Andrew Lilico: We've been focused on the wrong sort of health reform

The Editors have made a little noise with their call for the health bill to be dropped.  My view on the matter remains much as it has been for many years: we've been focused upon the wrong sort of health reform.  Past governments, Major's, Blair's and now Cameron's have sought to enact supply-side reforms - by "supply-side" I mean they re-organised how healthcare is supplied.

There are, of course, good reasons for seeking supply-side reforms in any sector - management re-organisations and continuous improvement programmes to increase quality and reduce costs are valuable in any industry.  But they are of no interest to customers.  When I buy a car, I couldn't give two hoots what is the management structure of Ford or General motors, what productivity-enhancing techniques have been agreed with the unions, what are the flexible working practices, the mechanisms for establishing profit centres, the key performance indicators used to assess business lines and the like.  None of that matters to me one jot.  Of course, these things have an impact on me, in the sense that they affect how reliable and how costly is the car I buy.  But that is an indirect stake.  I have no direct stake in these matters at all.

Similarly, when there is some supply-side reorganisation in the health service, patients and potential patients have no direct stake in them at all.  They don't care about them "commercially", as it were, in their capacity as consumers.  They care about them only "politically" in the sense that they have views about the political cased offered on either side.  To put the matter more concisely, they care about such reforms as voters, but not as patients.

The other thing to note is that the political debates about such reforms involve a clash between the abstract and concrete.  Those favouring such reforms do so on the basis of abstractions such as "efficiency, "competition", and "choice".  Those opposing them do so mainly on the basis of concrete points such as "they will imply the closure of our local A & E unit".  In terms of giving such reforms a face, those in favour are fat capitalists with big cigars; those against are the nice nurses that helped cure my little Billy when he had that nasty chest problem last winter.

But a demand-side reform involves a completely different clash.  With a demand-side reform then patients experience concrete visible changes, creating at least some clear winners, and many of the arguments against must appeal t abstractions such as "the public service ethos" or "the principle of the NHS".

How so?  What do I mean by a "demand-side reform"?  A demand-side reform is one that does not directly affect how healthcare is supplied, but does affect how it is demanded.  I have in mind two such reforms that could be implemented fairly quickly and straightforwardly.  The first is to create a property right in healthcare entitlement.  What you get under the NHS should be something you own, not something you get according to the whim of the moment.  Each year the Health Secretary should produce before Parliament a statement of what care people are legally entitled to (across the NHS - no "postcode lottery" or "local priorities"), and Parliament should have a setpiece debate in which amendments are proposed and the entitlement is approved.  This entitlement would specify matters such as how long was the maximum people should wait for different categories of treatment, what standard of hospital care they were entitled to (e.g. when a room to themselves, what sort of food, whether television and what sort, the required cleanliness quality kitemark for the wards, and so on), what medicines would be available to treat various diseases, and so on.

Then, if you didn't get the level of healthcare you owned a legal right (a property right) to, you would not write to your MP.  You would write to your lawyer.

I would recommend introducing this part (Part A) of the reform and securing it in place for a couple of years before moving on to a Part B of the first reform - though Part B could be debated and agreed at the same time as Part A.  In Part B of the first reform, we would identify on everyone's pay slip, and in an annual statement letter, an amount they paid for their NHS healthcare.  This would secure the notion of NHS healthcare being something people owned - they would see an amount of money they had paid for it, and thus feel a direct stake.  Those on benefits would receive notice of a specific "NHS benefit" that paid for their healthcare policy.

Once that were securely in place, we could, as a separate matter in principle, to be voted on or rejected separately, a second reform.  This would allow people to purchase, from the NHS, more extensive healthcare entitlements than the standard NHS healthcare property right.  For example, it might specify shorter waiting lists or higher quality food or additional medicines.  I have in mind for people to be entitled to purchase extra extending policies from the NHS, not simply to pay extra at the time.  The principle is already established in the NHS that patients are allowed to pay extra for additional medicines, not offered under the standard NHS contract.  This proposal would simply generalise that already-established principle.

Note again why these reforms, though doubtless controversial in their way, would involve different kinds of controversy from supply-side reforms.  First, they would have direct, tangible implications for patients, so that people had opinions as consumers, not simply as voters.  That would mean there would be much more active agitation on behalf of the reforms from certain patient groups than ever happens for supply-side reforms - that could make all the difference in a political scrap.  Secondly, we would reverse the abstract-vs-concrete play-off.  Whereas supply-side reforms rely upon persuading people that abstractions (e.g. "choice", "efficiency") are more important than concrete issues (e.g. my local A & E shutting down), demand-side reforms relying upon concrete points ("I am entitled to precisely this healthcare" or "I could buy my gran a shorter waiting-list entitlement") defeating abstractions (e.g. "the public service ethos").

Ditch the supply-side-driven reform programme.  It involves political pain for relatively little tangible benefit.  Instead, focus upon demand-side reforms, and in due course the supply side will take care of itself.