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Editor's blog Tuesday 9th February 2010: The politics of promises

So on Sunday Gordon Brown told The Observer what he was going to say in his Kings Fund speech yesterday.

Then he said it.

It included, "In the next few years - and because of our decisions on national insurance - we are committed to maintaining real term spending on the front line services of the NHS"

Not to mention "new and ever more stretching guarantees to secure for every family the right to get the best possible personalised health care when and where they need it. Our aim is personal care whenever you need it, to the standard you need it - and as quickly as you need it"

Guarantees R Us
And we got guarantees: "The Cancer Guarantee is the right for anyone with suspected cancer to see a specialist within two weeks of diagnosis ... in the coming Parliament we will take this guarantee further to ensure that in addition to rapid access to specialist care, all cancer tests will be completed and results given in just one week.

"The Waiting Time Guarantee: that there will be no return to the long-waits which plagued the NHS before 1997. Our guarantee is that no-one should wait longer than 18 weeks from the moment of GP referral to hospital treatment. Today in fact the average wait is less than 10 weeks

"The GP Access Guarantee: we intend that everyone will have the choice of GP services open on evenings or at weekends in their area. And to back this up we will abolish GP practice boundaries so that everyone can register with the GP most convenient for their needs, be that near their home or place of work.

"And a Health Check Guarantee. In the next parliament everyone between 40 and 74 offered a regular health check on the NHS - something for too long available only if you paid in the private sector".

No surprises ...
And none of it was a surprise if you were actually paying any attention during the party conference. There we go.

... but some sense
Now much of the general drift of the speech is actually sensible. Preventative care is good. Delivering more care out of hospitals and in community settings - yes, that's only been a policy objective since, um, Shifting The Balance Of Power (which policy connoisseurs will remember for Sir Nigel Crisp's gloriously straight-faced suggestion that by 2008, the DH would have reversed its situation of setting 80% of targets  nationally, and would set just 20%. If anyone has seen this in action anywhere, do please get in touch).

It is not in any way a bad idea that reconfiguring the delivery of healthcare to treat people outside acute settings wherever appropriate. It is a good idea. But it comes, as do all significant changes, with opportunity costs.

Opportunity costs
The first is financial. This change will involve re-skilling parts of the workforce. That costs money and time. It has to involve taking the cost out of the acute setting, as double-running services to meet a political commitment is simply not going to be financially possible. It involves spending money on effective and secure mobile IT and monitoring (and secure transport and storage facility for high-cost cancer drugs).

All of this could be worthwhile to improve the quality of care. It might even be cost-neutral. But the chances it will save a lot of money? Very uncertain, and probably unlikely.

Because of opportunity cost number two: the correct level of healthcare and medical unemployment. We have probably tested to destruction the theory that the appropriate level is zero. Very few NHS managers believe it would not be possible to save money currently being spent by reconfiguring services, and also still delivering acceptable safe and quite possibly better care. I have heard serious people talk - unattributably, so sorry, but no names - about the possibility to save 10-20%.

Do-able but un-done
But they have not done it.

Because when push has come to shove on reconfiguration decisions, the culture still believes that the acceptable level of healthcare and medical unemployment is zero.

If I were David Cameron, I'd probably say something like "we can't go on like this". (Of course, if I were David Cameron, I'd have implausibly glossy hair and be airbrushed, which I think we all know is not going to happen.)

The experiment in Torbay with the Kaiser beacon integrated care pilot, detailed in the recent Lib Dem health policy document, is proving that integrated community care can work well. It's not really a surprise. What is a surprise is the very few PCTs (Birmingham East and North, Tower Hamlets - you really can count them on your fingers) who are doing this stuff in a consistent manner and at any scale.

These are not bad ideas. They are just short of the crucial detail about how and how fast the changes will be made. Given the NHS's traditional slowness to adopt new ways of working, there is going to be a need for an arse-kicking force to get this change under way. The Modernisation Agency went and did change to places quite effectively. It wasn't loved for doing so, but being loved is not the point.

National Care Service - numbers and thresholds missing
But whoa! Hold on! Brown's commitment over the National Care Service is much more equivocal: check out the careful wording of "A clear entitlement to this choice is possible within the next few years and we are determined to deliver it."

There has been pundit-scepticism over the mooted social care savings, which can mostly be found in a good new report from Jon Glasby and collegaues at HSMC Birmingham. Glasby and colleagues suggest that without significant change to the social care system, its costs will double in two decades. It doesn't seem an unreasonable assumption.

The politicians' equivocations and sums on the National Care Service, by sharp contrast, continue to look dodgy. At Labour's NHS press conference this morning, Andy Burnhoid denied in wooly terms the previously-briefed figure of a £20,000 levy, which was The Guardian's take on this story.

There is also no information on the thresholds that would trigger the right to access. Which anyone who knows anything will tell you is the crucial issue for social care.

The Conservatives' policy, of an £8,000 insurance fee on retirement to fund permanent residential care, was dfismissed by Burnhoid as "backward-looking".

So what is Labour's policy on funding the social care guarantee (or aspiration)? They're not telling us! Cunning of them.

Therefore we'd have to assume that it will be a forward-looking percentage charge on the estate of homeowners. Will taxing death cost New Labour votes?

Raising the tone of the debate
What joy to also discover that Labour has launched an NHS attack blog - http://www.votenhs.com. When I was trying to google it, I found this - http://votenhs.blogspot.com/ - an invitation-only blog.

How soon will the Conservatives get theirs up?