Mixed reaction to new Tory health tactics

The Telegraph and The Sun lead the criticism of David Cameron's new NHS tactics this morning.  Much more positive is The Guardian (perhaps encouraged by Polly Toynbee - who welcomed David Cameron's new position on last night's World Tonight programme).

The Telegraph: "Mr Cameron's speech was disappointing because in it he ruled out a great many options for the future of healthcare in Britain that were, at the very least, worth considering. Conservatives were told that their new leader would not rush into formulating policies, but that the party under his command would take time to examine all the choices available.  Instead, Mr Cameron shut down much of the debate yesterday by renouncing the "health passports" policy on which he fought last year's election. This would have helped huge numbers of patients on NHS waiting lists by offering them the chance of going private for their operations. In the same speech, Mr Cameron rejected Margaret Thatcher's idea of offering tax relief on medical insurance premiums."

The Sun:

"The Tory masterplan for saving the NHS is to maintain the status quo, with a minor adjustment or two.  No promise of major reform. No mention of how the Tories would stop billions of Pounds of public money disappearing into the void.  Quite the contrary, in fact. Tory plans to expand the NHS and make it more efficient will not be cheap, Cameron pledged — to reassure us that they take the matter seriously.  Where will all this new money come from? Taxpayers are at the limit of their bank balances and their tolerance... Tony Blair has spent eight years promising NHS reform but all the extra money has achieved too little.  It would be healthy for Britain if the Tories offered the choice of something different at the next election."

The Times: "Voters were understandably confused at the last election when the Tories promised, on the one hand, that they could improve the NHS “for all” and, on the other, suggested that some might want financial help to escape it. This was a policy that it did not take much effort to demonise. Those attacks were often gross distortions of the truth, but they exploited the sense that the Conservatives were ambivalent about equitable treatment."

The Guardian: "One of the attractions of Mr Cameron is that he realises that high levels of public welfare provision do indeed require high levels of taxation and no attempt to magic away expenditure by cutting so-called waste can cover the gap. Yesterday he pressed on, cancelling the Tories' election promise to fund part of the cost of private medical care, in an intelligent speech to the King's Fund that made it explicitly clear that he sees the NHS as more than an enabling service for independent healthcare providers to reach consumers. The speech was notable for what it did not contain: no routine bashing of health managers, no declaration that he would extend the market to community health programmes as the government proposed briefly last year and no wriggle room to introduce NHS funding through social insurance."

Stephen Pollard, The Times:

"In nailing his colours so firmly to an exclusively tax-funded NHS mast, Mr Cameron is making a huge mistake, both politically and for the good of the country. Labour’s policy of spending as much money as possible and fiddling with the system is a form of controlled experiment to discover if that is indeed all that is needed. The answer is now becoming clear: it isn’t.  For years, those of us who have argued that it is the very notion of an entirely tax-funded system that is the real problem were dismissed as ideologues and lunatics. Now, with the evidence showing that the NHS cannot deliver even with massive funding, real reform has at last entered the realms of acceptable debate."

Comments

[Jonathan Sheppard]

I think The Times claims Liam Fox is Party Chairman -

"The main victim of his (Cameron’s) new policy is the abandonment of the patient passport, invented by Liam Fox, now Tory Party Chairman"

Has anyone told Francis?

[Richard]

So we have The Daily Telegraph, The Sun and The Times rubishing David Cameron's policy on the NHS and we have The Guardian and in particular Polly Toynbee praising the policy!

[James Hellyer]

It's interesting that both News International titles have come down against Cameron's decision, repeating Stelzer's phrase "a choice and not an echo", while the Guardian welcomes his abject surrender to Blair and Brown's form of socialism-lite.

[Mike Christie]

Now I'm worried. Cameron has just condemned us to keeping the method of health funding favoured by Cuba, North Korea and er...

Cameron was adamant throughout his campaign for the leadership, and is still adamant in some policy areas, that all options must be explored and no ideas are off-limits.

