Traditionally, Labour has sought to frame the political debate on health as a choice between investment and cuts. That’s not looking viable now that the public expects any party in government to cut public spending. The Conservatives have also positioned carefully, with health as their number one priority, one of only two areas of spending that will continue to increase if David Cameron enters No 10.
In its search for new dividing lines, it is crucial that Labour neither retreats from the market-based policies it has put in place, nor shrinks from the hard but vital task of getting ‘more from less’ through substantial productivity gains. Those foundations are essential to maintain the new political consensus New Labour has won for a universal NHS free at the point of access. They also allow new progressive dividing lines between the parties about different conceptions of fairness and the role of the state in improving health outcomes. A failure to use the market reforms fully to boost productivity will, however, undermine the progressive consensus and generate renewed interest in more radical options of charging or passporting patients into private provision, ending the concept of the universal NHS as we now know it.
Labour’s health policy has come a long way since 1997. Stage one, argued Gordon Brown early in his premiership, was to set minimum standards. Key to that was to drive down waiting times, a huge achievement that currently enjoys too little recognition. Stage two was to create incentives for better local performance, which required new policies like patient choice, competition and a restoration of the internal market. Many of these are still new and have not yet reaped benefits. Stage three should have been giving the majority of us access to the quality of care that had previously only been enjoyed by those who went private. And then along came the credit crunch, which changed all of our assumptions.
As several commentators have reported, the recession means that we have no alternative but to fast-track the search for major efficiency gains and productivity improvements. It is worth remembering, however, that there is a strong moral and political case for efficiency in any case. Efficient spending means that there is more money to treat more patients, that the latest technologies and drugs can be introduced and standards raised. The alternatives to greater efficiency are unpalatable for progressives: a return to greater rationing, through waiting lists and an extension of charging, along the slippery slope marked by top-up fees. Both rationing and charging will mean that people will not get the treatment they need and will legitimise arguments that the NHS is not sustainable and needs to be reconceived. And we can no longer rely on such arguments being politically toxic. In a poll conducted well before the credit crunch changed the rules, 57% of people agreed that ‘there are some good things in our healthcare system but fundamental changes are needed to make it work’.
For progressives, those fundamental changes should be seeing through the market reforms Labour has already put in place and not the privatising reforms others are advocating, which would open the door to mass privatisation of healthcare via a return to queues, waits and rationing.
The scale of the spending challenge, however, means that we need to fast-track these reforms and, in places, ‘re-invent the value chain’ in healthcare, along lines successfully introduced by other industries. We need greater convenience for patients in order to increase their engagement with healthcare and we need to provide care at the most cost-effective levels, which will mean more care in the home, in the workplace and in the community, and less in hospitals. This is starting to happen – nurses doing tasks previously undertaken by GPs, GPs doing work previously the reserve of hospitals – but not fast enough. And there is a vacuum in education and self-management which means that many patients aren’t treated at all until they become ill and end up in A&E.
All of this implies some de-commissioning of existing services. Completely new models of provision are needed that support self-sufficiency and they need to be much more convenient for patients. People simply won’t take time off school or work to see a GP who is only open during office hours, when their health problems are chronic enough to be a problem but rarely acute enough to be an emergency. Until, of course, it is too late and people end up in A&E in their tens of thousands.
In order to win the confidence of voters on the NHS, Labour will need to show it is the party to take tough choices to dramatically improve results while retaining the core values and principles of the NHS. If Labour can achieve this, then the dividing lines will be on progressive territory – about different interpretations of fairness in delivering health; about the means of achieving more altruism as well as individual choice in the consumption of NHS resources and, above all, in the concept of active government and the role of the state in improving health outcomes.
Labour’s vision of fairness begins with the steep gap in life expectancy that exists in many cities and urban areas and has seen extra resources targeted towards inner cities, especially in the north. Recently, there has been a renewed focus (but less action) from Labour ministers on the social determinants of health, which mean the poor do much worse in health outcomes. The Conservatives’ vision centres instead more on demographics than geography, with targeted policies for different age cohorts and a likely shift of resources away from urban centres towards older people in coastal and rural areas. Their vision for a more equal society is not to address the social determinants of health but to take on the major public health challenges like smoking and obesity. In effect, Labour offers to improve health by improving incomes and education, while under the Conservatives the NHS becomes independent and Richmond House will become a Department of Public Health.
After a long focus on consumerism in public services, there is also a real need to emphasise, too, our responsibilities towards others in our use of public resources like the NHS. This is a crucial part of the public’s support for the NHS as we know it. Again, political visions differ. Labour sees the state as the crucial means to achieve fairness and improve outcomes. This requires an active state, driven admittedly more from a local level but with national entitlements and guarantees. The Conservatives place more emphasis on patient choices, the professions and on charity. The differences are symbolized in the parties’ different prescriptions for social care: an active state and new social insurance model on the one hand, a reformed market supporting greater individual choice on the other.
Neither party has yet explained how it will encourage greater individual responsibility in our use of NHS resources, although thinktanks from both sides of the political spectrum are now advocating an extension of charging, for example for GP visits. No party is likely to want to be painted with that brush in the next election campaign, but the idea neatly signals the very different future debate we will have if demand management and productivity improvements are not achieved through other means than charging.
New Labour has been successful, then, in mapping a progressive territory for debate in the 2010 election, but cannot win it on a platform of spending versus cuts. Instead, greater articulation and detail is needed about Labour’s vision for fairness, choice and altruism through an active state as well as reassurance that it can achieve ‘more from less’. Failure to see through and build on New Labour’s reforms will, however, see the breakdown of the progressive consensus and mean that subsequent elections will be fought on much less progressive terms.