The Conservatives have pronounced themselves the party of reform but are too wedded to the status quo. Andrew Haldenby argues they need to spend more energy advocating change
When David Cameron became leader of the Conservative Party, one of his core promises was to deepen the Blairite reforms of public services rather than abandon them.
The government has been able to postpone the consequences of its prevarication with a tidal wave of money. The next government will not have that luxury
Of course there was a political subtext; Mr Cameron wanted to present himself as the reforming heir to Blair in contrast to Gordon Brown’s reactionary. But the policy was right - to continue the Blairite agenda of public services reform to deliver not only value for money but also social justice (since the monopoly structure of the NHS and state schools had provided the worst results for people on low incomes).
For the NHS, this meant the Conservatives would push forward with greater patient choice based on much better information, with competition between any willing providers and with real power for commissioners to make change.
Much of Conservative policy since then has stayed true to this initial commitment. At some points, they have shown real courage, not least this autumn when health secretary Andy Burnham threw down the gauntlet on competition. The secretary of state’s statement that the NHS should be the “preferred provider” of care was a U-turn that made a nonsense of great swathes of policy on choice and market development. It was a transparent calculation to gain some transitory support from certain unions and bodies at the cost of the permanent loss of the benefits that competition would bring.
Shadow health secretary Andrew Lansley resisted temptation and stuck to the basic principle that any willing provider should be able to treat NHS patients. He spelt it out in his party conference speech: “Labour have turned their backs on competition and choice. We will not.”
In similar vein, the fringe of the Conservative Party conference heard praise of NHS Great Yarmouth and Waveney for putting all of its community services out to tender. At a Reform fringe meeting, shadow health minister Stephen O’Brien explained that a revolution in patient information would give patient choice the kickstart it has needed.
These are the kinds of ideas that explain why some senior Conservatives think people have not realised how radical their policy is. The three policy documents released under Mr Cameron underpin this vision of information, competition and choice. Top down targets would go, replaced by outcome measures, such as cancer survival rates. Commissioning would be separated from provision. A reformed tariff would target resources on providers that achieved better quality. And once the management of the NHS was decentralised and competition working, the Department of Health could take on a new role - “a Department of Public Health”, as Mr Lansley said, speaking to Reform in 2008.
But this is not the whole story. There is another side to the Conservative policy which undermines what has gone before. Perhaps it was this contradiction that led former Conservative health secretary Stephen Dorrell to call for his party’s spokesmen to shine “a little sunlight” on their policy before the general election.
The problem is they have spent as much energy opposing change in the NHS as they have advocating it, in particular in 2007 when Mr Cameron opted to play the reactionary to then health minister Lord Darzi’s reformer over district general hospitals.
A basic fact of the health debate is that modernisation, involving the development of primary care, integrated care and prevention, needs resources currently tied up in secondary care. District general hospitals, too small to offer comprehensive specialised care, are most in question. Yet Mr Cameron promised the government a “bare knuckle fight” over these hospitals, saying “we believe in them” and “we want to save them”.
The Conservatives went on that autumn to campaign against “Gordon Brown’s NHS cuts”, defining a “cut” as any reduction in any service at all. They are still committed to a moratorium on hospital closures should they win office. These policies are bad enough in themselves but the collateral damage is the signal they send to the rest of the NHS - that change will only happen within strict limits, and that when push comes to shove, the historic pattern of provision, however inefficient, will be defended.
That signal has been reinforced by the commitment to spend more on the NHS no matter what in the next Parliament. As Reform consultant director Nick Bosanquet has said, nothing concentrates the minds of managers more than a declining budget. The Conservatives would not apply that pressure.
I happened to speak at the NHS Confederation annual conference in June on the day Andrew Lansley said on the Today programme that, because his budget would be protected, all his colleagues’ departmental budgets would be cut by 10 per cent over three years. One primary care trust chief executive told me of her anger. She had been telling her senior staff the world was different now and the tough decisions on service redesign could be postponed no longer. Suddenly Andrew Lansley had taken the legs out from under her.
Another policy for the status quo is the commitment to give more commissioning power to GPs at the expense of PCTs: clearly GPs should be able to commission services on behalf of their patients. But GPs, even in collective form, will never be able to drive a redesign of services in a way that would challenge the big acute trusts.
So the party’s appetite for reform is not as strong as it would have us believe. The incoherence in its position mirrors that of the government’s throughout this Parliament; a government which nominally stands for competition and choice but which in practice has sought to soothe the professions rather than push for change.
But the government has been able to postpone the consequences of its prevarication with a tidal wave of money. The next government, inheriting a public sector that spends six pounds for every five it raises in tax, will not have that luxury. Protecting the producer, as the Conservatives promise, would leave the consumer to take the hit, unveiling the depressing prospect of rising waiting times and declining quality.
Given the need to revolutionise the pace of change, what should the Conservative policy vision be? Like Chris Ham, Birmingham University professor of health policy and management, Reform points to competing, vertically integrated insurers - almost certainly based on PCTs in the first instance - who can deliver integrated care and who have real incentives to improve population health.
Just as importantly, what should be their message? That if the values of the NHS are to be sustained, the public should expect the day to day feel of the NHS - its staffing and its buildings - to change in almost every respect.
That would be a tremendous change from their current position. But it would be consistent with David Cameron’s pledges in his first days as party leader and with Andrew Lansley’s decision not to follow Andy Burnham’s grandstanding.
It would enable them to make progress towards the defining objective for the next government of whatever stripe - through reform, to reduce the fiscal deficit while achieving better social outcomes.
Cameron and Lansley in their own words
“I can promise what I’ve called a bare knuckle fight with the government over the future of district general hospitals. We believe in them, we want to save them and we want them enhanced, and we will fight the government all the way.”
“We are at, what, 9 per cent of GDP. We don’t want to get to 14 per cent of GDP. We’re going to get probably to 11 simply through the progress of rising health expenditure and life.”
“It’s so disappointing that during the last two years, the reforms that began under Alan Milburn and Tony Blair have completely stalled under Alan Johnson and Gordon Brown.”
“We have made it clear where our priorities lie: we are going to increase the resources for the NHS, we are going to increase resources for international development aid, we are going to increase resources for schools. But that does mean, over three years after 2011, a 10 per cent reduction in the departmental expenditure limits for other departments. It is a very tough spending requirement indeed.”
- Acute care
- Alan Johnson
- Alan Milburn
- Andrew Lansley
- Andy Burnham
- Ara Darzi
- Change management
- Community services
- Competition and co-operation
- Conservative Conference 2009
- Conservative policy
- David Cameron
- Foundation trusts
- Gordon Brown
- Government/DH policy
- Payment by results (PbR)
- Primary care
- Public health