However, on one of the most fundamental areas of public service policy he rules out, almost on a whim, the method of funding used in one form or another by most of the developed world.

So it's OK for Zak Goldsmith to spend 18 months pontificating whether we should support organic farming, but the future of the NHS is decided off the cuff?!?

[kim ll sungs puzzled and depressed grandson]

Conservative principal or not?

Hypothetical

1. Rich man requiring operation waits one month, goes private. Is OK
2. Poor man requiring operation waits 1 month. Cant pay. Has operation 3 months later. Life expectancy reduced by 2 years as a result. Dies as a result of delay.

Personally speaking if the NHS is reformed so it works efficiently which as far as I can work out, is DC's aim, then I am with the NHS available to all with no opt outs category.

How can you put a price on your life?

[Michael McGowan]

It is hard to dissent from one word of Stephen Pollard's critical article, and it is equally hard to dismiss Pollard as instinctively anti-Cameron.

[Mike Christie]

"Personally speaking if the NHS is reformed so it works efficiently which as far as I can work out, is DC's aim, then I am with the NHS available to all with no opt outs category"

Can the NHS in its current form be reformed and made efficient? That is the key issue.

Most of the developed world has abandoned the monolithic tax funded health service in favour of an insurance based system. We see such systems working fantastically well all over Europe, yet we have just rejected the idea out of hand.

Conservatives should be driving the debate, winning public opinion over.

Just how do you reform a vast behemoth like the NHS so it works properly? An aging population and an ever-increasing range of treatments and equipment will see more and more demand being placed on the NHS. If its struggling to cope now, what will it be like in another ten years?

We should be arguing the case for fundamental reforms, not yet more tinkering around the edges. If the UK's way of doing things is so great why is it only third-world marxist dictatorships that emulate us?

We should be comparing the NHS to all those other great examples of state-run monopolies, British Leyland et. al.

The public are used to the fact that the government couldn't run a car company, or an airline, or a telecoms provider. Why should it be any better at running a healthcare provider? The truth is that it isn't, and the sooner that discussion is had the better it will be for EVERYBODY in the country.

[Wat Tyler]

Our hopes were never high. But this is bad, bad, bad.

Social insurance based reform looks by far the most realistic way forward for the NHS, and he's just ruled it out. Just like that.

Whether he means to or not, what DC is doing here is conniving in the continued growth of two-tier healthcare, with excellent private medicine for those that can pay, and a dysfunctional, managerialist, dangerous morass for everyone else.

I feel ashamed for him.

[Matthew]

I really think the newspapers are way out of tune with the public on this issue. However, obviously a problem for Cameron is that most of the people who support the NHS through thick and thin are die-hard Labour voters, who would never vote Tory, especially not for a toff Tory, no matter how much they agree with him. So being so unequivocal this early might be an error. On the other hand, the speech was excellent and it stops Labour focusing on the issue as a distraction from all else. Cameron has focused on all these 'distraction' policies, like immigration, like the NHS, like massive tax cuts=massive public service cuts; anyone who remembers that fool John Reid going on TV all the time over the election campaign and trying to bash us will remember how distracting they have been. Cameron has found the way to beat the New Labour machine. Hopefully, once he's beaten it off, some discussion about the NHS can take place, perhaps while we're IN government. Now there's a thought.

[Mike Christie]

"Hopefully, once he's beaten it off, some discussion about the NHS can take place, perhaps while we're IN government. Now there's a thought."

The problem there is that if we have given categoric assurances not to make fundamental changes to the NHS, then we either break our pledges or stick to the status quo. Either way we lose. The radical reforms will have to wait to a hypothetical 2nd term. Do we really want to have to wait another 10 years for the reforms that healthcare funding so badly needs?

We keep hearing how the public quite liked most of our policies, until they found out they were Tory policies. So why are they all being jetissoned or watered down?

I know it is early days, but after months of saying that he would make no firm policy commitments until things had been thought through and properly discussed, we are now getting some very disturbing, sweeping decisions that stifle whole areas of necessary debate.

