Making your mind up
Labour is yet to spell out what it would do with the NHS
As the dust settles following the passage of the Health and Social Care Act, one of the most absorbing questions for health policy watchers will be how Labour responds, having fought so hard and long against the bill. Should its policy be to repudiate the entire act, or are there, in fact, elements which are sound and should be kept?
A few hints about how things might develop were dropped by Ed Miliband in his recent speech to the Royal College of Nursing’s annual conference. Miliband unequivocally embraced one new element of the act’s architecture: health and wellbeing boards, which he suggested could be used as a tool to counter government policy on competition. This reflects an enthusiastic response by local government to the new structures created by the act and the move of public health into local authorities along with ringfenced budgets. For those in local government with a desire to tackle the determinants of ill health, such as poor quality housing, this is an element of the coalition’s reform that makes absolute sense. There are plenty of enthusiasts – including Labour-led councils – for the potential of health and wellbeing boards to create powerful vehicles for mobilising local government, local GPs and hospital trusts towards a shared set of objectives.
But there are some underlying snags in the system. However enthusiastic local government partners might be, it is not clear how much power health and wellbeing boards will have, especially if clinical commissioners are less than engaged, while, simultaneously, real power lies with the NHS Commissioning Board. And in many cases the incentives facing local government are very weak. An imaginative and engaged local government can potentially save the NHS a considerable amount of money with investment in preventative work, particularly by targeting additional social care at people with long-term conditions. But finding such investment from public health budgets will be very challenging (public health expenditure has tended to be about four per cent of the overall health budget). More importantly, any savings from this investment will not accrue to local government – which is faced with ever-higher bills for adult social care among other pressures – but would, generally speaking, return to the NHS in the form of avoided admissions.
In addition, in the public’s mind an engaged local government will be increasingly identified with local health services. But the largest savings for the NHS are likely to come from shifting care from acute hospitals and closing all or part of a hospital down: also known as political suicide for locally elected officials. National and local Labour politicians will, like several coalition cabinet ministers, be very tempted to cash in on the anti-closure sentiment that builds up whenever hospitals are threatened. But Labour must not fall into the easy trap of opposing all NHS reconfigurations to gain local support, however powerful the views expressed to campaigners on the doorstep. In his speech to the RCN Miliband was unsurprisingly coy on this point. He recognised that longer lives and more chronic conditions will bring ‘service change’ in the NHS, but at no point explained what that might mean.
Labour’s position on the increased use of competition and market forces in the NHS appears to be more clear-cut. Miliband promised he would repeal the ‘free market free-for-all’ created by the act. But, even if Labour were to find a way of containing the growth of private provision in the NHS, the bigger, more interesting, question is how much space it is willing to give to market-inspired ideas when it comes to formulate its own approach to public sector improvement.
Labour’s previous term in office was notable for its reliance on two contradictory approaches to change in the NHS. On the one hand, there were top-down, ‘command-and-control’ techniques, such as targets, which were effective but often unpopular with clinicians, and a raft of national quality standards to guide service development, which were more popular. But in parallel there was a vision of a self-improving system, driven by a quasi-market motor. The myriad choices of informed consumers – patients – were supposed to shape the services of autonomous, income-maximising, hospital providers – foundation trusts – while commissioners were encouraged to procure services from a range of for-profit, not-for-profit and other kinds of provider. Ministers also relied on financial incentives and contracts to drive improvement among doctors: extrinsic motivations trumped intrinsic ones.
The evidence of what worked is unclear because policies were being implemented simultaneously: targets almost certainly demolished waiting times, but independent treatment centres may only have had an impact at the margins. It is not clear which approach to public sector change now dominates Labour’s thinking. Will the party try to develop an alternative, non-market driven vision that can persuade and enable NHS professionals to improve the quality of care in the midst of financial constraints? This is not a doorstep campaigning issue. But any discussion about the ends of new policies will be incomplete without a debate about the means.
Ruth Thorlby is senior fellow in health policy at the Nuffield Trust
Ed Miliband, health, Health and Social Act, healthcare, NHS, Royal College of Nursing