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Editor’s blog 25th September 2008 – Labour policy and a Crisp rejoinder to top-ups

So, what do we have in health policy terms from the last few days, during which the Labour Party has had its conference?

First things first: we still have Gordon Brown in Number 10 Downing Street. This was by no means a foregone conclusion even a week ago. Synchronised resignations within Labour (maybe an event for the 2012 Olympics?), and dismal poll ratings and a hostile media without, had Kircaldy’s favourite son looking like a distinctly sub-prime minister.

Three things conspired to call off the dogs – at least for a while, and for a little way. Neither of them was his speech, which was less bad than many he has made, but was not the kind to swing an undecided or hostile voter.

The first was the same problem Brown was himself accused of when failing to call a general election last autumn when he and Labour rode high in the polls. Lack of bottle. Yet on this occasion, it was not Brown’s but those who think they could do his job better. Quite simply, there was a Cabinet-wide (and beyond) failure on anyone’s part to put down a marker as an obvious leader-to-be.

The second was a piece of political cross-dressing (which, living as we do in a post-Blair, pre-Cameron era, should surprise nobody). Labour stole and deployed the Conservative Party’s traditional ‘secret weapon’ – loyalty.

The third was the credit crunch. In financially turbulent times, an experienced former finance minister (who some will argue created parts of the problem) may look a less bad bet.

Brown’s speech
So what did the man himself have to say on health policy? NHS 60 was mentioned, staff thanked, and his personal debt to a service that saved his sight “care my parents could never have afforded”.

Yet in the next sentence, as well as outlining his “passionate” support of NHS values, Brown is clear that he is “committed to reforming it to serve these values”. Immediately he trumpeted the successful reduction of MRSA rates – one of his two health policy priorities when taking office, alongside increasing GP access.

Brown referred to this just a few sentences later: “that there is no vested interest, no matter how powerful, that we are not prepared to take on when change is needed for the sake of the nation's health”. So the Government's mixture of Blitzkrieg and Sitzkrieg with the BMA has not gone anywhere, we may reasonably assume.

The two substantive policy announcements were on prescription charges – to be abolished for cancer patients from 2009, and in time (and conditional on other budget savings) for all those with long-term conditions.

The man who could have been king?
Had he not made the error of telling an interviewer he didn’t think he would be up to the job of PM, Alan Johnson could have been a thoroughly credible caretaker / defeat-with-honour candidate to replace Gordon Brown. His speech to the conference was utterly devoid of traces of lese-mejeste, and was also, at around 20 minutes, rather short

The jokes, as ever were good. The political reclaiming of the NHS for Labour was passionate. But looking ahead to the next ten years, Johnson declared “there are five main healthcare objectives all of equal importance”.

A decade of priorities?
First, he warned that “the crucial debate on the future of adult social care must produce a radically revised system which promotes independence and control for people, provides greater consistency of care and is affordable to the taxpayer”. However, detail came there none.

Johnson’ second priority was “to ensure that the patient is placed even closer to the centre of the NHS. 

That is why I'm going to be asking every hospital Trust over the next year to collect immediate feedback from patients on their experience of care.

Each hospital will know within two weeks how patients feel about their care. Only then can we start to link patient experience with the clinical outcome”.

Thirdly, and perhaps inevitably, he assured delegates that “there will be a far greater emphasis on prevention”. He highlighted the proposed new health checks for the over-40s, set out in Gordon Brown’s address. Unarguably the right thing to do, but the absence of detail on how this will be prioritised is a concern.

Fourth, Johnson emphasised the importance of keeping the momentum against healthcare-associated infections: “there can be no complacency.  The fight against infections goes on every day in every hospital led by the matrons and nurses who told us they wanted more control over cleaning standards on their wards.  We will spearhead a new public awareness campaign aimed at visitors as well as staff to bring the infections rate even lower. 

In parallel we are developing a new British standard, a kitemark to help Trusts guarantee high levels of cleanliness”.

As above, self-evidently correct, but hard to sustain staff interest if other priorities or financial pressures swell.

Health inequalities were, he concluded, “he fifth and most daunting task is to break the pernicious link between wealth and health. It's an affront that someone's place of birth should determine their length of life.
But the health inequalities gap can only be closed by concerted efforts to improve people's life chances.  From Sure Start to the expansion of higher education; from parental leave to the minimum wage; from tackling illiteracy to half a million apprenticeships.”

Here the detail mixed with the politics: "all of these Labour initiatives have a health dimension in seeking to unravel complex, entrenched and inter-related social problems.
The Tories refused to recognise the problem of health inequalities and did nothing for eighteen years except exacerbate them. In contrast under Labour the health of the poorest in our society has improved to reach the level that the rest of the population enjoyed eight years ago when we began this quest”.

Johnson announced a pilot of free healthy school meals for all primary school pupils “in at least two local authority areas.
We'll examine the results so that we can gauge whether the clear early improvements in Hull are sustainable elsewhere”.

He also contended that “tackling health inequalities means ensuring that those areas with the greatest health needs, no longer have the fewest GPs.
This is one of the reasons we're introducing so many new GP surgeries right across the country”. The opponents of polyclinics will need to be able to counter this line of argument if they want to prevail. Equally, the provision of polyclinics will need to match up to this lofty rhetoric.

It was a good speech – and its politics and Tory-bashing will have cheered the traditionalists. Yet for all its high profile and politicised nature, health policy may sway less wing voters if the NHS keeps up its progress on waiting and HAIs and thus keeps off the front pages.

Crisp makes the case against institutionalising top-ups
In The Times, former NHS chief executive and DH permanent secretary Lord (Sir Nigel) Crisp made an elegant and eloquent summary of the case against permitting top-ups – or rather, against institutionalising them into the fabric of the NHS.

Crisp concludes, correctly, that something is going to have to change. However, his suggested solution to “allowing NHS patients to pay for extra cancer drugs … is to recognise that they are exceptional cases and treats them as such. This controversy is in danger of undermining the principle of fairness at the heart of the NHS.”

He lucidly points out that while “nothing in healthcare is easy”, the number of patients currently affected is relatively small (but will of course grow as cancer becomes a chronic disease); that higher spending is not automatically a guarantor of better outcomes or healthcare; and that systems with core minimum packages of care deliver worse cover for the poorest.

Crisp also warns that in a choice between “a system that aspires to comprehensive coverage and uses NICE to set some limits as to what is available, or a new system that specifies every core treatment available and charges for add-ons, the first is, quite simply, cheaper and fairer”.

It would be highly welcome if this serious policy contribution to the discussion received the consideration it deserves by Johnson and Brown when they prepare the Government’s response to the Richards review on top-ups.