[a-tracy]

Wat - I don't understand you comment. NI contributions are social insurance payments, the fact this money is then not spent wisely is the issue surely. I've no objection to this money being used in private hospitals as long as the price is competitive and let's face it the NHS doesn't price up it's procedures properly it just overspends and doesn't declare properly.

An employee and an employer pays a considerable amount now, I've always thought half towards the state pension and half toward the national heath insurance scheme.

Some of the problems that I see are too much self-employment reducing NI contributions, too much state reliance, people living much longer than anticipated in the 1940's who don't have to pay their national insurance stamp over 60/65 many of whom wouldn't be able to afford it on the low state pension.

[Rob]

Seriously what is Cameron thinking?

Again it is overdue that the Conservatives should put focus on the issue of Healthcare. But what is the man thinking? Cameron should be saying that the Conservative party is and always has been committed to the greatest healthcare for everyone, however the NHS is not the best way of providing the best healthcare for the most number of people. He talks of the care of NHS doctors and nurses and ambulance drivers etc. but why cant he say, that these people work hard and are caring, despite the NHS, not because of it. That we must radically reform healthcare in this country to free the doctors and nurses so they can do their jobs even better.

At the very least he shouldnt rule out any significant changes to the NHS just to have a good first 100 days with the left wing media.

[James Hellyer]

"I don't understand you comment. NI contributions are social insurance payments"

No, they're an income tax. Calling it insurance doesn't make it insurance!

On the continent, social insurance is often collected by non-governmental body and is not managed by their equivalent of the Treasury.

[Oberon Houston]

I would analyse the situation as this:

Cameron has made a policy pledge to allay the fears of a huge number of voters that the next Conservative Government will retain a publicly funded NHS. In return we can re-introduce independence for hospitals and the internal market to make the service more efficient i.e. provide better value for taxpayers and better care for users.

Once this reform is embedded and established, and popularised, then we can worry about selling the next reform to the electorate, it will take one term to complete the first anyway – and with his pledge, we will get elected and be allowed to do it. The alternative is a radical agenda and another 5 years in opposition – i.e. a waste of time.

Sit back, relax, he is doing the exactly the right thing.

[William Norton]

Any one remember Red Ted Knight, leader (I think) of Lambeth in the 1980s? Told that Maggie's policies were popular (probably sale of council houses, but I forget the exact detail) he replied: COMRADES, WE MUST NOT COMPROMISE WITH THE ELECTORATE.

Older bloggers will recall that Red Ted did not become Prime Minister.

We've got ourselves in a classic Catch 22:
(1) We know the current NHS structure is not really working.
(2) The voters know that the current NHS structure isn't really working.
(3) The voters however rather like the idea behind the NHS - now the Queen Mother is dead it's replaced her in the popular psyche. Blair has picked up on this - recall that when challenged as to what he understood by being a socialist he replied that it meant things like the NHS (truer than he probably meant).
(4) More importantly, voters have a residual fear that under a more exciting, efficient etc etc health system they'll be the ones who lose out. They'd prefer a system where everyone hangs together over a system where "the rich" can "jump the queue".
(5) Making the case for a better more exciting NHS is therefore more principled but a vote-loser - and it could be the one thing which turns a General Election.

My guess is that like privatisation of the utilities, systemic reform of the NHS will require advocacy from office and Fabian tactics (pun intended). It's not like union reform where we can make the running from opposition (the NHS hasn't had its equivalent of the Winter of Discontent). Cameron has decided to secure his flank before picking a better ground on which to fight Brown in 2009/2010.

The Patients Passport was a good idea - except that I could never find anyone who knew how it would really operate in practice. When I tried to cost it out, I found a £4 billion spread between different interpretations of the policy and nobody sure which one was right. More work needed.

