Are the Conservatives serious?BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4847 (Published 17 November 2009) Cite this as: BMJ 2009;339:b4847
- Nigel Hawkes, freelance journalist
How seriously should we be taking the Conservatives’ plans for the NHS? At one level, obviously, very seriously indeed: they could well be the policy of the next government, within six months or so.
But are their plans serious in the sense of being a well considered, carefully argued, and defensible set of policies that will make for a better NHS? That isn’t a given, as we saw when Labour was elected in 1997 with little more in its manifesto than a promise to cut waiting lists (a bit) and to abolish the Tories’ internal market. By coming in with such a weak hand, Labour wasted at least two years.
Given the financial constraints, there isn’t time for the Conservatives to ride a similar learning curve. So policy analysts have been poring over David Cameron’s speech to the Royal College of Pathologists on 2 November, the most comprehensive account yet of Conservative plans. Does it gel? Or is it simply a list of aspirations, contradictory promises, and wishful thinking?
As a political platform, it lacks oomph. There isn’t a single central idea in it that defines it as different, if you exclude the notion that it is possible to depoliticise the NHS by floating it off as a super-quango. This has never struck me as serious, in the sense defined above. You cannot spend more than £100bn a year of public money without being answerable for it in the House of Commons. And you cannot be answerable for something you no longer control.
That apart, maybe the only element in Tory policy that looks distinctive is the promise to abandon centrally imposed targets. They would be replaced by a combination of choice and outcome measures, if I have understood this aright. Patients would be given greater power to choose and better information on which to base that choice, such as survival rates and patient satisfaction. To try to trump this policy the government last week introduced the idea of replacing targets by a different measure: giving patients the right to treatment anywhere, including the private sector, if guaranteed waiting times were exceeded (BMJ 2009;339:b4699, doi:10.1136/bmj.b4699).
Neither of these seems to me a lever powerful enough to replace top-down targets. What has happened to the NHS in the past decade has largely been the result of targets. They work. Without them, everybody goes on much as before, nothing changes, and poor services remain poor. Of course, targets distort, but they also impose change.
What other force is strong enough to achieve that, especially in an NHS divorced, as the Tories intend, from ministerial nagging? Patient choice has, alas, proved a weak reed. The vast bulk of patients choose to be treated at local hospitals. Where they do choose to go somewhere else, there is little evidence that the choice is driven by clinical quality—a correlation between referrals outside the patient’s area and Healthcare Commission ratings has not been shown. Would more or better information change that? To believe so is an act of faith.
To improve commissioning, the Conservatives want to give true budgets to general practitioners rather than just indicative budgets, as the government has done. Few policies have fallen flatter than practice based commissioning, which even the government’s primary care tsar, David Colin-Thomé, has called “a corpse not for resuscitation.” (Having once endured an explanation from Dr Colin-Thomé about what practice based commissioning was supposed to achieve, I was surprised more by his honesty than by his message.)
But giving the money to GPs assumes they want it, and it also assumes that primary care trusts have failed as commissioners. And even if the rebirth of fundholding did unleash a fervour of creativity in commissioning, the Conservatives have already created roadblocks to prevent it. They are the party that has sworn to defend district general hospitals to the death, with a promise of a moratorium on hospital closures. You can either have creative commissioning, with lots of new services, or you can enshrine the current disposition of secondary care as immutable. You cannot have both.
Traditionally the Conservatives are hard on “waste,” but even here their promises cut both ways. They have promised not to make any reductions in NHS spending, which sends out all the wrong signals if they really mean to tackle waste. It is unclear, anyway, how much there is to discover. Mr Cameron expresses shock that the NHS spends £4.5bn (€5bn; $7.5bn) on administration, but as a proportion of a £100bn budget is that a lot? He is also “astonished” that nurses spend a million hours a week on paperwork, but given the number of nurses, that is only a few hours each. Where else is he going to get the data for the outcome measures he wants patients to have?
Cutting management costs by a third would release an annual saving of 2%, Andy McKeon of the Audit Commission has calculated, when what is needed to cope with the recession is 15-20%. So, from somewhere, whoever is in government after the election is going to have to find efficiency gains that far exceed anything possible by eliminating managers. If the Conservatives really do plan to preserve the status quo in secondary care, where are those gains to come from?
But if the Conservatives are incoherent, the government is no less so. Its “new” guarantees on choice already existed, unless I haven’t been paying attention. Its backtracking on competition in tendering for services is a betrayal of its own reforms and its last election manifesto, as Tony Blair’s health guru, Paul Corrigan, has forcefully pointed out.
Both major parties are muddled about what to do and how to do it. Choosing between them on the basis of their health policies is going to be an interesting challenge.
Cite this as: BMJ 2009;339:b4847