As the end of the 2005-2010 Parliament approaches, and the political classes gear themselves up for the general election, each of the political parties’ health teams will be looking to prove that they have the big ideas to take the NHS forward in a period of tight public finance but escalating public expectation.
In this short series of opinion pieces, Health Mandate’s team of expert health policy consultants look at some of the big issues that will shape the political and the NHS landscape in the next parliament. Today’s piece sees Sarah Winstone examine the impact of a hung parliament on health policy.
In the balance: what does a hung Parliament mean for health?
With the electoral map stacked against a landslide, the prospects for economic recovery uncertain and the opinions polls still volatile, the odds on a hung parliament are narrower than they have been in a generation.
Nick Clegg has said that talk of an election pact is "putting the cart before the horse".
But he will be considering the very real possibility that he will find himself as king-maker – choosing whether to prop up a Labour administration reeling from a significant loss of seats, or put in power a Conservative Party disappointed by its failure to make the final breakthrough. Although the Liberal Democrat leader has stated that he is not inclined to join a coalition, he will bidding for policy concessions.
Mind the gap
A hung parliament would give Nick Clegg more power than any liberal leader since the 1970s.
But it could also expose serious fault lines within the Liberal Democrats, particularly on health.
It is noticeable that Norman Lamb’s recent policy paper, which provides the clearest articulation of his views to date, was published by a think tank rather than his party. Less than two months before the expected start of the election campaign it remains unclear whether these views represent party policy.
This presents fundamental questions about what attitude the Liberal Democrats would adopt to health in the next parliament. Would Nick Clegg be able to back Conservative plans for greater market involvement in the provision of NHS services?
Norman Lamb’s recent commitment to compulsory market testing might delight some of the Orange-bookers but it is not yet party policy – and it could leave the social democratic wing of the party feeling betrayed. It is as hard to imagine Dr Evan Harris helping the next government push through measures to enable the market testing of health services as it is to foresee David Laws agreeing to a policy of retaining the NHS as the provider of choice.
Prevention and public health could also provide an early challenge to Liberal Democrat unity if, as expected, both the Conservatives and Labour determine to take (and be seen to take) early action to improve public health and tackle health inequalities. Norman Lamb’s recently announced plans to explore charging drunks for A&E attendances indicate that he is intent on emphasising responsibility as well as rights in healthcare. Whether he can do so without offending the libertarian instincts of his party members remains to be seen.
Reconciling rhetoric and reality
Perhaps the biggest area of contention could come around localism. Superficially the Liberal Democrats, Conservatives and Labour Party are all committed to devolving decision-making in the NHS. However, this top-line rhetoric masks fundamental differences in approach.
The Liberal Democrats’ commitment to making local commissioners directly democratically accountable to local populations and giving them the power to raise revenue locally is at odds with Labour’s commitment to the importance of national standards. Nor does it sit well with the Conservatives’ proposal to shift the statutory duty for commissioning to GPs and devolve budgets accordingly.
Whether Norman Lamb will be able to defend the acceptance of ‘postcode’ variations in services which are implicit in this policy is a different matter. Are Liberal Democrat councillors, who form the bedrock of the party, really prepared to face down local patients denied services readily available elsewhere as a result of localism in action?
Even setting aside these political considerations, there is a clear philosophical difference in approach between the Liberal Democrats and their potential coalition partners which could be hard to reconcile.
So there are significant uncertainties about the position that Nick Clegg would adopt on health in the event of a hung parliament.
There is no doubt that his room for manoeuvre on public services would be restricted by the debates within his party that have yet to be resolved: the role of the state; the importance of localism and how to make it work in practice; the tolerability of any further restrictions on liberty to improve public health. These debates rage in every party, but they take on a new importance for a party that could be a powerbroker and where every parliamentary vote could be vital.
In reality, it is likely that health will be relatively far down Nick Clegg’s "shopping list" for a hung parliament. Securing concessions in areas of policy where there is greater consensus within his party – increased funding for education; more redistributive taxes; a greener economy; and political reform – will have a higher priority.
This approach may help the Liberal Democrats navigate the tricky process of coalition building, but it will not resolve the fundamental tension in health policy which exists between the two very different wings of the party. How they reconcile these differences will be a major challenge for Clegg and the party in the next parliament.