As the political parties prepare for the general election in 2015, HSJ has commissioned a series of articles from party insiders to explore the reality of how policy is made. In the first column, Bill Morgan, a former special adviser to Andrew Lansley, examines the tensions within the Conservatives over health policy, and explains why all parties shy away from addressing the challenges of NHS finances
NHS divides the Tories
For decades the Conservative Party has been an uneasy alliance between “small c” conservatives and liberals.
Maintaining this has been no small feat, for each political philosophy gives rise to sometimes completely polarised policy solutions.
Liberals tend to welcome the disruption of the established order. Conservatives, by definition, seek to conserve it.
More analysis and comment ahead of the 2015 general election
An uneasy alliance
For health and Conservative Party watchers, this will be the first tension to look for over the coming year.
The conservative wing of the party will seek reassurance on health, stressing their support for incumbent NHS providers. The liberal wing will seek to challenge this order, calling for the competition that threatens them.
Bolstering each of their cases will be the second tension that plays out.
The liberals will justify their radicalism by demanding clarity about the challenges that will face the NHS in the next parliament, and how to address them – explaining that in doing so, they will have a mandate for implementing the policies once returned to government.
For their part the conservatives will stress they need to win the election first, and unsettling the electorate with radical plans for health is unlikely to help them over the line.
‘None of the ways to address the challenging NHS finances are easy, which is why the parties shy away from them’
I suspect political expediency will mean the latter approach will win out. This is a shame, because if the Conservatives form the next government, a clear mandate to implement policies that tackle the most challenging issue of all – NHS finances – will be needed.
Much debate is currently being held on how best to address this financial challenge; from raising taxes, further pooling health and social care budgets, to introducing charges.
None of them are easy, which is why the parties shy away from them.
Frankly, all are far less preferable than the accounting fiddle I would choose, which is to move providers off the government balance sheet.
At a stroke, such a move would allow commissioners to do what we want them to do: redesign services.
It would allow foundation trusts to spend their surpluses without the Department of Health having to carve into commissioning budgets.
‘Convincing the DH it will not have to bail out failing providers is hard when they are doing so right now’
More importantly, it would stop the DH having to worry about providers falling over whenever commissioners find more efficient ways of delivering care.
At present, whenever a NHS provider falls over, the DH has to account for it, which it does by raiding commissioners’ budgets – surely a recipe for inertia.
This is such a good idea it is sad that it is so hard to implement. Convincing the DH it will not have to bail out failing providers is hard when they are doing so right now.
Convincing the Treasury that the DH does not have control of providers is challenging with special administration regimes which have proven so susceptible to political intervention.
Convincing anyone that the government is not responsible for NHS hospitals is impossible when the secretary of state is ringing up their chief executives to demand performance improvements.
Making a manifesto
Making any significant headway against these obstacles in the next Parliament will require a distinctly liberal and unsettlingly radical Conservative Party manifesto.
Such a document would need to be clear that sometimes drastic and unpalatable action is needed to stabilise the increasing number of financially failing hospitals.
It would need to promise a further rewrite of the legislation governing NHS failure regimes. It would need to set out, as a core mission of the next government, a technical change in the national accounts. And it would have to explain clearly why all of this is needed.
‘Truly dreadful policy ideas can emerge from the chaotic zones in which “doorstep friendly” policies are devised’
This leads to the third tension in manifesto making: trying to find a policy that is workable in practice, but also “doorstep friendly”.
Striking a balance between these two aims is virtually impossible, so instead compromises are made and as elections draw closer, the latter tendency moves into the ascendancy.
Truly dreadful policy ideas can emerge from the chaotic, largely evidence free, zones in which “doorstep friendly” policies are devised.
Some ideas can be successfully choked off at their genesis. I spent a September in one year successfully fending off the announcement of a new hospital building programme.
Some ideas keep resurfacing year on year, despite their obvious drawbacks: introducing charges for GP services – have you heard of perverse incentives?; abolishing car parking charges for hospital patients – can we spend money on healthcare instead?; or refusing treatment to people who are aggressive in accident and emergency – what happens if they have a neurological injury?.
Sadly, other ideas slip through the net: the friends and family test is a good example of a bad and expensive doorstep friendly policy that is not particularly doorstep friendly.
The latest such example doing the rounds is the concept of hypothecating national insurance and using it as an “NHS tax”.
This is undoubtedly doorstep friendly: the electorate likes the idea of knowing where their money is going, especially when it is going to the NHS. It is also unworkable.
National insurance is cyclical, so when the economy is strong the NHS would be spending money like it is going out of fashion, and when the economy is weak it would be starved of funds.
‘As we watch the health debate unfold over the coming year, we will undoubtedly see all of these tensions play out’
In a big, ugly recession, an NHS funded by national insurance would inevitably have to be topped up by general taxation and borrowing, which is exactly what happens now to smooth the bumps in tax receipts.
As we watch the health debate unfold over the coming year, we will undoubtedly see all of these tensions play out. Remember them.
First, policies that can be explained in a sentence are more likely to be terrible than not; or at least expensive, and often both.
Second, there is no easy answer to the funding question everyone is asking, and even if there is, it is hard work.
Finally, a Conservative Party manifesto that is conservative in nature means that their politicians are not facing up to – or fessing up to – the radical steps that need to be taken to address the challenges that will face the NHS over the coming Parliament. The same goes for Labour too.
Bill Morgan is a founding partner of Incisive Health and a former special adviser to Andrew Lansley