The view from abroad

Ross McL Wilson

Director
NSH Centre for Healthcare Improvement, New South Wales, Australia

The Australian healthcare improvement expert Ross McL Wilson thinks that Labour�s plan to reward high performing hospitals could be as important in the long term as the Tories� plan to channel more money into the private sector

When British voters go to the polls in May they will be able to choose between the parties on the basis of health policy posted on their websites. My discussion is based on the documents available on those sites and does not make any assessment of the likelihood of implementation of these policies.

All the three main parties presume that the current clinical performance in the NHS can be improved, although Labour asserts that current performance has already improved substantially during its tenure. Its claims are supported by data indicating better clinical outcomes for cancer and heart attack patients, as well as data indicating a significant increase in capacity through funding and workforce increases.

All the parties seem to ignore the longer term question of whether the NHS model of free universal access is in fact financially sustainable. This seems a particularly relevant question given that the cost of delivering health care in developed countries is rising much faster than gross domestic product in those countries.

All the parties aspire to more involvement of the private sector in delivering health services in a way that should increase capacity; but marked differences in their approaches will have implications for cost, choice, and equity. Undoubtedly Conservative health policy would lead to a major flow of public money to private providers with the party�s promise to contribute 50% of the NHS cost of an operation to an independent provider of that service.

Although all the parties make a commitment to patients� choice, their definition of the term varies. It could mean choice of GP, of specialist or procedural doctor, of hospital, and of public or independent provider. None of the parties properly addresses how patients will obtain enough information to make informed choices.

Another aspect of choice that is explicitly included in Labour policy is that higher performing facilities will have a higher income as a result of more patients choosing their care. This represents a fundamental shift from current funding methods that could be as significant as the Tory use of public funds for the independent sector.

The Tories and Liberal Democrats promise to reduce red tape in managing the health system and to undo some recent structural changes, such as strategic health authorities in the case of the Tories. Of much more strategic importance are the promised abolition of centrally driven targets by the two larger parties and the proposal for local commissioning of care by the Liberal Democrats. Both these proposals could lead to considerable geographical variation in clinical care and outcomes and hence could threaten equity of care (and its transparency) across the country. The unpopular aspects of targets deserve a more sophisticated discussion: are they a bad idea or a good idea whose implementation could be improved?

None of the parties really successfully integrates the government policies that affect the determinants of health, such as education, environment, and socioeconomic issues, as well as public health policy. It is encouraging that the Tories and the Liberal Democrats specifically address public health policy and mechanisms of delivery, and the Liberal Democrats take a strong line on smoking in public places. All the parties have started to address needs for personal care for elderly people and dependent members of our society, with all mentioning the Royal Commission on Long Term Care. This is a huge issue that the Liberal Democrats have directly addressed with their promise to provide free personal care for elderly people, funded by an increase in tax on incomes over ₤100 000. The Tory approach involves elderly people paying the cost of the first three years of care themselves, after which they get free care (with means testing for people unable to participate in the scheme).

In summary, there are clear choices if we start from the assumption that all the promises can and will be implemented. Access to health services is most explicitly addressed by Labour. Equity is at risk from all parties, but mostly from the policies of the Tories and the Liberal Democrats. Choice is espoused by all parties but is best addressed in the Labour party�s policy. The necessary capacity in the workforce is most clearly promised by Labour, but aspects at the levels of facilities and diagnostic testing are addressed by the other two parties. Long term personal care is best addressed by the Liberal Democrats and Conservatives, though they offer different funding mechanisms.