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A Government worth having: Health policy

In the latest of our 'A Government Worth Having' series we look at health policy.  Top-up payments, patients being able to choose their healthcare commissioner and strong Matron-like figures are just three of the ideas suggested below. We've previously looked at new directions on economic and foreign policy as part of this series.

Simon Chapman: "The next Conservative government will have to face up to the overwhelming pressures that the NHS faces: demographics, dementia, obesity, technological and treatment advances, and rising expectations. These are already upon us and will only increase.  We will spend over £100 million on the NHS next year. That is highly political. At the moment there is no direct democratic accountability. An unelected NHS Board won’t make that better.  Tax funds are already insufficient to meet demand, although there is undoubtedly room for more effective spending. Decisions about priorities and rationing should be brought as close as possible to the people affected by them. Personal budgets (vouchers) and locally elected health boards are the levers. Co-payments are also inevitable.  Health reform must become a first term priority. The public are ready for honesty and candour – certainly more eager than the current Westminster consensus is prepared to allow.  We need to close the gap between health and social care. Joint commissioning and pooling budgets is one way forward. Bringing both under the strategic responsibility of one department is another: how about changing Andrew Lansley’s job title to Shadow Secretary of State for Health and Social Care? Before anyone shouts, I know that Local Authorities are responsible for social care, but they could be made accountable to a different Secretary of State.  Finally, if we want to improve confidence in the NHS, we need to make end of life care more of a priority. Over half of all deaths occur in NHS hospitals, and over half of all complaints about NHS hospitals concern dying and bereavement care. Hospices are often superb, but they cannot provide a complete answer."

Nadine Dorries MP: "I trained in an NHS which was run with consideration and discipline. The first concern of any nurse was to reassure her patient. To be aware that a hospital was a scary place, that we knew most things weren’t going to hurt and would probably be ok, but that the patient didn’t.  As a night nurse I spent many an hour sat on the edge of the bed of a sleepless worried patient, with tea and toast, listening to the dark worries keeping my patient awake. How long will I be off work? Will this affect my life?  I worked on wards which had dedicated ward cleaners and Auxiliary nurses who took pride in their wards and were in silent competition with the cleaner on every other ward in the hospital.  Nurses never wore their uniform outside of the hospital. A plastic apron was donned every time you treated a patient. Hand washing was automatic, cleanliness imbued throughout every aspect of the ward day. Visitors limited in order that a ward could be properly cleaned. There was no MRSA and poorly patients got the rest they needed.  Matron ruled, Doctors trembled, no nurse failed to give anything but her best. Everyone was accountable via a very clear line of command. Everyone knew who was responsible for what and when.  The NHS of today is driven by targets and process, not patients. Sometimes it feels as though patients are an inconvenience, lying in the way of clipboards and men in suits.  We need to make healthcare delivery totally patient focused. By remembering patients are there because they are vulnerable and ill and by giving patients respect and putting them at the top of the NHS agenda, by removing business suits and replacing with caring  uniforms, we may just begin to see a shift of priorities."

Andrew Haldenby, Director of Reform: "The issue of top-up payments for NHS care is waiting to be grasped by Government or Opposition.  This year a series of cases have proved that the existing rules are a classic example of how bureaucratic inflexibility can become cruelty.  Currently Norman Lamb is the only frontbencher spokesman who has argued for change bravely and positively rather than reluctantly.  A majority of patients and doctors are in favour.  Allowing patients to top up would be directly in line with the modern Conservative ideas of social responsibility and the post-bureaucratic age."

Dr Rachel Joyce, our PPC for Harrow West and a former PCT Director: "The NHS internal market failed because the “commissioner” is a poor proxy for the patient. Bureaucratic rules and targets make meaningful clinical and patient involvement in commissioning impossible, leaving managers to make decisions on what services are provided for patients.   “Successful commissioning” in the NHS is judged by performance against targets and rules. Success, in contrast, as judged by a patient is on good clinical outcomes and convenience.  Therefore much of the increase in health spending has been wasted on the administration of targets, resulting in high comparative costs but poor outcomes.  Patients should be able to choose who commissions their care. If GPs could choose their commissioning organisation, then patients could choose their GP practice (and therefore their commissioner) on the basis of outcomes. An independent NHS Board could be responsible for monitoring outcomes and quality via agreed indicators.  Patient choice of commissioner would drive down unnecessary bureaucracy and inefficient care, and would enable the NHS to provide comprehensive care that is not only efficient, but has world-class outcomes. "

Andrew Haldenby and Lucy Parsons: Higher spending does not equal better services

Andrew Haldenby is Reform’s Director and Lucy Parsons is Reform’s Economics Research Officer.

