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A very political summertime – Health Policy Today, 31st July 2008

Tom Smith on the political overtime we are 'enjoying' this summer.

Ordinarily in the summer, there is an empty space where the football should be – not a problem this year, as we have had the European Championships.  And as Parliament rises there is a similar pang in July when the start of the new political season seems a long way off (for me at least).

Yet thanks to the Glasgow East by-election, we are experiencing political extra time, likely to go carry on throughout the summer.  As politicians position themselves for the coming political season, health policy is becoming one of the key areas defining a shifting political landscape.

Will the arguments over health policy that characterised the last political season continue into the next?

An example of the summer’s continuing daily politics appeared in yesterday’s Healthcare Republic.  Its main story is that Alan Johnson has ‘hit out’ at PCTs http://www.healthcarerepublic.com/news/GP/LatestNews/835305/Johnson-blasts-PCTs-polyclinics/?CMP=EMC-DAILYNEWS.  

On examination, it is clear that the website is bringing up old news.  The ‘hit’ took place over a week ago, before Parliament rose, during health questions on July 22nd, two days before the Glasgow East election.

The timing of the story will lead its GP readers to assume it happened today or yesterday and keep alive the burning argument over GP-Government relations, which have been going on for over a year now.  While there is little point in rehashing arguments (age old in political terms at 9 days!), this is an argument that will not go away.

It may be that the Government’s stance will soften, as they grow keener to avoid criticism after defeat at Glasgow East and the sustained debate over the position of the Prime Minister.  Or alternatively, the Government’s position may harden, with politicians keen to flex their reforming muscles.  Given recent political shifts, it is worth asking whether the arguments that characterised the first part of the year will continue in the second.  

It was a Labour MP, Geraldine Smith (Morecambe) who forced the response from Alan Johnson when she asked about greater freedom for PCTs.  She said that GPs in her constituency were concerned that investment in primary care was going into new practices rather than to develop existing ones and that “the PCT would like to do it another way, but the government will not allow it to do so” - http://www.theyworkforyou.com/debates/?id=2008-07-22b.641.3&s=speaker%3A10548#g642.5.

Alan Johnson gave a very angry reply, suggesting the behaviour of the PCT was disgraceful.  Up until now, the line from Alan Johnson (if not Ben Bradshaw) has been to say that polyclinics are a London concept and in the provinces it is up to PCTs to decide how to develop access, in ways of their own choosing.  But these comments, no matter the specifics of the case in Morecambe, imply that is not the case.  

Johnson suggested that attempts to increase access by working with GPs had not been successful and new approaches were needed.  It hardly chimes with the clinical engagement mantra in the Dari report.  

For a number of reasons, the Government needs a step-change in the way it relates to doctors generally and the BMA in particular.

Moving on from the long running row between the government and the doctors’ trade union?

In his response to Geraldine Smith, Alan Johnson could not be calmed on the idea that GPs could themselves improve access.  “If it was just a matter of handing over the money to the BMA, which is what its political representatives on the opposition benches argue for, it would have been resolved years ago”.

That’s quite a sentence and a statement. This line is likely to alienate a lot of doctors who genuinely want to develop services, but who, quite sensibly, are BMA members. It hardly needs to be said that the money paid for services does not go to into the coffers of the BMA.  Furthermore, by equating the BMA and Conservatives, he will be dismissed by a large number of doctors who are not enamoured by the Tory Party.  The line might actually rebound upon Labour, and the Conservatives may benefit from being seen as on the side of the family doctor.

The consensus statement that Labour agreed in Warwick said that the Government would work productively will the trade unions, and that it saw a role for the independent sector in offering additional services to the public sector, which would be the dominant provider.   The Government often point out that the BMA is a trade union, but for the purposes of Warwick it is clearly not.

Likewise, while has been more positive language about the public sector, Alan Johnson clearly does not see general practices as part of this either, which, to be fair, is consistent and something he has said many times before – GPs are small businesses.  But again, he may be making a political mistake because despite Johnson’s analysis, the vast majority of the public, when they think of the NHS, they think of GP practices.

The Government’s position towards the BMA runs the risk of being counterproductive.

Today’s report from the Healthcare Commission on access to GPs finds that GPs continued to be popular, with about 93% of patients saying they had been treated with respect and dignity, and 74% being completely satisfied with the care provided.  It also shows that around 13% of patients are finding it difficult to make an appointment within 48 hours. http://www.healthcarecommission.org.uk/newsandevents/pressreleases.cfm?cit_id=6528&widCall1=customWidgets.content_view_1&usecache=false

A Department of Health spokesperson told the Guardian that since the survey had been completed, the Government had invested £250 million in improving access and taken action to extend opening hours in GP surgeries (http://www.guardian.co.uk/society/2008/jul/31/nhs.health). If you ask GPs, they will say that this extra money is being used to seed the development of polyclinics many of which will go to the private sector rather than into the development of existing GP surgeries – the same point made by Geraldine Smith.

So are GPs failing in the way that Alan Johnson suggested on July 22nd?

