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GB talks about “tough choices”, but not the choices to be made - Health Policy Today, Wednesday 24th September 2008

Reports that Gordon Brown’s speech saved the day are wide of the mark.  It was not brilliant rhetoric or piercing analysis that has staved off a challenge to his premiership, but the shift in global economics giving him the opportunity to take a political lead in uncertain times.  Having pleased everyone from the Mail to the Mirror , Brown must now set out the substance of the tough choices he talked about - by elucidating what these are.  


Gordon Brown’s speech had been keenly awaited and a long time in gestation.  He apparently ‘began writing his first draft on his summer holiday, but the text has been through substantial redrafts as the scale of the global financial crisis has grown’, according to the Guardian . Yet as Polly Tonybee says today, it was Gordon Brown’s best speech, but not a great speech .

For long-term followers of the PM’s speeches, this is another one that textual analysts will pore over, trying to translate words from symbols to letters of substance.

In the last few days GB has talked about the importance of a long-term view; the need to take tough decisions; and for government to show leadership in a changing and uncertain economic climate.  Early on his speech, he talked about the need for “tough choices” and “new priorities” – “we will have to prioritise”, he said. But Brown talked more about the need to make choices rather than the choices that need to be made.  

Instead, Brown reserved the right to govern, hitting out at recent Lib Dem and Conservative critiques of a big state. “Those who don’t believe in government shouldn’t be allowed to form one”. “To govern is to choose. “This is when a government reveals its heart”.

Over the last few months, the government has been preparing its response to some tough choices in healthcare: the issue of top-ups as well as the six-month ‘public debate’ (taking place nowhere near you) on the future of funding long-term care for the elderly.   Brown talked a lot in his speech about long-term conditions, the NHS expanding and the needs of the elderly – “we have more pensioners than children” - but he didn’t say much about the tough choices and the financial challenges that relate to each.  

'He meandered around the terrain of the top-ups debate in healthcare ... but didn’t say anything about changing NICE or the way the NHS accesses and assesses new interventions'

He meandered around the terrain of the top-ups debate in healthcare, talking about people dying from cancer and the need to expand the NHS, but didn’t say anything about changing NICE or the way the NHS accesses and assesses new interventions.  He said the NHS should be focused on 21st century need.  He even talked for a minute or so about his ambition for Britain to lead the world in beating disease, making breakthroughs in research.  

Just recently, however, it has been suggested that there is something fundamentally wrong if UK plc spends so much on research whose fruits are not being translated into clinical practice here.  At a few stages, it seemed that Brown might begin to expand upon a new settlement in NHS funding or on changes in the relationship between the individual and the state, but he always stopped short.

Brown’s tone was more populist: free check-ups for the over 40s pleased the unions; the left of the party were cheered by Brown’s positioning of health as “a right, not a commodity”; the Mail and Express were delighted by free prescriptions for cancer sufferers.


Offering free prescriptions to cancer patients was unexpected, will cost little, and looks like being a popular move, though Metro (the London version of the free commuter paper) today references MacMillan Cancer Support saying that 54% of cancer patients receive free prescriptions anyway.  The tone may be the fault of the editor, but this quote seems churlish when just a fortnight ago MacMillan Cancer Support called on the government to adopt just this measure.

The Express reported that eventually the government aim to provide free prescriptions for those with long-term conditions.  They are now talking to stakeholders and other groups about how which conditions carry this definition and the technical aspects of the policy.


Brown’s speech was peppered with interesting sounding soundbites: he wanted to usher in “a new settlement for new times”; a “fair Britain for a new age” and there are a number of challenges across social policy that require a new settlement.  In health, for example, is there a way to fund long-term care without the elderly having to sell their home?

Previewing Brown’s speech yesterday in the  Guardian , Patrick Wintour said that Brown will extend help for carers who are looking after sick or elderly relatives.  But while Brown talked about the health and social care needs of the elderly, he said little of substance and there was no announcement to extend help for carers.