Arguments about health care structure are very similar to those about education structure. The better strategy is to win the argument over education (which for some reason has never attracted the same quasi-religious devotion in this country; probably something to do with summer holidays for teachers but not nurses) and then in office copy over education reforms into health care.

[William Norton]

I see Oberon has beaten me to it, and more succinctly.

[a-tracy]

No, they're an income tax. Calling it insurance doesn't make it insurance!

I understand what you're saying James and it also helps when you need to add 2% onto income tax to call it National Insurance! None the less the majority of people I work with believe their and their employer NI payments are specifically for health, benefits and state pensions.

[Michael McGowan]

If I follow Oberon's thinking correctly, then he is saying that DC will "talk left but act right" once in office. Firstly, I don't believe it: there is nothing in the fifty-year track record of the One Nation patrician wing of the Tory Party to suggest that this will be true. Quite the reverse: see David Green's article in today's Telegraph. Secondly, even if I suspend my disbelief, on the timetable you have sketched out, we will be waiting a minimum of ten years for improvements to the NHS which the "Times" today rightly described as "insipid incrementalism". Long before then Labour will have boxed DC into a corner by spooking the electorate with stories about him being a wolf in sheep's clothing.

[Geoff]

The moment that Polly Toynbee agrees with any policy we put forward then I start to get nervous. If Micheal and I understand Oberon the same way then apparently DC is supposed to be some sort of Trojan Horse - people who have actually got principles and beliefs will suddenly appear in our first Cabinet, the nice and smiley but shallow voter-friendly wets will be taken out and shot, and we'll have gained a proper Conservative government by stealth?

Really? Is that the best conspiracy theory on the market? Good grief. Listen to what DC is saying and take it literally. What we voted for is what we are going to get. Like it or not.

[Oberon Houston]

I'm not saying that Michael. Read again about 1st Term objectives.

If introducing an internal market into the NHS, or giving independence to hospitals was 'left', then Brown would not have torn it all down in 1997.

The political journalists attacking Cameron over this are showing either just how unqualified they are for the jobs they have, of how thick they think we are.

I am amazed at the lack of quality centre-right political journalists and commentators that have got jobs. For every one bed-blocking a position, there are ten better ones who would love their position. Editors of these papers should be considering this carefully, and if not, the owners should be considering their Editors carefully.

Despite the fact that many on this blog attack the BBC, I think they provide pretty good analysis, and the FT is usually excellent. The Times is the best of the poor bunch, and the Sunday Times is usually very good.

[James Hellyer]

"I'm not saying that Michael. Read again about 1st Term objectives."

You're talking about supply side reforms. They have been shown to be simply not enough to improve services. When an NHS Trust can't even manage a cleaning contract, it's hard to accept it can successfully manage any more serious contracts. Allowing trusts more autonomy has similarly not done anything to control their spending patterns.

[Michael McGowan]

Put another way, James, all this talk about giving hospitals autonomy and introducing an internal market is meaningless verbiage unless patients have the right to choose between providers and the money to back that choice. They don't now (because that would depoliticise the NHS which Labour doesn't want to do). They didn't really under John Major and it looks as if they won't under DC. The one bright spot on the horizon is that the ECJ is busy developing the legal right to go to other European countries for better healthcare and to force the NHS to pay for it. Clearly the ECJ, that the bastion of right-wing thinking, is more progressive than the spineless Tory Party. Unlike Cameron, it recognises that so-called "taxpayers' money" is in fact your money and you are entitled to value for it.

[Mike Christie]

'Unlike Cameron, it recognises that so-called "taxpayers' money" is in fact your money and you are entitled to value for it.'

Here here, personally I'd like to do away the term 'government spending' and 'public spending' and replace it with 'taxpayer spending' just to reinforce the notion of whose money it is getting shovelled into these black holes.

Lets remind people that when Blair says 'we are spending more money than ever on...' what he really means is 'we have decided to spend more of your money than ever on... whether you like it or not'

[James Hellyer]

Indeed. Supply side management - even with autonomy - just focusses services on const control. The problem with this is that a patient represents a cost(witness the sudden spate of NHS trusts cancelling operations because their year end is almost upon them). By contrast, a demand managed system seems a patient representing income, which means the service directs its management priorities towards treating more people and thus earning more.

