In a 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 our team of consultants examine the health challenges facing David Cameron.
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.
New government, new problems: What health challenges will face David Cameron?
It has become almost axiomatic to say that there are no dividing lines between Labour and the Conservatives on health, and that the same challenges which face Labour today are those selfsame ones that will face David Cameron tomorrow. This belief is misguided, however: the apparent similarities between the parties occurs only because securing support as the most trusted party on the NHS remains a vital determinant of a political party’s success. After all, and despite the economic crisis, both parties’ internal polling demonstrates that healthcare remains the number one issue amongst the 20- and 30- something female voters who will decide the outcome of the next election.
It is this importance that has seen the Conservative Party ditch long-cherished policies on healthcare in its quest for key swing votes, including tax relief on Private Medical Insurance and its ideological successor, the Patients’ Passport – and in the process decisively move itself closer to Labour. People should not be fooled however, scratch the surface and there are many radical and controversial ideas which expose deep ideological differences. Chief among them a rapid return to GP fundholding, free price competition between NHS and non-NHS providers, and the scrapping of NHS targets. Every single one presents a potential challenge for David Cameron.
Strengths or weaknesses?
Many of the challenges facing Cameron are those which should be strengths: the commitment to real-terms protection of the NHS budget, together with the statement of support for the NHS frontline, imply that the first 18 months of a Cameron administration should be relatively trouble-free. But these apparent strengths hide great weaknesses:
- Funding. The Conservatives remain the only major party to date to have pledged themselves to real term increases in the NHS budget, resulting in the media having turned a blind eye to the pain the NHS will have to feel under a Conservative Government. Right-wing commentators have fed this narrative by scornfully dismissing the Conservative Party’s commitment as one of pouring money into an inefficient black hole, willfully neglecting the fact that the slight ‘real terms increases’ promised will feel like savage cuts to an NHS which is used to seeing growth in its budgets in real terms of 7% a year and which faces an ongoing struggle to meet the costs of rising demand for healthcare. Watch out for proposals to close services early on under the Conservatives, and – unlikely as it seems now – a potential return to cancelled operations and ward closures as the NHS runs out of money towards the end of each financial year.
- Industrial relations. Cameron’s Conservatives have been the arch-exponents of a ‘hugging the NHS close’ strategy, fearful of antagonising staff in the run-up to a general election. This strategy has led to commentators bemoaning the Conservatives’ ‘producer capture’ (ie being nice to NHS staff) – despite the cultivated image being so evidently on inspection a mirage. Look closely at Conservative announcements, and they reveal policies likely to stir up a hornets’ nest of staff trouble.
The funding crisis and the need for efficiencies will put downward pressure on staff pay at a time when pay in the private sector will start to bounce back after the recession. The Conservatives’ ‘Any Willing Provider’ policy, designed to stimulate competition in healthcare provision, will demand wholesale changes to, and even the closure of, the NHS pension scheme. Finally, Shadow Health Secretary Andrew Lansley has pledged to renegotiate the GP contract and rip up GPs’ beloved performance-related ‘Quality and Outcomes Framework’. The British Medical Association has proved a thorn in the side of dozens of health secretaries in the past: will a new Conservative Health Secretary fare any better?
- Targets. Conservative disdain for ‘targets’ looked like a strong message in the 2001 and 2005 General Elections, when they so obviously distorted priorities (think back to the beating Tony Blair took on GP appointments during Question Time), but the message looks muddier now that the targets have not only delivered 18-week waits but that Labour themselves appear to be moving away from them. Nevertheless, the election battle looks set to be dominated by the issue, with the 18-week target likely to assume totemic importance as the most obvious dividing line between Labour and the Tories. The target will have to go if Cameron enters No. 10 – Conservatives have said it too much to do anything else – but how long will that same Cameron-run No. 10, and the Labour opposition, tolerate waiting times nudging past 18 weeks? Will the technocratic Shadow Health Secretary Andrew Lansley – a man steeped in the finest traditions of the civil service – even allow it to happen, or will he find within the darkest corners of the Department of Health obscure policy levers to ensure that patients do not have to wait longer?
