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Sunday, 21 February 2010

After the election: what next for Labour's health policy?

A blog post I wrote for work which I thought might be of interest here. It outlines the major challenges and opportunities for Labour in healthcare after the next election.

"The NHS is probably the most important public service institution for the centre-left" - Neal Lawson (Director of Compass)

The reform of public services is the bread and butter of British politics.

The party that positions itself as the champion of reform and the deliverer of quality services usually reaps the electoral rewards.

Over the last ten years this party has been New Labour.

In two important areas, New Labour has made significant advances. One, it has improved health service delivery. This has meant addressing the chronic under-funding of the NHS, modernising ageing hospitals, increasing the numbers of doctors and nurses by 38,000 and 80,000 respectively and significantly reducing long waits for treatment, particularly in areas like cancer care. There is more progress to be made, but much has been accomplished.

Secondly, New Labour has given huge priority to the development of our public services and set the environment for the future development of health services. The fact that the Conservatives now talk of investment in health services before tax cuts, is testament to this. It was a Conservative Chancellor, Nigel Lawson, who once observed that the NHS was as close as Britain came to a national religion. If that was true in the 1980s, an even stronger case can be made for it now. New Labour's achievement has been to put public service reform at the heart of political debate.

But this does not mean that the NHS is inoculated from future spending cuts. The crisis in the public finances will eventually hit the NHS and healthcare hard. All of the political parties will stress value for money and will debate how that money is spent.

The Next Debate

For Labour, the question after the next election is: After reductions in public spending, what will the future shape of the health service be?

Before it can begin to answer that question, New Labour will have to accept that it has not been able to convince a majority of people that its spending on healthcare and reforms have delivered real improvement. For a party that has an ideological commitment to health care free at the point of need and seeks to improve the NHS because the vast majority of people depend on it, this will be a tough debate to have. Pundits and strategists will wonder why Labour spent all that money and why it devoted all that energy and political capital to the NHS and still achieved little political gain.

If Labour loses the next election (and this is a big if judging by the polls) this debate is likely to take place against a background of political division and bitter recrimination. It will make a meaningful debate about the future of Labour's health policy even more difficult. In opposition, there will be a likely shift to the left which will result in a thorough re-examination of the party's policies.

So then, what next?

At the moment, the NHS is in a transition phase. As the former Health Secretary, Alan Milburn, recently told an audience:

"The NHS today is in transition between a 20th century model characterised by state control, monopoly provision and a provider-dominated culture - and a 21st century one where the citizen is in control and there is a mixed economy of provision and a user-led culture".

Although Alan Milburn is standing down at the next election, he is not alone in arguing for greater radicalism.

There are many within the Labour Party who would like to see the party push for more payment by results, more use of individual NHS budgets so that patients can buy their own treatment and more use of the private and third sector in providing healthcare.

On the other side of the argument are those in the party pushing for less privatisation and commercialisation, the end to the 'command and control' culture of centralisation of the NHS and a more democratic, accountable and bottom up organisation.

The two approaches are not mutually exclusive but advocates of each will have to grapple with some serious challenges and pressure points over the next few years.

The Challenges

Firstly, if Labour loses the election, it will inevitably find itself having to react to a more modest funding settlement for the NHS. The party will relish a battle with a Conservative government on the issue but it will also be an opportunity to re-open a debate in the party about ways to bring in new resources to fund some parts of the NHS. There will be an argument about how to get better value for money and what the priorities should be. It is not impossible to imagine left wing Labour MPs suggesting that private health insurance benefits should be taxed at a higher level or that pharmaceutical companies should face a surcharge on their profits.

On the other side, some on the right of the Party will argue for a debate on charging patients for health services. For many in the party, this remains a taboo subject. The party is wedded to the basic principle that healthcare should be free at the point of need and this will not change. After all it was Nye Bevan, the Labour Minister and founder of the NHS, who resigned in 1951 over the Atlee Government's decision to bring in prescription charges. Nevertheless, one idea on the Labour Right is to introduce a charge to see GPs.