[Derek]

Those who can afford to pay will still be able to go privately. It is those with small savings who will be prevented from taking the private option. Mind you there are many who already have private insurance, often provided by their employers. Whatever the political parties do, it will not affect all those, whose numbers will increase. We will, or already have a two tier system. The politicians are becoming increasingly irrelevant to the middle classes. No wonder turn out is falling.

[Chris]

The NHS can be reformed without the subsidisation for the rich, it can be made more effecient if competition is increased (which needn't mean the NHS being broken apart) within and outside the monolith and as far as I understand he has not denied this will take place.

[Oberon Houston]

my my.

Well.. if it is taxpayers money then and the majority reject wholesale dismantling of the NHS (and they do), then you cannot argue that to ignore this is valid. It isn't, politically or logically.

ps - I'm not denying that the service might be better with a more radical agenda, I'm just saying it is political suicide to stick to it. We need to differentiate between what is BESt for the service (in a perfect world), and what is politically possible given that we are a political party living in a Democracy.

[James Hellyer]

"Well.. if it is taxpayers money then and the majority reject wholesale dismantling of the NHS (and they do)"

Actually a poll commissioned by Reform showed that the majority of people thought we should consider different ways of funding and managing the health service.

And it's an great big straw man on your part to try and portray anything more than the most timid of reforms as "dismantling the NHS".

[William Norton]

"The best is the enemy of the good" (Voltaire).

[Rob]

THe majority of people now, if asked, say they dont want the 'dismantling of the NHS' this is largely because no seriously coherent and well thought argument has been made in favour of radically changing the NHS by a major political party. The only way to change public opinion is to argue the case, not shelve any effective discussion on the NHS and wait in hope for public opinion to mysteriously change in our favour in 10 years time.

[Andrew]

The NHS will never be substantially remodelled - Thatcher barely touched it, Blair has just thrown money at it. It's just politically far too difficult, not least because of the (faintly utopian) national ideal we have of a health system. Apart from that, a major reconstruction would likely screw up the service for a decade or so. Can anyone seriously see the public accepting that?

In an ideal world we'd have a system like the Dutch or Spanish - much less centralised, cheaper on the public purse, yet delivers sigificantly better results. In reality, we're stuck with a system that more closely resembles a postwar communist state - yet absurdly, the Cuban system is vastly more efficient on a tiny budget.....

[Andrew]

"I am amazed at the lack of quality centre-right political journalists and commentators that have got jobs"

Absolutely - it's just plain depressing the drivel we have to put up with. Still, at least we don't have Fox......

[James Hellyer]

"The NHS will never be substantially remodelled"

"Nobody has done it before, therefore nobody will ever do it."

What a marvellous political philosophy.

[Andrew]

Politics is the art of the possible.....

Seriously, it's nothing less than a complete minefield. Any party advocating the sort of reconstruction the NHS needs will either get voted out of office, or never get there in the first place. That's the limitations of elections every 4/5 years - necessary longer term projects with short term political pitfalls tend not to happen, barring the strangest of circumstamces (eg the unions pushing their luck enabled the climate where Thatcher could emasculate them).

[James Hellyer]

"Politics is the art of the possible....."

Congratulations, you're a Butskellite and would spend decades selling the people of this country short.

[John Hustings]

"Politics is the art of the possible....."

I wonder why such people get into politics.

Where is the "new Tory idealism" we heard so much of in the leadership contest?

[Richard]

"Congratulations, you're a Butskellite and would spend decades selling the people of this country short."

