Carefully does it!

Health policies can easily cost votes, but are unlikely to win many. Maybe that’s why the proposals are so mealy-mouthed

By Nigel Hawkes

Writing a health manifesto is like tip-toeing on thin ice. Political parties want to appear bold and decisive, but know that promises to reform the NHS are easily turned by their opponents into threats to demolish it. And this time round, writing large cheques to provide better services is not an option, since all the parties agree that cuts will be needed.

The result is a more-than-usual mealy-mouthed set of proposals, with lots of emphasis on protecting the “frontline” (code for not sacking doctors or nurses) in the hard times to come. So where will the cuts come? In the IT system, says Labour, the party that invented it. In bureaucracy, say the Conservatives, who promise to cut administration costs by a third and cap top peoples’ pay. In structure, say the Liberal Democrats, who plan to halve the size of the Department of Health and abolish strategic health authorities, as well as cutting spending by health quangos and limiting top salaries to the same as that earned by the Prime Minister.

A common feature of Labour and Conservative proposals is the emphasis on patients’ rights. Labour says that patients will have the right to be treated by any provider, private or NHS, that meets NHS standards, that cancer patients will get quicker tests and faster access to specialists, the right to one-to-one nursing, and to palliative care at home, while every expectant mother will have a named midwife to look after them. The Conservatives agree on the right of patients to be treated wherever they wish, and offer the guarantee that a GP (but not necessarily “your” GP) will be available to all, seven days a week, 12 hours a day. This promise is possible only because the Labour Government has set a target of providing a GP-led health centre open all hours in every primary care trust. The Conservatives plan a bonfire of targets, but this one has suited them nicely.

Both Labour and the Conservatives believe all hospitals should become foundation trusts, an idea opposed tooth-and-nail by Gordon Brown when it was first suggested by the then Health Secretary Alan Milburn. Now “new old Labour”, as you might characterise Mr Brown’s rediscovery of the joys of reform, says that foundation trusts should have the right to expand into primary and community care and increase their private services.

But while Labour promises no changes to the structure of the NHS, the Tories would establish an independent board to run it, and turn the Department of Health into a Department of Public Health. Local authorities would get their own public health budgets, with the more successful being rewarded with more money. Labour has little to say about public health but does reiterate its promise to provide health checks for all those aged between 40 and 74.

All three parties want to abolish traditional boundaries for GP practices, so that everybody can choose any GP, regardless of where they live. It is not clear how this idea has achieved all-party support, since continuity of care – being treated by the same GP cradle-to-grave – was once seen as the NHS’s main contribution to healthcare. Now nobody even mentions it.

The GPs are paying a price for their 2004 contract, which made some of them a lot richer while doing less work. The LibDems want them to re-assume responsibility for out-of-hours care, while the Conservatives want them to take control of commissioning care locally, with real rather than notional budgets, and plan to link their pay to the results that they achieve. Labour, perhaps more conscious of the awesome power exerted by the British Medical Association, has resisted stirring the hornets’ nest.

Both the Conservatives and the LibDems disparage the target culture erected by Labour. The Tories’ alternative is patient power, driven by better measurement of results and greater choice for patients, in spite of evidence that the patient choices offered by Labour in government has so far been less than transformative.

The Conservatives seem to have identified cancer treatment as Labour’s Achilles’ heel; in the first TV debate David Cameron said it was a scandal that drugs available elsewhere were denied cancer patients in the UK. But the example he chose, the kidney cancer drug Sutent, is available to those patients where evidence supports its benefits. Was he suggesting that it should also be given, at a cost of £3,139 for a six-week course, to those who would like to have it but where there is no evidence it would benefit them? He appeared to be, in spite of Conservative enthusiasm for the National Institute for Health and Clinical Excellence (NICE), the body that makes these decisions.

Labour’s counter-promises on cancer are about speed of diagnosis and treatment, two areas that have been identified as weaknesses by Professor Mike Richards, the National Director for Cancer. But why both parties chose to emphasise cancer rather than other conditions, such as stroke where NHS care remains imperfect, is unexplained. The Liberal Democrats stayed silent on this topic.

The LibDem surge in the polls after the first TV debate has exposed their policies to greater scrutiny. Few, possibly including themselves, expected they might ever be in a position to implement them. Their most ambitious plan is to abolish the existing NHS superstructure and replace it with local health boards, elected to run services. But the manifesto is canny about handing over the NHS budgets to the local boards, suggesting that “over time, they should be able to take on greater responsibility for revenue and resources”. That may be prudent.

The Conservatives have also thought twice about earlier promises to protect all hospitals from closure and provide 45,000 single rooms in NHS hospitals. Now it is maternity wards and A&E departments – the hot-button issues – that the party promises to protect, and private rooms will be provided as resources allow.

On care for the old, where Gordon Brown tried to steal the advantage with his hasty and poorly-costed plan before the election, Labour now promises a commission to determine how to finance it, and another general election before anything is actually done. The LibDems also want a commission, but one that moves more energetically and reports within a year. The Conservatives don’t disagree about further discussion, but suggest that care could be financed by a one-off voluntary payment of £8,000 per head. At least that has the virtue of reminding people that care won’t come free, even if the precise figure has been questioned.

Health policies can easily cost votes, but they are unlikely to win very many. While it is disappointing to radicals of both left and right that the policies put forward are generally unadventurous, there is little evidence that the public as a whole is in the mood for adventure. It may not idealise the NHS in the way that Gordon Brown and, especially, David Cameron, appear to believe, but it does harbour a fear that too much change could result in something worse.

26 April 2010

Nigel Hawkes. Director of Straight Statistics and former Health Editor of The Times,