The charts that the Healthcare Commission produce show a small increase in satisfaction with GPs and quite a large increase in the numbers of people able to get an appointment the same day.  The proportion of patients who are put off trying to seek an appointment by inflexible opening hours rose slightly, but overall is small.  It is difficult to portray GPs as having failed and, in all likelihood, the public would not necessarily pin the blame for problems onto the doctors.

What will make Labour different to the Conservatives?

Perhaps the most visible difference to the man in the street, between Labour and Conservative policy, is that Labour attack GPs while Conservatives are more supportive.  And during the last few weeks of the Parliament, Labour was keen to contrast their own approach with the ideas of the opposition, which, Labour say, have been captured by professional interests.

It is likely that this divide will continue.

Even if Alan Johnson becomes leader or deputy leader – as various rumours place him – the cabinet seem pretty united on their challenge to GPs. They also collectively push the notion that the Government’s radical ideas for health policy put the Conservatives on the back foot.  James Purnell, who is recently talked about as a potential leader, told the Andrew Marr Show two Sundays ago that it was Labour, not the Conservatives, who had the courage to force longer opening hours by GPs.

In his much publicised interview with the Guardian today, another leadership contender David Milliband, says that despite Labour difficulties, “we need to remember that there is little real sense among the public – or even among Tory MPs – of what the Conservatives stand for, or what they would do in power”. (Though if Mr Milliband had read the Guardian on Monday he would have seen polls that suggest something similar about the Labour Party – people are not clear what they stand for.)

Milliband says the challenge for the public sector is now different.  “The task of Government after 1997 was a rescue mission. Now we need the imagination to distribute more power and control to citizens over the education, healthcare and social services they receive.”

That second sentence could easily have been said by David Cameron, and the two parties have quite small differences between their positions, even if they would go about them in different ways.  But according to Steve Grice, writing in the Independent yesterday, the Conservative strategy is to match Labour on health.  ‘Some senior [Conservative] figures even believe they can pull off a stunning away win on Labour's ground’.  

Labour against the Conservatives; Labour against itself

This morning, the debate about the future direction of the Labour Party continues as, under questioning from the media, David Milliband refuses to rule out a challenge to the Prime Minister.

The Times says that when he was ‘asked why he had failed to mention Mr Brown in his article, he said: “The debate has to be about issue and argument, not personality.” He added: “There is a very clear Labour vision for the future which offers change, significant change. And there is an emptiness about the Conservative Party that means we can get at them in a very serious way, and that is the right approach for the party”.’

Milliband insisted he was criticising the Conservatives rather than the Prime Minister.

Where next for Conservative health policy?

To be fair, many Conservatives feel the party is a bit weak on health policy – something mentioned by many commentators, most recently Janet Daley, in the Telegraph.  In a piece entitled, ‘where next for Conservative health policy?’ on today’s www.conservative.home.com, four conservatives offer alternative directions. Simon Chapman calls for greater local accountability, which, he says, will not be delivered by an NHS Board.Andrew Halpenby, Director of Reform, says someone should embrace co-payments.Dr Rachel Joyce wants patients to be able to choose their commissioner, which if practice-based commissioning develops, they will.  

My personal favourite of the Conservative contributions, however, comes from Bedfordshire MP, Nadine Dorries.  All we need is a time machine to fix the ills of the NHS.

"I trained in an NHS which was run with consideration and discipline. The first concern of any nurse was to reassure her patient. To be aware that a hospital was a scary place; that we knew most things weren’t going to hurt and would probably be OK, but that the patient didn’t.  As a night nurse I spent many an hour sat on the edge of the bed of a sleepless worried patient, with tea and toast, listening to the dark worries keeping my patient awake. How long will I be off work? Will this affect my life?  I worked on wards which had dedicated ward cleaners and Auxiliary nurses who took pride in their wards and were in silent competition with the cleaner on every other ward in the hospital.  Nurses never wore their uniform outside of the hospital. A plastic apron was donned every time you treated a patient. Hand washing was automatic, cleanliness imbued throughout every aspect of the ward day. Visitors limited in order that a ward could be properly cleaned. There was no MRSA and poorly patients got the rest they needed.  Matron ruled, Doctors trembled, no nurse failed to give anything but her best. Everyone was accountable via a very clear line of command. Everyone knew who was responsible for what and when.’

Oh –those were the days.  Nadine was born in 1957, so assuming the time she was working, she seems to have found precisely the opposite to Roy Griffith who in 1983 famously found that there was no accountability and no one was in charge.  
As a commentator on the ConservativeHome site noted, ‘Yet again, more tinkering with the current model, more viewing the past thru' rose-tinted specs.’

It is, of course, impossible to guess how current political dramas will play out, whether there will be a new leader of the Labour Party, a general election sooner than we thought or even whether Alan Johnson will still be secretary of state for health when Parliament resumes.  But what we can be sure of is that the dividing lines between the two parties will remain subtle – to do with differences of presentation and implementation. Politicians will continue to debate health policy to accentuate their differences and the way that policy is developed will be significantly affected by how this drama plays out.