Speaking to conference today, Alan Johnson talked about a ‘crucial debate on the future of adult social care must produce a radically revisd system which promotes independence and control for people, provides greater consistency of care and is affordable to the taxpayer’.


Both the Times and the Mail understand that the government is set to allow top-ups.  Both papers say they are likely to be capped and patients may also have to pay for any associated costs incurred by the NHS, ‘such as treatment for side-effects’.

A news report in the Times says ‘Professor Richards is expected legitimise practices that circumvent the current guidelines.  Some hospital doctors turn a blind eye to the rules and allow NHS patients to receive privately funded drugs’.

The changes will accompany other reforms, with the government emphasising that a range of changes are needed.  They will introduce measures to speed up the approval process and are keen to find ways to make drugs cheaper.

The changes are also expected to clarify how PCTs deal with exceptions.  Where NICE has turned down a drug, or is yet to make a decision, patients will be able to appeal to their PCT as an exceptional case.  The government will be keen to try and introduce national rules that are followed uniformly, but it seems inevitable that decision–makers in different areas will make choices on different grounds.  Indeed, you could argue that this is desirable.

As a spokesperson for the DH tells today’s Daily Mail, “whatever is recommended won’t satisfy everyone.  There is no magic bullet that resolves this very difficult issue”.  

A leader in the Times notes ‘there is one argument against copayments’ – the inequity arguments.  But it says inequities exist already and in this case  the iniquity of banning co-payments is worse that that of allow them .  The paper says ‘reform of the system is welcome, but overdue’.


The theme of fairness was cast as a central theme in Brown’s speech.  In an email to Labour members today he repeats he wants to achieve “the fair society, fairness at home, fairness in the world – that’s the new settlement for new times”.   Yet the question everyone is asking is, in the light of top-ups being introduced, whether change can be introduced fairly.  Even the Times carried articles with headlines warning about two-tier care, despite their Sunday sister having led the campaign for their introduction.

Speaking to a Labour fringe meeting, the general secretary of the RCN, Peter Carter, worried aloud that top ups would lead to a two-tier system.  He fears that Pandora’s box has been opened.

'Crisp says the way to treat any application to make a top-up as an exceptional case, not the usual way of funding or accessing NHS care.  He would keep the scheme tight and limited.'

The former NHS chief executive Nigel Crisp hasn’t made a habit of intervening in health debates.  A few weeks ago he co-authored a piece for the BMJ warning against the introduction of top-ups.  In the Times today he concedes that their introduction cannot be blocked, but he hopes the government will be true to their word and introduce the scheme fairly.

Under the headline, Don’t let cancer controversy destroy the NHS, Crisp says there are good reasons that the introduction of top-ups should be done in a narrow and heavily-managed way.  First, ‘these cancer drugs are controversial precisely because they are, as yet, unproven or because their known effect is limited or uncertain’.  Second, the numbers affected ‘represent les that a quarter of 1 per cent of NHS spending.  There is no need to change the NHS on their account’.  The third reason is that widespread introduction would lead to the introduction of a core package of care, which will mean that ‘poorer people get a worse deal’.  

Crisp says the way to treat any application to make a top-up payment as an exceptional case, not the usual way of funding or accessing NHS care.  He would keep the scheme tight and limited.

Crisp offers ‘a straightforward choice.  ‘We either stick with a system that aspires to comprehensive coverage and uses NICE to set some limits as to what is available or we create a new system that specifies every core treatment available and charges for add-ons.  The first is quite simply, cheaper and fairer’.

There are tough choices to be made.  This autumn, Gordon Brown and Alan Johnson need to redefine the relationship between the state they represent and the individuals they serve.  At present, during an unprecedented period of economic uncertainty, the state is being presented as a rock we can trust and cling to.  Brown says it will guide us through.  

A ‘new settlement’ was promised by Brown. In health policy, in the areas of top-ups and financing long-term care, there is a need for a new explanation of the relationship between individual and state.