What should we make of Gordon Brown’s call this morning for a new “stage” in the Government’s policy on public services reform?  Writing in the Financial Times, the Prime Minister identifies two new goals: “no tolerance of under-performance” and “empowering the users of services themselves”.  He ends by repeating the call for “investment and reform” that has underpinned the Government’s policy since the first Comprehensive Spending Review in 1998.

We should first be pleased that the Government is committed to reform.  The message from today’s Reform report – A lost decade: Counting the opportunity cost of public spending 1999-2008 – is that such a commitment is essential.  So many social trends point towards public services with more individual and less government input: greater consumerism, prosperity, educational attainment, connectivity, for example.  At the same time greater globalisation will make it much harder for governments to solve problems with higher taxes.  As Sir Gus O’Donnell, the Cabinet Secretary, said recently:

“We are going to have real problems.  Because of the competitive nature of globalisation, it is going to be hard to put tax rates up.  The increasing demand for spending more ... means that we are going to have to do more with less.” 

Second, we could ask the Prime Minister to look again at the progress so far.  In his article he says that the Government is about to launch “the third stage” of the reform programme.  Stage one was extra spending, to repair under-investment.  Stage two was on a “greater diversity of providers and more choice”.

Today’s Reform report suggests that there is still much to do if those stages are to be completed (let alone left behind).  Spending has certainly been increased but as a flash flood rather than a planned irrigation.  Its greatest impact has been to increase the costs of existing programmes rather than transform them.  Where it has happened, reform has been marginal and uncertain. 

Andrew Haldenby and Helen Rainbow: Reform is the only way to unlock value in the NHS budget

Andrew Haldenby is Director of Reform and Helen Rainbow is Reform’s Senior Research Officer.  The report “NHS reform: national mantra, not local reality” is available at www.reform.co.uk.

To say that the health service is big and complex is an understatement – it has the biggest budget in government (£90 billion in England alone and counting), a staff of 1.35 million (5 per cent of the entire workforce) and more political issues than any Secretary of State for Health can cope with.  But today’s annual NHS report by the think tank Reform suggests that the challenge of health policy reduces down to something manageable: redesign and improve services within a ceiling of 9-10 per cent of GDP.

There is a massive need for services to improve.  The quality of the NHS and the outcomes that it delivers remain behind other peer group countries.  We identify a “cradle-to-grave gap” – from infant mortality, to maternity services, to chronic care, to life expectancy.

This means a need for new investment in many areas – within a restricted level of funding.  Taxpayer funding is (and should be) limited for the next five years given the immediate pressures of a slowing economy and longer term concerns over economic competitiveness.  Greater productivity is the answer to this strategic challenge.

Andrew Haldenby and Laura Kounine: Michael Gove should fund but not manage the nation's schools

Andrew Haldenby is Reform’s Director, and Laura Kounine is Reform’s Education Research Officer.

Last week's Conservative Green Paper has divided opinion.  We can discount the hostile criticism from most of the teaching unions; their opposition to the very principle of parental choice is steadily pushing them out of the mainstream of the education debate.  The real debate is between those commentators who concluded that the proposals would indeed deliver a revolution in schooling – and those who were concerned that the methods of reform might defeat its admirable intentions.  Who is right?

The first part of the paper set out the principles of new Conservative thinking on the curriculum and school management.  It proposed some adjustments to the compulsory requirements on schools, for example a phonics based reading test at six instead of a general literacy test at seven and compulsory setting in academic subjects.   Otherwise it claimed a shift away from central regulation.  Central government would only publish best practice, in very considerable detail, including the use of credits and debits for discipline and the optimal length of lunch breaks.

Anne McElvoy was surprised at this:

"Politicians who claim one day to 'set schools free' and 'trust the professionals', only to slide into the minutiae of how good heads do their jobs or whether children stand or sit to say good morning are inviting puzzlement."