Potential pitfalls and problems
One doesn’t have to delve very deeply into Conservative Party health policy to identify radical differences between it and Labour – differences which, however technical they appear now, signal trouble in the months and years to come.
- GP fundholding. The abolition of GP fundholding was a clarion call of Labour in opposition, and the policy was so vehemently despised by them that they scrapped the system even before they could find the parliamentary time to repeal the legislation which underpinned it. Conservatives – at least those interested in health – have been desperate to right the perceived wrong ever since. They have pledged to give virtually the entire health service budget to GPs, and intend to ask them to organise and accept responsibility for all health services delivered in their local area. GPs, they say, will be paid according to the quality of care provided to their patients by the NHS – whether or not GPs have delivered the care themselves.
This policy (NHS-watchers will recognise elements in it of the ‘Total Purchasing’ pioneered in the dying days of the last Conservative Government) amounts to one of the most fundamental realignments of NHS power in its history. And yet the Conservatives have failed to plug some of the obvious gaps in the policy. What if GPs do not have the specialist expertise to do the job they are asked to do? What if GPs use up their budget before the end of the financial year? What if the services GPs choose to invest in happen to be owned by those selfsame GPs?
All of these gaps need to be plugged, but coupled to this is the fact that inherent in the policy itself is that GPs will have to do much more work for the same amount of money. A stand-off early on in a Cameron administration is inevitable.
- The ‘Independent NHS Board’. An announcement from David Cameron’s first year as Conservative Party leader (in October 2006) was the pledge to establish an independent NHS Board to free the NHS from political interference.
There remains some confusion as to what the Tories actually intend the NHS Board to do – confusion stemming from the failure of many Conservatives to understand precisely how the Board fits into the complicated tripartite policy framework (based on quality regulation, market oversight and consumer ‘voice’) announced by Andrew Lansley in September 2005. Some commentators argue that the Conservatives want the NHS Board to ‘run’ the NHS, though these commentators are misguided: the Board itself will ultimately performance-manage GPs (although only in their role as the NHS’s budget-holders, not in their clinical capacity), whereas the ‘providers’ who actually deliver care will be independent of the independent NHS Board itself. Confused? Probably – though thankfully for Cameron, in the frenzy of a general election campaign, voters will only need to hear that the Conservatives will establish an independent board ‘to take the politics out of the NHS’, leaving the Byzantine technicalities to the civil servants working out how to pass the system into law.
The policy itself might be admirable – discuss – but the practicalities of it are debatable. All Labour’s attempts to give operational independence to the NHS have floundered on the rock of political necessity. Labour’s flirtation with free-standing foundation hospitals rapidly came to an end with last year’s Stafford Hospital scandal, which resulted in the Government grabbing back many of the powers it had devolved so willingly six years before. In the face of similar scandals, potentially rising waiting times and public protest, will a Cameron government hold firm to its pre-announced course or, like so many politicians before, end the professed aim of NHS independence it has espoused for years?
- The ‘moratorium’ on hospital closures. The Conservatives have announced that they will pause hospital and service closures upon coming to power, whilst the evidence base for them is reviewed. The policy is designed to appeal to voters in a general election campaign, and give Tory candidates free rein to campaign against ‘Brown’s NHS cuts’. What will the Conservatives do when they come to power and find that in many areas of the country the evidence is in favour of Brown’s cuts? Will a Cameron No.10 watch nervously as its hard-fought popularity on health evaporates in a storm of protest over hospital closures, or will the Conservatives plough ahead with the market-reshaping which the logic of their policy dictates?
The greatest challenge
Huge swathes of Conservative Party health policy pose questions that need to be answered. Whilst the Conservatives can, quite legitimately, claim that they cannot possibly answer them all while in opposition, this rather misses the point. Conservative Party health policy is so broad in its scope and so deep in its reach that it might have overstretched itself.
Cameron’s greatest challenge will be finding answers to the questions asked by his policies before the pressures of government bursts them asunder. Put simply – for an NHS notoriously resistant to change – the Conservatives may find they have too many questions to find answers to, and not enough time to find them.