Students, the unemployed, the under 16s, the old and the chronically ill would be exempt but a nominal charge would apply for everyone else. It is argued this would force people to think about the best way of using the NHS and it is hoped this would encourage people to seek out alternative assistance eg at pharmacies, walk in clinics or NHS Direct. In the long term, this would prevent the bottle-necking that occurs at the primary care level.

Secondly, the public's expectations and demands of the NHS will only increase in the future. Patients will demand a personal, tailored service. Across the Labour Party, there is a strong belief that the best way of doing this is to democratise the NHS. Labour will pursue policies that it believes will empower the users of healthcare services and give them more choice and power over services. This could mean that GPs will suddenly be made accountable to the local communities in which they operate or hospitals held to account through commissioning or local elections to vote for the Chief Executive of the PCT. This is an approach the Liberal Democrats have long advocated.

Labour modernisers on the left and right argue that genuinely redistributing power throughout the system will transform the culture of the NHS and lead to innovation and experimentation.

The pursuit of democratisation will also bridge the gap within Labour between those who think the market has all the answers and those who do not. Although there are issues regarding who is elected and what they are responsible for, most party members will agree that the democratisation of the NHS chimes with their own values of equality, empowerment and redistribution. It is likely, therefore, to underpin the party's approach to healthcare.

As a result, those that seek to shape public policy in healthcare will quickly realise that the levers of power do not begin and end at the Department of Health. Labour will push for a genuine redistribution of power. This will mean that decisions which are currently made in Whitehall will be passed down to a local level. As a result, charities, patient groups and the commercial sector will have to re-evaluate their public affairs strategies in the future.

Thirdly, Labour will respond to demands by patients for a more personalised service by stressing the benefits of improved technology. As products become cheaper and easier to use, Labour will want to find ways of using technology to improve healthcare, a goal President Obama is also pursing in the United States. For example, it will campaign for health tests and screening to be done at home rather than in the hospital. Pharmaceutical companies and the rest of the commercial sector will have to find ways of responding to Labour's demands that specific drugs are tailored to meet the needs of individual patients.

Finally, Labour will have to find ways of responding to the demographic challenge. People are living longer and leading more active lives. Labour will again stress the importance of preventative healthcare to allow doctors to spend more time treating chronic illnesses. Successful policies like free swimming places for the elderly (keeping the older generation fit and away from hospital) will be pursued more vigorously. We can expect to see Labour campaigning strongly on anti-smoking, anti- obesity and food education platforms. A new generation of school nurses may be advocated to provide healthcare advice and minor treatments for children and families, thus freeing up other healthcare professionals to spend more time treating and caring for the elderly.

Why the Labour Party will still matter

For Labour in opposition, health will be the litmus test of whether Cameron's conservatives stay true to their modernizing beliefs or revert to a more traditional Conservative agenda. Therefore, expect whoever becomes Shadow Secretary of State to assume the position of leading opposition attack dog.

Many of the ideas outlined in this article will assume centre stage in debates about the future direction of the Labour Party.

The Party will also need to reconcile itself to perceived areas of failure over the last ten years.

The debacle over doctor recruitment. The fiasco over the NHS IT project. The failure to stop mixed sex words. The obsession with targets. And worst of all, the demoralisation of staff. Expect all of them to be thrown across the Despatch Box with regular abandon.

Some of Labour's reforms have alienated the very people they were trying to help.

Consultants, doctors, nurses and midwives feel undervalued and underappreciated. Labour has failed to get the best out of people because it has failed to root those reforms in the very values that underpin the public service ethos. After the next election, Labour will have to find a new way of speaking to public sector workers that does not demean or antagonise them.

Even if Labour loses the next election, the party will still remain the second largest in Parliament. It will continue to be an important political stakeholder. Many of its MPs and members will have, at one time or another, worked in the public services. What it does and what it says on the NHS will still matter. How the Labour Party responds to the challenges outlined will determine its ability to get back into power again in the future.

Of course Labour might win the next election (and I hope it does), in which case all of these issues will assume an even greater importance as the Party struggles to stay in power with a much reduced majority.

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