What is often forgotten is that Butskellism came about due to a refusal of the electorate to accept necessary free-market policies. Had the Tories run on a "Thatcherite" programme in the 1950s and 60s they would probably have been massacred at the polls. It simply became a case of "we can govern the country less badly than Labour". I fear we may in in for several decades of "neo-Butskellism" where the Tories have no choice but to shift away from the Right, at least on economic policy. Fortunately, public attitudes remain right-wing on law and order and immigration.

[Andrew]

"Where is the "new Tory idealism" we heard so much of in the leadership contest?"

Idealism needs to know its limits. Better to get into office to implement some of your philosophy, rather than losing to that all too predictable 'The Tories will privatise the NHS'.....

Serious NHS reforms are needed, and personally I'd advocate full scale private provision with a mixed insurance/public funding model. Mention that pre-election, and you've just given number 10 to Gordon Brown.

Would you rather be in office implementing 75% of your ideals, or in opposition after advocating the full 100%? All politicians face that question at some stage - ultimately if the electorate is scared of long-term reform, it's not going to happen.

[Mark Fulford]

Which is where pressure groups come in. Political parties are forced to operate in the centre ground. Pressure groups have the ability to move concepts from the fringes to the centre - and into the domain of the parties.

There's no chance of an NHS pressure group so we'll just have to wait for the problems to become so dire that restructure is unavoidable.

[Sean Fear]

You may be right Richard. Perhaps people do need to see the world falling down round their ears before they'll agree to necessary reforms (which would of course be much less painful if they were carried out earlier).

I think the Conservatives ought at least to have *tried* to offer an alternative to Attlee's settlement, before concluding that the public didn't want it. My impression is that while the NHS and Welfare State were popular with public, nationalisation and trade union privileges were not. The Conservatives could certainly have reversed the latter two.

[Sean Fear]

"Would you rather be in office implementing 75% of your ideals, or in opposition after advocating the full 100%? "

If it's a choice of advocating 100% in opposition, or implementing 75% in government, then it's quite easy to choose the latter. The choice becomes much harder when you're implementing a good deal less than 50% in government.

And oppositions can be very influential, if they force a government to move in their direction to retain its support. Think how influential the Labour Party was from 1900 to 1945, and indeed how we were able to force Blair to promise a referendum on the European constitution.

[William Norton]

Oppositions can be influential and make the weather, but it largely depends on the circumstances, and the subject. Which means that an Opposition has to pick its subject.

We were able to force Blair to promise an EU referendum largely because there is a large but inactive pool of cross-party Euroscepticism in the electorate, which in turn causes Blair himself to lack the courage of his convictions.

Advocating trade union reform in the late 1970s found a receptive audience for all too obvious reasons; ditto "monetarism" (helped by the IMF).

On the other hand, Scargill, CND & Co did not get very far with their agenda in the 1980s.

DC has decided that he won't win a fight over the NHS and could be damaged if he tries. Fine - now we wait to see whether that makes NHS reform a second-term issue, and which ground he will fight on (presumably education?)

[Mike Christie]

Surely if we believe something is right we should be laying out our arguments and trying to convince the electorate. We have around three years to the start of the next election campaign. We should be spending some of this time quietly preparing our policies and lines of attack and argument.

The public can be convinced of the benefits if we remind them constantly and subtly of the fact that only impoverished marxist dictatorships try to fund healthcare the way we do, and all those lovely liberal Swedes, Dutch etc. have some form of social insurance scheme.

Barely a week should go by without a top Tory questioning why we persist in sharing a healthcare funding mechanism with Cuba rather than France, Germany, Sweden, Switzerland and the rest of the developed world.

Percieved wisdom will remain just that if it is never challenged.

[Michael McGowan]

Those who suggest that a Butskellite approach will work forget that the assumptions underpinning Butskellism no longer hold. In the 1950's the middle classes reflexively voted Tory; there was a very high level of social deference; and the Tory Party was a sort of middle class social club. None of those assumptions are true any more. The middle class vote is much more volatile and includes the very large number of non-voters. There is no respect for the leaders of the Tory Party in the way that there was (however misplaced) for the leaders of the 1950's Tory Party. Thinking voters want a leader who can do rather better than manage decline in an orderly manner while emptying their wallers and harvesting the (ample) fruits of office for himself and his mates.

