There has been so much focus on the right or wrong turnings taken by the Coalition on health, that it is easy to forget that there were alternatives. The peculiar mix of political imperatives that was created by the heady early days of coalition government have undoubtedly impacted upon the scope, scale and timescales of NHS reform, but what would have happened without the Coalition? This blog is my attempt to examine what might have been different if David Cameron and Nick Clegg, as well as Andrew Lansley and Paul Burstow, had not been thrown together in a way which was as unexpected to them as it was to health watchers.
First, however, it is necessary to consider what wouldn’t have changed. The NHS would still have faced the need to deliver massive efficiency savings (the exact scale would have depended on the party in power), whoever was Secretary of State would still have been tested by a nasty flu season in 2010/11 and – from funding to quality – social care would still be a mess. This would have been the context facing whoever was the incumbent in Richmond House as winter approaches. But what would have been different?
If the Conservatives had won…
If David Cameron had achieved the majority that the polls had for so long predicted then the direction of travel for the NHS would look very similar to that today – these are, undoubtedly, Andrew Lansley’s reforms. However, there would also have been some important differences.
SHAs would still have been abolished – Lansley always had them in his sights but was prevented from making a pre-election policy on the issue due to David Cameron’s commitment to avoid structural change. Whatever the formulation of this pledge – "top down" and "pointless" reconfigurations were both used at different times – there was plenty of wriggle room, and it would have been used.
However, the fate of PCTs would have been a different matter. As I have written before, Andrew Lansley is no fan of democratic involvement in commissioning and would have been eager to keep local authorities away from health. PCTs would have retained responsibility for public health functions, although – with much NHS commissioning responsibility transferred to practice-based commissioning clusters with hard budgets – their number would have reduced radically (probably to about the number of PCT clusters that exist now).
It is also important to remember that Lansley would have faced an emboldened right wing who, far from seeing themselves as defenders of his reforms, may have resumed their pre-election grumbling about the lack of radicalism and the commitment to spend on health at the expense of tax cuts.
There would still be massive upheaval, rows about the role of competition and accusations of the "wrong reforms at the wrong time," but the scale of structural change would be more modest. And there would have been those on the right eager to look for more radical solutions.
If Labour had won…
Had Labour won (presumably with a wafer-thin majority) they would have faced an immediate challenge. Having decided not to match the Conservatives’ commitment to deliver real terms increases in NHS funding, Labour would have been faced with the decision about how much they would strip out from health – never an easy decision for the party of the NHS. Higher than anticipated inflation may have called into question the extent to which George Osborne and Andrew Lansley are meeting their commitment, but it could have felt far worse. And the political heat for a Labour government would have been intense.
Faced with this challenge, Labour would have probably sought to reduce management costs by merging PCTs (clusters anyone?). After all, every party faced with unpalatable cuts goes in for a bit of bureaucrat-bashing.
Labour would also have pursued plans for a National Care Service – this was one of the few parts of a fairly uninspiring manifesto which caught the attention and social care is, after all, a classic fourth term issue (this is partly why the Dilnot proposals may run into the sand).
Hostages to fortune, created in the previous Parliament more in hope rather than expectation of another election win, would also have had to be dealt with. There is no better example than the ‘NHS as a preferred provider’ policy, which even before the election had the Cooperation and Competition Panel sharpening its teeth. Given the political passions the issue arouses (and the differences that exist on the issue within the Labour Party), it would have been difficult to wriggle out of this one or let it die quietly.
The other issue which would have bedevilled Labour is access to cancer drugs. It is easy to forget the extent to which the Cancer Drugs Fund has defused NICE/postcode lottery stories in England – without this, media and charity outcry would have continued to grow, leaving whoever was Secretary of State with some difficult decisions.
If the Liberal Democrats had won…
Okay, this scenario is highly unlikely to have occurred, but it is still worth considering. Whoever had become the Liberal Democrat Secretary of State (probably Norman Lamb) would have faced a difficult task. As well as managing the same spending issue as Labour, there would have been the need to fill in some serious policy gaps. The health section of the Party’s manifesto is notable mainly because of its lack of detail. So we know that a third runway would not have been built at Heathrow (this made it into the health chapter, which is probably more of an indication of the absence of other commitments than it is of the comprehensiveness of the analysis of the impact of air pollution on health), and we know that there would have been a big push at increasing democratic involvement in and oversight of commissioning (through directly elected local health boards). But beyond this, the details are sparse.
Probably a more informative document to look at is Norman Lamb’s own policy paper. The very fact that this is not party policy, but rather the personal musings of the then Shadow Secretary of State is an indication of some of the challenges the Liberal Democrats would have faced: it had to be published personally because even members of his own frontbench team did not agree with elements of it. It does, nonetheless, provide the best insight into the personal direction in which a Lamb-led NHS may have travelled.
So what could we have expected? Policies such as compulsory market testing ("the test should always be the quality of care irrespective of who provides it") would not have sat well with the Liberal Democrat left any more than Any Willing Provider did. Shifting responsibility for funding NHS communities to local communities would also have been highly controversial. Equally big structural change (abolishing SHAs, changing PCTs into local health boards, culling quangos etc) would still not have sat well with an NHS facing a big efficiency challenge.
So the reforms may have been different, but the scale and scope of change sounds familiar. Given the serious disquiet within sections of the Liberal Democrats about the current reforms, it is hard to see how a similar fate would not have befallen the Lamb proposals.
Different parties, same problems?
Whoever won the last election was going to face big problems in health. The exact nature of the policy challenges may have differed but the fundamental context would have remained the same: a pressing need to do more with less; a service tired of change and with huge fixed costs; and a party not wholly united. The counterfactuals are not actually that different from the real situation.