Politicians who get tangled up with healthcare usually end up regretting it. Ask Barack Obama. One day you have this dream of bringing medical coverage to 30 million of your unprotected fellow citizens. A year of drift, squabble and dodgy compromise later and your party is booted out in Massachusetts, the US electoral equivalent of Labour losing Barnsley Central.
It is hard to believe in the land of socialised medicine, but America’s uninsured millions are just not the political scandal over there that they would be here.
Unsuccessful American presidents of recent history – Carter, two Bushes – may have left to the sound of a jeering populace, but it wasn’t their failure to reform healthcare that did it.
By contrast, President Obama, who chose to invest some of his stratospheric popularity in health reform, ends up paying a high political price, the full extent of which we may yet not have seen.
I was thinking about all this as I read Paul Corrigan’s recent opinion piece about the conflict between Andrew Lansley’s policies and politics. Paul is right, of course, that Lansley – who is now into his sixth year, and second party leader, on the health beat – has in the past talked up the virtues of freeing the health service from political control.
That promise, however, has now been downgraded.
The draft Tory health manifesto still talks about an “independent NHS board”, but describes its remit as being limited to allocating resources between different parts of the country. This then it seems is not to be Solomonesque band of worthies that, once upon a time, the Tories said they would summon to run the NHS with incorruptible judgement.
Indeed, the manifesto gives rather more prominence to a promise that “instead of bureaucratic accountability there will be democratic accountability” in the NHS. Sounds good, until you remember the rather depressing truth that the lofty ideal of democracy takes shape on earth in the form of politicians.
If you believe that healthcare is sufficiently important in people’s lives that the people’s tribunes should have a say in how it happens, then that means Andrew Lansley or Andy Burnham, or whomever else we choose, all over it.
To this extent, the Tory manifesto takes us further away from the idea of an “independent” NHS, rather than closer to it.
The trick is in defining the proper limits of political involvement. What may seem like a straightforward operational matter – to “rationalise” services onto a single site, for example (in other words, shut down the local A&E) becomes so political that one member of the current House of Commons owes his position there entirely to an issue of this kind.
Even an apparently medical decision – what drug to prescribe a patient, for example - gets political. The cost of the alternatives is these days a key factor, and as soon as money is involved, so are the politicians.
As Paul Corrigan observes, David Cameron claims that the decisions of the National Institute for Health and Clinical Excellence are “inherently technical”. On the contrary, they are all about money and are inherently political.
NICE, in fact, offers an interesting study in where the limits of political involvement should lie. Many people would agree that it is not the place of politicians to interfere in individual appraisals, no matter how loudly complains the Daily Mail. Patricia Hewitt’s trespass into the whole Herceptin issue made her roughly as popular with the NHS establishment as she is today with the Labour Party after ham-fistedly trying to depose Gordon Brown.
Arguably the opprobrium she attracted was (in both cases) no more than she deserved.
The Conservative opposition today is, in fact, maintaining a fairly impressive discipline against agitating for every drug blocked by NICE - despite there being obvious cheap political advantage from joining each chorus of outrage.
However, being virtuously neutral in individual cases should not mean hiding behind the facade of a belief that NICE is all about “objective evidence” or “inherently technical” judgements.
Since its creation, NICE has changed from being a source of benign advice on “clinical excellence” into a hard-nosed instrument for controlling the prices of drugs.
Nothing wrong with that, you might say, except that no elected politician ever gave it that mandate, still less answered for it in the House of Commons. On the contrary, when the Department of Health renegotiated drug price regulation with the pharma industry in 2008, it wrote into the deal that NICE would not control prices.
NICE’s principle weapon - a threshold of “cost-effectiveness” above which almost nothing passes - was not handed to it by a minister. Yet the setting of such a threshold defines what is or is not “affordable” to the NHS. It is, by any measure, a core decision of public policy.
In this case, however, the threshold emerged from an undocumented, unaccountable mash of economists and accountants. For many years NICE even denied, in the face of all the evidence, that they were operating a threshold policy at all. And a supine political establishment allowed them to get away with such behaviour.
My point is that if politicians want to use NICE to ration healthcare or control the price of drugs that is their right, but they ought to have the courage to say so and to answer for it through the democratic process.
It is unrealistic to expect those we elect to be disinterested in how the vast, taxpayer-supplied resources of the NHS are spent. We should even admire them for their involvement as they head towards the inevitable yells of outrage. Democracy demands nothing less.
Shame then that the obligation to set policy is so often misused, abused or not used at all.
Richard Marsh is a consultant with Fleishman-Hillard.