For all the rhetoric about the cupboard being bare and an age of austerity the reluctance of the Tory leadership to make difficult decisions is becoming worrying

Yesterday evening I set out the five reasons why David Cameron can win the NHS debate for the Conservatives.  But that's entirely a political victory.  The Tory leadership has offered every support to the professionals within the NHS and is willing to cut deeply into other public sector budgets in order to achieve this victory.  If the Conservatives couldn't at least neutralise the NHS issue on the back of this breaking-the-bank spending (opposed by 63% of Tory members) then it would be a pretty poor performance.

Speaking in Bolton later today David Cameron will say "We've earned the right to call ourselves the party of the NHS."  "Earned" may not be quite the right word.  The fiscal implications of the Tories' NHS spending pledge are enormous.  Mr Cameron will use his Bolton speech to explain why increases in NHS spending are justified:

"The debt crisis means we need a new approach to public spending, to make sure we get more for less.  But in the NHS, even that won’t do.  The pressures on healthcare spending – from an ageing population, from medical advances, and from rising expectations – are simply too great... Spending on the NHS cannot stand still, because standing still would be taking a step backwards.  That is why we have pledged real-terms increases in NHS spending - unlike Labour – a fact which, to put it mildly, takes the wind out of their point-scoring sails."

The Conservative leader will insist that Conservatives will reform the NHS to deliver more effective use of the current investment in the NHS:

"We need reform on both sides of the cost equation.  We have to make the supply of healthcare more efficient, and we must also do something about the increase in demand for healthcare.  The first set of reforms is all about choice, competition, and a focus on outcomes not targets, while the second is about public health.  But I believe we in this Party have shown that we now have the credentials to achieve both. The end of top-down targets and the introduction of transparency - the collection and publication of health outcome information - will give people the power to hold the professionals to account.  The power of competition – the opening up of the NHS to new providers – will bring innovation and investment.  And the power of choice – the ability for people to control what service they get – will lead to better quality care.  These reforms will create a more user-friendly and efficient NHS that both meets patient expectations and restores professional responsibility.”

I'm still unpersuaded that the Tories have done all they can to reduce NHS costs.  We should be getting a lot more reform for the extra spending.  Yesterday we learnt that absenteeism and sickness among the NHS staff was costing £1.7bn-a-year.  Performance between hospitals with the same funding is very variable.  Productivity in the NHS has fallen by 4.3% since 1997.  Staff costs have soared in the NHS - GP pay now exceeds £100,00pa - as Labour lost control of public sector pay more widely.  Spending on bureaucracy within Primary Care Trusts has doubled in four years.  The number of staff dedicated to controversial counselling and ineffective drug treatment programmes has risen sharply within general practice.  Difficult decisions are also being ducked on cancer drugs that can prolong life by four to eight weeks but cost £10,000 to £15,000 in the process.  Read this Telegraph piece by Andrew Haldenby of the Reform think tank for more on private sector/ public sector efficiency comparisons.

For all the rhetoric about the cupboard being bare and an age of austerity the reluctance of the Tory leadership to make difficult decisions is becoming worrying.

Tim Montgomerie

10.30am: Read the full text of David Cameron's speech.