It’s pantomime season again. That time in the electoral cycle when politicians present their ‘retail offering’ to the public and strut the boards with faux sincerity worthy of Academy award winners. As with all works of fiction, if the show is to be truly enjoyable voters are required to demonstrate “willing suspension of disbelief”. Unfortunately, that’s where the game comes apart. Because to be frank, the manifestos stretch credulity well past breaking point.
The Daily Sceptic have asked me to comment on the health policies apparently on offer. I will firstly comment on the Conservative and Labour proposals and then consider the Reform party document. I don’t consider the Liberal Democrats or any other fringe organisations to be relevant.
Comparing the health positions of the Conservative and Labour parties is easy. They are virtually identical. The presentational language and imagery differ between the sanctimonious socialism of Labour and pretend pragmatism of the Conservatives, but looking through the bluster the policy offerings are remarkably similar.
On every substantive health issue, Labour and the Conservatives say the same thing. They will both grow the workforce by implementing the existing “Long term NHS workforce plan” and reduce waiting times for treatment. They both commit to “building 40 new hospitals”. Both sides pledge to improve the NHS app to enhance service accessibility; to improve dental and mental health services; to regulate hospital managers; to leverage our “world leading” health sciences sector and to enhance primary care. It is extremely difficult to find any major disparity between the two offerings – the only ones I can find are that Labour pledge to pay for more MRI and CT scanners, whereas the Conservatives propose to use unspecified new technology to improve reporting efficiency. The King’s Fund has provided a helpful summary for those readers interested in checking it out for themselves.
From a wider perspective, the Conservatives are trying to persuade the electorate to overlook the colossal failure of the NHS system under their stewardship to provide anything approaching an acceptable level of productivity. Labour, on the other hand, attempts to gull voters into believing that shovelling yet more taxpayers’ money into a deteriorating service will miraculously turn things around when the constraints on progress are systemically baked in.
Neither side make any attempt to address the core issues of culture and practice that make it unlikely that the NHS’s performance will improve in the foreseeable future. Both sides are conspicuously silent about the unending industrial dispute with the juvenile doctors – about to embark on another four-day strike directly before polling day in a pointless pursuit of a 35% pay rise.
My explanation of the extraordinary concordance in health manifestos is that the two main parties both realise that elected officials have next to no agency when it comes to dealing with the NHS. The sole function of politicians is to feed the machine with more and more taxpayers’ money, irrespective of falling productivity. Control does not lie with democratic representatives, but with technocratic functionaries. The functionaries in question are aware of their powerful position and also aware of the lack of moral hazard – simply put, they can’t be sacked for poor performance and have complete freedom to continue to act as an entity outside state control. The reason the Labour and Conservative health manifestoes are identical is because they’ve both effectively been written by NHS senior managers.
Which brings me to the Reform manifesto offering – plainly not written by NHS apparatchiks, if only because there is a clearly stated intention to reduce the numbers of NHS managers. There are some interesting and quite radical proposals in this document – but then, being radical is easy when there is virtually no prospect of you facing the challenge of having to implement any of these changes.
Taken at face value, the Reform proposals attempt to circumvent NHS vested interests and cultural intransigence by bypassing the organisation completely. Workforce incentivisation would be addressed by generous tax breaks for clinical staff. Student loans would be written off for doctors and nurses after 10 years’ service. Patients would be given vouchers to use with any health provider if waiting time targets were not met, and there would be 20% tax relief on private healthcare insurance. Whoever wrote the Reform document appreciates that attempting to achieve change in U.K. healthcare is not feasible by working within the NHS’s existing frameworks because the system will always act to resist and frustrate change.
Nevertheless, I see problems with this approach – as ever, the devil is in the detail. Exempting frontline NHS staff from basic rate tax is a bold attempt at incentivisation – but what is the definition of ‘frontline’? Given the NHS propensity for pushing the envelope, that definition could encompass all 1.5 million employees of this bloated monstrosity.
Writing off student debt for doctors and nurses also has its appeal – although that would incentivise students to borrow as much as possible in the first place. And if doctors and nurses are to have debt forgiveness, what about physios, and occupational therapists or hospital pharmacists, and so on.
Patient vouchers for private healthcare is an eye-catching proposal – at one time this was a Conservative policy. But it paradoxically incentivises doctors to prolong NHS waits on the basis that the government will then fund care in the private sector, for which the practitioner, moonlighting in the private sector, will then be paid extra by the taxpayer.
Finally, there is the issue of tax relief on private insurance premia. At first glance this seems prudent – why not directly incentivise people to use alternative routes to reduce pressure on the NHS? Unfortunately, there are potential problems here too. Such a scheme provides a subsidy to the private health insurance providers, allowing them to grow their market while maintaining their already substantial profit margins. If any senior person in Reform believes that a healthcare sector dominated by private insurance companies will provide value for money or an equitable approach to dealing with patients, they are mistaken. Having dealt with the insurers for 20 years as a private medical practitioner, I wouldn’t trust any of them.
So, in summary I’d give two cheers for Reform. I wouldn’t go as far as Professor Sikora’s ringing endorsement in the Telegraph, but the insurgent party does deserve credit for thinking differently. I would have preferred to see a specific commitment to examining fundamental change of the NHS to a mixed healthcare economy modelled along European or Antipodean social health insurance lines. These models of delivery have a long and consistent track record of outperforming the socialist NHS monolith or the inequitable and inefficient US system. Such a proposal would take decades to implement, require all-party support and be fiercely resisted by NHS unions and management. In short, it is highly unlikely to happen within my lifetime.
Despite the practical difficulty of this truly radical and necessary change, the first step is to get the idea on the national agenda, which might eventually move the ‘Overton window’ of political discussion. That would be real Reform. Feel free to call me sceptical, but we are nowhere near it yet.
The author, the Daily Sceptic’s in-house doctor, is a former NHS consultant, now retired.
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