settings, modern AI, cyber technology and state-of-the-art medical equipment, including more MRI and CT scanners.

“We will ensure data protection for NHS and patient information, a highly valuable publicly funded resource that can be used for better diagnosis of conditions and for ground-breaking research. We will ensure NHS data is not exploited by international technology and pharmaceutical corporations”.

Also positively, there are pledges on moving support to community settings: to “allocate a greater proportion of overall funding to close-to-home health services and build interdisciplinary, patient-focused services across primary care, mental health and social care. We will ensure patients in deprived and remote communities will have better access to primary care services. We will also ensure those living with long-term conditions can access the care they need.

“To support our transition to community health care services, we will expand GP training places to provide resources for 27 million more appointments each year and ensure community pharmacy is supported”. There are pledges on free dental check-ups, a net zero carbon NHS policy (with an exciting NHS Forest!)

Leftwards ho! Mind the fictional privatisation!
The party’s strong swing to the left is clear in its pledges about the private sector: Labour would “end the current presumption in favour of outsourcing public services and introduce a presumption in favour of insourcing. And we will stop the public getting ripped off by taking back all PFI contracts over time”. The last point here is an affordably ambiguous form of wording, given that in the long run, all PFI contracts end and the assets belong to the Government.

Labour will also “end the competitive tendering of services; ensure services are delivered in-house; and also bring subsidiary companies back in-house”. It is unclear whether the second of these pledges will eradicate services provided by third sector organisations such as Macmillan Cancer Support.

The party’s confused and paranoid attitude to fictional NHS privatisation gets plenty of space, with the striking statement that “every penny spent on privatisation and outsourcing is a penny less spent on patient care”. This isn’t the reality for an NHS patient being treated at the NHS tariff price in a private hospital due to long NHS elective waiting times.

The purest example of this comes when the manifesto states “we will stop Tory plans to further entrench the private sector delivery of health care under the cover of integration plans set out in the NHS Long Term Plan. Instead we will join up, integrate and co-ordinate care through public bodies”. This description of the NHS Long Term Plan has absolutely no basis in reality.

Conservatives
“My job is to make sure you don’t have to wait 3 weeks to see your GP and we start work this week with 20 new hospital upgrades, and ensuring that money for the NHS really does get to the front line.

“My job is to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care and so I am announcing now – on the steps of Downing Street – that we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve.”

Boris Johnson's first speech as Prime Minister: 24 July 2019

The Conservative manifesto and accompanying costings document form an interesting contrast.

The Conservative manifesto has the air of the surreal, pledging “20 hospital upgrades and 40 new hospitals, while delivering 50,000 more nurses and 6,000 more doctors and creating an extra 50 million general practice appointments a year”.

It’s hard to know where to even start with such a blatant cocktail of the misleading and the untrue. These pledges imply that there is a magical warehouse, full of new doctors, nurses and GP appointments, waiting for the courier to deliver them to the front line.

The reality is that the NHS has a longstanding workforce crisis. Solving it will be expensive, and will take years - and probably significant immigration, which is interesting given the points on migration charges and health tourism below.

And we now know that 18,000 of the 50,000 new nurses are not new, but the result of an aspiration to retain current nursing staff who would have left the NHS.

On the ‘taper tax’ pensions crisis, the manifesto’s plan is to hold an urgent review with the BMA and Academy of Medical Royal Colleges within the first 30 days of a new Parliament. You have to wonder whether senior doctors will be any more reassured by this than by the recent ‘pledge’ that the NHS will find any ‘scheme pays’ shortfall to their pension pots on retirement.

It is unambiguously clear that just six hospitals have actually been meaningfully promised money for significant redevelopment by 2025, with another 38 pledged ‘seed funding’ sums of money to plan for redevelopment.

While Mr Johnson has , as in the BBC TV ‘Question Time’ special programme, the costings document introduction by Chancellor Sajid Javid gets the numbers correct, referring to “20 hospital upgrades … and an extra £1 billion for social care”. It also gives the correct figure (though not, as would be usual in financial forecasts, adjusted for inflation to allow like-for-like comparison) of “a cash increase for the NHS of £33.9 billion a year by 2023-24 compared to 2018-19 budgets”.

Health migration and tourism
The costings document also advises that “if returned to office, a Conservative government would align new EU nationals’ access to non-contributory benefits with that of non-EU nationals and take steps to reduce the incidence of ‘health tourism’.”

The notion of the NHS suffering from significant health tourism is one of the classic health policy zombies: it has been killed many times, yet somehow does not die.

It is an instructive indication of a party heroically unserious about public policy that this zombie should be mentioned in a manifesto costing document, which goes on to claim that ‘health tourism enforcement’, alongside ‘extend(ing) Cancer Drugs Fund into ‘Innovative Medicines Fund’ and ‘NHS visa’ will all be funded from existing budget allocations. It does not describe what current spending will be cut to pay for all of these.

The costings document outlines that increasing the ‘health immigration surcharge’ from the current £400 a year to £625, and universalising it to all EU nationals, will raise £320 million in 2020-1, rising to £578 million in 2023-4. There must be serious questions whether this projection is realistic, given the downside risks to immigration numbers that implementing a hard Brexit, such as Mr Johnson’s deal will entail. The independent fact-checking charity Full Fact have noticed this implausible claim. The House of Commons library briefing on this subject is worth reading.

Nor is there any mention of the impact on UK public finances if Brexit causes the end of reciprocal healthcare: EU countries treat an awful lot more British pensioners than we do theirs. Should that system end, the impact on NHS demand of returning retired expats could be significant.

It is also of concern that the costings document makes no detailed mention of the pledged and urgently required capital investment in the NHS estates.

Not everything in the manifesto is stupid: there are repeated references to public health, early diagnosis and prevention. There is a commitment to reduce health inequalities (although no detail how), and a pledge to give mental health parity of priority with physical health.

Towards social care reform (very, very slowly)
When he became Prime Minister, Mr Johnson pledged on the steps of Downing Street that “fix the crisis in social care once and for all with a clear plan”. The Conservative manifesto leaves us still awaiting any clear plan at all.

There is merely a commitment to build a cross-party consensus of the kind that the Conservatives scuppered in 2010 with the ‘death tax’ attack line, which was roundly played back on them in 2017, forcing then-PM Theresa May into a humiliating U-turn.

That doesn't seem like a plan.

There is also a “guarantee that no-one needing care will have to sell their home to pay for it”, which is also very much not a clear plan. There is a rich irony here, given that in 2015, it was former Tory chancellor George Osborne who introduced the pension taper tax currently causing such harm to NHS service delivery to fund the effective raising of the inheritance tax threshold on main homes to £1 million.

Expensive stuff, property.

There is slightly more than nothing for social care, however. The manifesto costings document notes of the “allocation of £1 billion to social care in 2020- 21. The Prime Minister has recently confirmed that this funding will be maintained throughout the Parliament”.

But as every independent body has pointed out, social care requires serious funding. As the Health Foundation points out, “Government spending on adult social care in England fell from £345 per person in 2010/11 to £310 in 2016/17. If funding levels in England had grown in line with increasing demand since 2010/11, adult social care funding would have been £6bn higher than actual spending in 2017/18.

“Without additional government funding, there will be a gap between demand pressures and available resources of at least £2.7bn in 2023/24. This gap would be £4.4bn by 2023/24 if social care staff were given a similar pay uplift to the planned increases for NHS workers. Without this, social care will continue to struggle to compete with other sectors, including health care, in recruiting and retaining staff”.