Editor Richard Vize discusses whether the health policies of a Conservative government would deliver the right improvements for the NHS long after the applause of the voters has faded away
The great test for Conservative stewardship of the NHS would be whether they can retain the public’s confidence that the service is safe in Tory hands while overseeing the stripping out of billions of pounds of cost.
Andrew Lansley has repeatedly spoken against a bloated NHS bureaucracy
As shadow health secretary over the past six years, Andrew Lansley has managed to bury Labour’s claim that the Tories cannot be trusted with the NHS because they are ideologically opposed to it. This success has been an essential foundation for leader David Cameron’s “caring conservatism”. Indeed, at the beginning of the NHS’s 60th anniversary year Mr Cameron even declared 2008 was going to be when the Conservatives established themselves as “the party of the NHS”.
This was a step too far - Labour’s counter-attack with the next stage review defused voters’ growing unhappiness with Labour’s health service management after rows over deficits and service closures. But the Conservatives still see vote winning opportunities in health policy - attacking the “army of bureaucrats”, giving more commissioning power to GPs, abolishing targets and ending “ministerial meddling”.
What will each of these policies deliver, and will they meet the challenges the next government will face?
Mr Lansley has repeatedly attacked the “bloated health service bureaucracy”. In a World at One interview on 3 September, for example, he cited an 80 per cent rise over five years in the administration costs of primary care trusts. In a similar vein he can reel off all the working groups and administrative superstructure which his local strategic health authority - East of England - established in response to the Darzi review.
The number of managers has indeed risen sharply under Labour. NHS Information Centre data reveals that between 1998 and 2008 the number of managers rose 76 per cent from 22,693 to 39,913, while the number of professionally qualified clinical staff rose 171,593 - 32 per cent - to 701,324. In addition the number of support staff in “central functions” rose 34,275 - 48 per cent - to 105,354.
Much of the impetus for the non-clinical increases has come from trusts building their management capacity for foundation status and PCTs preparing for the first year of world class commissioning. And unfamiliar job titles such as social marketing manager have entered the NHS lexicon as PCTs push harder on public health areas of concern such as obesity.
The Tories would undoubtedly win praise for cutting managers, but even if the total was slashed by a quarter Mr Lansley would have saved barely 5 per cent of the money he would need to find.
Mr Lansley plans to move much more commissioning power from PCTs to GPs. HSJ understands the Conservatives are likely to require all GP practices to become practice based commissioners. Most of their commissioning functions would be performed through federations of GP practices operating as consortiums.
But there are two problems with this. First, many GPs will not want to become commissioners. Shadow health minister Mark Simmonds told HSJ that using companies such as Humana would be an option where GPs did not want these new powers.
He said: “There may…be circumstances where if there’s a continuing reluctance [from GPs] we may have to bring in others to commission on their behalf.”
Groups of GPs would be allowed to select another GP consortium, the PCT or a private firm to do the commissioning, he said.
This raises the prospect of large parts of commissioning being moved to GPs, many of whom would then either cede their powers back to the PCT or franchise them out. Franchising would entail a costly and lengthy tendering process, and there is no guarantee private firms would want to go to the expense and risk of bidding for what would often be small contracts. The costs of unsuccessful bids would feed into the cost base of other contracts; add the need to make a profit and it is hard to understand how this policy would cut bureaucracy and costs.
The second problem with handing more commissioning to GPs is the lack of evidence that it would drive quality and efficiency, especially in a tough financial climate. There are stunning examples of practice based commissioning delivering cost effective, excellent services, but there must be grave doubt that it can be a major contributor to reshaping the health service to the degree needed to save £20bn.
Hitting the target
Abolishing targets is easy to implement, would win massive support from voters, clinicians and managers and could backfire horribly.
Excessive reliance on targets as a means to drive up service standards finally undermined public support for Labour’s approach to public service reform. But it can justifiably claim that delivering 18 weeks referral to treatment, four hour accident and emergency waits and two week cancer referral times are among the greatest achievements of their 12 years in power, after John Major’s government bequeathed waiting lists in the hundreds of thousands. Long NHS waiting lists matter. They undermine the confidence of thousands of taxpayers in the efficacy of tax funded healthcare free at the point of need.
Abolishing these targets just as money tightens could quickly result in a highly visible deterioration in services. Labour would seize on media sensitive issues such as lengthening cancer waits as evidence the NHS was not safe in Tory hands.
The Conservatives believe patient choice will drive quality services. Its health policy paper says “we will publish information about what actually happens in the NHS - such as stroke survival rates…and let doctors choose how to deliver the best care. Publishing this kind of information…will enable patients to make really informed choices. They’ll be able to judge performance and decide which hospital they want to go to, how they are treated and which GP they want to use”.
This is a fantasy. Patient choice is an important principle and where there is a meaningful choice of provider it will go some way to promoting quality services. But there is, again, no evidence that millions of patients are going to make informed choices which will rapidly improve services. Stroke victims cannot choose who will treat them. After years of disgraceful stroke care across much of the country, the recent improvements have been driven by a national initiative and delivered by clinicians and bureaucrats - commissioners and hospital managers - collaborating across regions and sub-regions to deliver a faster, more effective service. It is hard to believe a mix of GP commissioning and patient choice would have made comparable improvements.
Labour’s obsessive dependence on targets has distorted clinical priorities and wasted money. It has also delivered dramatic service improvements. The Conservatives need to find a means to move power back to patients, clinicians and managers without undermining years of work by frontline staff that have improved and saved lives.
The Conservatives plan to replace the NHS executive residing in the Department of Health with an independent board appointed by the health secretary. It says one of the board’s first jobs would be to change the allocation formula to end Labour’s alleged bias towards deprived areas at the expense of relatively wealthy, rural areas with large elderly populations, often the places where trusts have run into deficit.
Labour has passed its high water mark of interference in NHS management, but Gordon Brown on his party conference platform in 2007 ordering thousands of cleaners to deep clean wards showed Labour cannot resist using the NHS as an arm of a centralised state.
An independent board would at least send the right signals about independence. But how we live and when and how we die are political issues.
No governance structure would free the NHS from ministerial direction. Since it accounts for around a quarter of spending on public services this would not just be unlikely, but negligent. The objective must be to balance the legitimate setting of broad policy direction with operational independence in delivery.
It is intriguing to consider how an independent board would sit with the personality of Andrew Lansley. He is seen in the health world as a technocrat, famed for his grasp of detail, rather than someone who focuses on the big picture. It is possible to envisage him getting the Tories’ health policy on the statute books, then making way for a new secretary of state with less understanding and more ideology to oversee it.
All the principal Conservative health policies - making management more efficient, giving more commissioning power to GPs, abolishing targets and ending political interference - have attractions. But they have yet to be moulded into a compelling narrative for why they are the right strategy for a health service which must raise quality, meet rising demand and drastically cut costs.