Some of my friends, with whom I have been debating the rationale for the coalition have referred to the NHS as the elephant in the room. I think it is that, but not in the sense they mean.
What they mean is, I think, this:
- both parties had policies for the NHS in their manifestos. The LibDem manifesto contained proposals for greater democratisation and accountability, and the Conservatives' for more efficiency, with a hint of privatisation. At the same time David Cameron was very clear in his promise that there would be no top down reorganisation. I read a blogpost which very helpfully set out the contents of the manifestos, but I can't find it now; I'll link later if I can find it.
- then Andrew Lansley came up with a radical set of “reforms” which suggested wholesale privatisation that went beyond either party's manifesto.
- the narrative is that the LibDems were bounced by this in a typical piece of right wing privatising Tory skullduggery. To an extent I think that is right, but he also bounced a lot in his own party. He bounced everybody in fact, not just the LibDems. The LibDem hierarchy was perhaps slow to respond in full measure, though in my view they've made up for lost ground since.
- although retrenchment is promised after the “listening” exercise, there is still a perception that further ambushes may be lurking round the corner.
- and there is a fear that the LibDems will get the kicking for this as we did on student fees, and will come out of it worse off.
But there is an entirely different set of issues which are really at stake, and nobody is actually talking about them. I want to deal with those and then deal with what I consider to be, in the scheme of things, a little local and temporary difficulty about this particular attempt at reorganising the NHS.
There are three key features to healthcare in this country at the moment. The first is that it is very expensive; the second is that the amount we are prepared to spend on it is limited; the third is that we are prepared to do very little about it. Neither of these is limited to the UK.
Western medicine is in the most expensive phase it has ever been in, and probably the most expensive it ever will be. We have much to be proud about. We are very good at major trauma and very good at keeping people alive. But our record on actually curing things is patchy to say the least. We cannot cure even things as simple as the common cold; what we do is deal with the symptoms until it goes away. We cannot cure AIDS, we cannot cure Parkinsons, we cannot cure Alzheimers, we cannot cure malaria, we cannot cure MS. I know, at bitter personal cost, that we don't have a clue about ME/CFS. We cannot even cure cancer – we can cure some cancers some of the time. The list goes on and on. What we do is keep people alive, often very expensively, often for decades, in greater or lesser degrees of comfort. Now, I expect and hope that as medical and biological knowledge advance, particularly at the quantum level, we will find ways of curing many of these conditions, or better ways of preventing them, and then we will all be leading better lives, and the average cost of care over each person's lifetime will go down. But for now we have to bear the cost. There's not much else we can do.
The second issue is what I regard as the actual elephant in the room – something nobody, least of all politicians, is allowed to talk about. We could undoubtedly keep more people alive, and keep them in less misery or greater comfort if we spent more money. I have no doubt that every hospital administrator in the country would efficiently and effectively spend an extra million doing good for a lot of people. But that million would come out of people's taxes, and the fact is that we – the public, you and I – are unwilling to see our taxes rise. So in the end it is you and I – not politicians – who decide who lives and who dies. But of course politicians are not allowed to say that; it would be taken as the worst faux pas imaginable if Andrew Lansley were to say “Actually people are living in misery, or dying, because you won't spend more money on their care”. But that is the truth of the matter. All the reorganisations in the world will not undo that truth.
There's another, although much smaller elephant, which is what we do about our own health. This is dealt with much more in public, although with not nearly enough effect yet. I speak as one of the villains here. I have just started taking blood pressure pills – yet to find the right combination or dosage. I am no doubt going to cost the NHS a fair bit over the rest of my life. This is largely due to the last ten years. I was fairly fit till around 2000, but since then I have sat too much, exercised too little, eaten and drunk too much and not the right kinds of food. My condition was avoidable, as are many of the conditions we are paying the NHS to treat. The difference that makes to the overall cost is staggering, but, despite great efforts by government and healthcare professionals, we are slow to get the message. In 2009 we topped a million alcohol related hospital admissions. That figure itself is staggering – I'll just say it again – over one million hospital admissions in 2009 were alcohol related. All but a few of those admissions were avoidable. I have not found any studies of what better personal health care might do for the NHS bill (if anyone has, let me know), but just let me put some very broad figures into the frame. The NHS costs approximately £2000 per person per year. (I'm using that as a very round figure for ease of use here.) That means that a village like this one, around 5000 people, is going to cost, or pay, whichever way you look at it, around a hundred million pounds over ten years. The effect of reorganisation on that (I'll talk more about reorganisation in a minute; this figure is for comparison) would be minimal, to be honest. If we were very lucky, we might save 10%, though I doubt if we'd ever see those savings materialise – see more below. But consider the possible differences if we lived “properly”. Our share of those million a year alcohol related hospital admissions would be avoided. My blood pressure pills – and those of most of the other other people in the village with blood pressure problems would be avoided – and I intend to live for a good thirty years more. I'm plucking a figure out of the air here, but I would not be surprised if the cost of treating us were halved by us living properly. Fifty million pounds over ten years, five million a year saved easily. And that's just one village. But we don't do it.