Another point that people like Oberon Houston forget is that the Butskellites dug the current Tory Party's grave, by spending most of the last fifty years helping the left to bed down the postwar collectivist consensus. Now their spritual successors such as Cameron are in a cul-de-sac of their own making, which is narrowing all the time. Successful centre-right parties like the US Republicans and the Australian Liberal Party were prepared to make the hard choices and take the time to break free of the left's ideological straitjacket. Failed centre-right parties like those in France are left to echo the left and feather the nests of the likes of Chirac.

[Rob]

Couldnt agree with you more!

I dont have a problem with healthcare not being the main issue Cameron chooses to fight the next election on. However I resent the fact that any effectove development on healthcare policy has been destroyed when the party is supposed to be going through a massive policy rethink and having to go campaigning at the next election being forced, if asked at the doorsteps, to support the NHS in full.

[Oberon Houston]

Couldn't disagree more!

We are ion danger of moving out of the realm of Democracy here... It still puzzles me at They are ALWAYS right.

[Oberon Houston]

Sorry guys, computer going wonky... should read ...It still puzzles me the number of activists that ignore the wishes of the electorate in these conversations. There is a very big difference between personal policy preferences and political expediency.

[Mike Christie]

http://www.timesonline.co.uk/article/0,,21129-1979680,00.html

Daniel Finkelstein provides food for thought on this issue today in the Times.

It makes one think, especially regarding the fact that those most likely to need expensive healthcare are often those least likely to be able to costly insurance.

I may have allowed my disappointment at the haste with which avenues of debate were closed off to impair my own judgement a little here.

Having lived in Belgium I know that many Belgians regard their social insurance as tax by another name. If you ask a Belgian how much tax they pay, they will invariably include the cost of their social insurance.

If 'social insurance' were to be true insurance then surely cost to the individual would go up according to the risk that individual presented. If it isn't proper insurance then it ends up like 'national insurance' as simply a tax pretending to be something else.

Some questions about 'social insurance' :

Who determines how much 'social insurance' is paid? If it is the government then it is just as susceptible to political tinkering (and just like National Insurance). If it is an independant body, then to whom are they accountable?

Who underwrites any shortfall?

When the little old lady next door needs a transplant, hip replacement and cataracts treated all in the same year, who pays? Does her social insurance cost go up fivefold, like my car insurance would if I had three major claims in a year or is the cost spread to the fit and healthy who don't see a doctor all year? Obviously we can't have grannies living in agony because their healthcare premiums have gone through the roof. It is a tax and we should be honest and call it such.

Maybe Cameron plans to introduce some changes by stealth... for example

Hypothecation of taxes is not something that happens much in the UK. If he were to introduce some clear lines where NI went to the NHS/pensions and benefits in clearly defined proportions, along with such taxes as tobacco and alcohol taxes also being put straight into the health budget. If the proportions of NI that were put into each 'social service' were clearly defined and open to scrutiny it would give the Chancellor of the day the ability to set it at a level necessary to provide the level of service that the public expected. It would also enable the Chancellor the ability to set tobacco and drinks taxes at a suitable level to offset the greater risk posed by smokers and drinkers.

Also in order to move to a more 'insurance' based system, why not bring in legislation to the effect of anyone claiming compensation for injury would have to claim the cost of their medical treatment as part of the compensation. This would push up insurance prices, but why shouldn't the NHS be able to claim money back for treating avoidable injuries. This fits in fine with our principle of responsibility, so long as it went hand-in-hand in ensuring that the courts gave greater weight to personal responsibility in deciding liability. It may also be that the need to produce documented medical expenses as part of a claim might help reduce unwarrented compensation claims.

We might not abandon the NHS and National Insurance, as that way lies electoral suicide. We could easily radically change the nature of them both within a pledge not to scrap either.