We should share her concern.  The history of the last twenty years of education reform - begun by a Conservative government in 1988, and based on ever stronger intervention into the curriculum and teaching methods – is that governments are not the best judge of what works in schools.  In good schools, headteachers spend hours per week protecting their staff from advice on so-called good practice.  The Green Paper proposes an even greater intrusion than the most absurd of the Government's current directives – that on hospital cleaning, which reminds hospital staff to do “wall-washing” and “floor scrubbing”.  This is not the end to top down centralisation for which David Cameron rightly argues in the paper's introduction.

Andrew Haldenby: Spending more and more on health and pensions adds to the already heavy burden our young people have to bear

Andrew Haldenby, Director of Reform, argues that the Government needs an approach that protects young people through spending control, realistic taxation and improved education

In many respects, 2007 has been the year in which the IPOD generation (Insecure, Pressurised, Over-taxed and Debt-ridden) have taken centre stage in global politics, according to Reform’s latest report – Class of 2007: Inaction sinks the IPOD generation – published today.  Much of the world has finally recognised the immense pressures that demographic changes and tight public finances will impose upon young people.  In simple terms, fiscal policy decisions today matter for the taxpayers of tomorrow.  The developed world is facing an unprecedented demographic change, as the “baby boomer” generation moves into retirement and the ratio of working age people to retired people falls sharply.  Politicians will face temptations to increase entitlements to healthcare and pensions; but these will place an unfair burden on the smaller numbers of young people.

Led by the US, governments now talk of fiscal restraint; of reductions in the tax burden; and of guarding young people’s priorities.  The testimony of Ben Bernanke, the Chairman of the Federal Reserve, to the Senate in January 2007 is a must-read (it is included as an appendix to the report). He said that the rising costs of healthcare and pensions demand “early and meaningful action”; without which, “the US economy could be seriously weakened, with future generations bearing much of the cost”.  That action should include sustained efforts over many years to control public spending; new fiscal rules, including targets measuring public spending as a ratio of GDP; and accurate estimates of the unfunded costs of pensions and healthcare programmes.

Andrew Haldenby: Brown must not be "the heir to Blair"

Andrew Haldenby, Director of Reform, asks if Brown really will change sufficiently in his approach to public services.

In his first speech as Prime Minister, Gordon Brown defined “change” as the mission of his premiership.  To quote the key paragraph:

“I have heard the need for change: change in our NHS; change in our schools; change with affordable housing; change to build trust in government; change to protect and extend the British way of life.”

He is right to do so.  Reform’s latest report – "Key policy lessons of the “Blair years” for future governments", released today – concludes that future governments should make a decisive break from the policies of the past decade if the UK is to overcome its deep-set problems of economic and social division.

Tony Blair’s valedictory speeches argued that his policies had delivered a Britain that is better across the board, and a public sector which is focused upon choice, competition, decentralisation and markets.  Some Conservatives have agreed with him, seeking to take his side against Gordon Brown.

Andrew Haldenby: The Growth Rule

Andrew Haldenby is Director of Reform - which celebrates its fifth birthday today. The report "UK growth and opportunity, the need for a fundamental reassessment" is available online.

The most important political events of this Parliament are now only three or four months away. By August Tony Blair is expected to have stood down and Gordon Brown to have launched the Comprehensive Spending Review (CSR) which will be this Parliament’s defining policy statement.

The discussion around both events will centre on the best means for the UK to meet the key challenges of the next decade. Reform’s latest report – UK growth and opportunity, the need for a fundamental reassessment, published today – shows that our success as a country will rest above all on low taxation and education reform.

We agree with recent Treasury analysis that the key challenges for the next ten years are globalisation, technological change and an ageing population. Globalisation and an ageing population require low taxation, to meet international competition and to lift the economic pressure on young people (whom Reform has termed the IPOD generation – insecure, pressurised, over-taxed and debt-ridden). Technological change requires quality in education and training. The latest US research indicates that skill levels are already the key reason that different groups enjoy different levels of income growth.

Put simply, low taxation will strengthen economic growth and education reform will widen opportunity. These are the minimum requirements of a modern political agenda.