That sort of figure puts reorganisations into context. I think organisation is a very good thing. We need to make sure that the services we get are organised as effectively as possible, and, as conditions change, so the means of effectiveness change and reorganisation is a part of the process of ensuring that. But the NHS is over-reorganised. It has had major reorganisations in 1974, 1982, 1990, 1994, 1997, 2002 and 2007. Now they want to give it another one. Part of the rationale is that we won't be able to afford it without the intended reorganisation. I doubt that very much. I also think that the theme of not being able to afford it is, for some people, an excellent rationalisation for a doctrinaire determination to marketise the NHS. But I also think that politicians get sucked into using this language because they're not allowed to use it about the elephants in the room discussed above. If we don't change our lifestyles, and if we don't accept that we are actually ourselves daily making life and death decisions about the facilities available to other people, then indeed we will not be able to afford the healthcare we need. But they're not allowed to talk about our spending at all, and not allowed to talk about our lifestyle enough, so the theme gets exported onto the issue of efficiency. Now it may be that whatever set of reforms eventually goes through will make the NHS marginally more efficient. I doubt that, because reorganisation is itself a costly process, a very large sunk expense, and usually results in a great deal of changing the position of the furniture without actually effecting any radical change in effectiveness or efficiency. But we shall see.
I note that there were three reorganisations under Labour. I also note that Labour is being castigated for having thrown so much money at the NHS. Some of that money was wasted and some of it was used to boost salaries rather than add to service. But do please think back to the state of the NHS in 1997. We now have a guaranteed maximum waiting time of 18 weeks. That would have been inconceivable in 1997, and in my view the road from there to here was paved partly with reorganisation but largely with money.
Bringing some kind of market disciplines to bear is one thing. There is a trick to doing that without making the NHS market led, a very difficult trick, but nonetheless an achievable one, I think. Ruling the NHS by market forces is a very different thing, and in my view is pernicious. I call the USA as my witness – a market led system, in which they spend nearly twice as much of GDP as we do, for outcomes that are only marginally different. The NHS is founded on the idea of equality and markets thrive only where there is inequality; to subject the NHS to market forces would be to build in inequality. Some will say we already have inequality; it is just masked by the current system. That is indeed true, but I suspect that inequality rises as market penetration into the system increases.
Anyway this reorganisation will make some sort of difference, I am sure, but not much. It is much more important to politicians than it is to the NHS. It will be a big political football over the coming months and years. It will make the careers of some politicians, maybe, and it will ruin the careers of others, most likely. It will be a massive political issue, but its effect on the outcomes of healthcare in this country will be minimal. That is why I regard this, big though it is for Tories, LibDems and Labour, as a little local and temporary difficulty in the NHS. It is a hamster in the waiting room by comparison with the two elephants discussed above. At last we've arrived at the title of this piece. Compared to our willingness to pay and our willingness to look after ourselves, it really is hamster sized. And that is why I am content to talk about it as a strategic and tactical issue for the LibDems, rather than something of genuine importance to the nation.
As for the strategy, I think it is quite simple. It's much easier for us than tuition fees. It is evident that this is a Tory thing, not a LibDem thing. We will be excoriated by some just for being in the coalition that is proposing this (they always will, regardless of how illogical it is), but for most people in the country, it is identifiable as a Tory issue. It is noticeable that the overall perception of the Tories as not safe for the NHS is still strong, despite David Cameron's best attempts to decontaminate. PoliticsHome's poll on this issue makes interesting if complex reading. Their conclusion is that the public still don't trust the Tories, despite apparently liking some of the ideas. They conclude that there is still more danger in it for Clegg than for Cameron; there is some truth in that. It may be perverse, but that's the way voters are, and it illustrates the need for LibDem strategy to illustrate that our power is limited, but that this is not in itself a condemnation of coalition, that we are different from the Tories in terms of our strategy for the NHS, that we have been instrumental in mitigating the Tories' worst ideas,and, above all, that coalition actually works. Tactically this calls for subtlety in handling, demonstrating the difference and the benefits of having LibDems in government, while not making relations so difficult as to prevent us doing the job we're there to do. Our leadership is capable of that.
The tools we use to implement those tactics are up for grabs, but just as a last note, it might enable us to resurrect Mark Pack's lost idea “community politics”. While I can appreciate our government's wish to foreground the big society idea, I think we can do ourselves some good by keeping the theme going, indeed emphasising it, that there are differences – notably that we've been on the ground of community politics for a long time, unlike Dave's relationship with his new Big Society idea. And we can also emphasise that what we want for the NHS is absolutely in keeping with the principles of community politics – giving genuine power to the people rather than trying to hand over responsibility without power.
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