Feature

And up with democracy... probably

Tony Jewell finds Labour is strong on some traditional commitments — but seems to have forgotten about others

Health 2000 restates the traditional view that the NHS should remain a publicly funded service, free at the point of delivery and funded by general taxation. It reinforces Labour’s commitment to this and to the need to ensure that values such as equity, quality and accountability drive the service. Such sentiments are easy to say, but have been much harder to deliver — and are threatened by recent changes.

One of the reasons that health inequalities have been so difficult to address through the NHS is of course that the determinants of health are wide and encompass social and economic factors that are within the influence of the state but outside the direct remit of the NHS. Improving the public health is acknowledged, in this document, to be a broad-based goal which includes standard of living, housing, transport, food and the wider environment. Health 2000 would, like the current Health of the Nation strategy, need joint cabinet committees to ensure a coherent strategic approach, and this needs spelling out.

Health 2000 proposes to ban tobacco advertising and promotion — surely the most embarrassing example to the present government of a relatively simple act which they refuse to undertake (despite medical advice) in the face of powerful commercial interests and Treasury opposition. If the policy of implementing measures of proven effectiveness is to gain credibility then a clearly effective policy such as this needs to be enacted. The document stresses the need to develop health promotion and illness prevention measures and rightly emphasises a key role for primary care.

‘Planning’ has been reintroduced to replace ‘market forces’. This is a strong point when seen in the context of currently increasing commercialisation within the NHS and underlines the idea of a health service as a comprehensive system, not just a safety net for the underclass. But a return to a bureaucratic planning system would be unwelcome and the NHS changes have not all been bad for people or the service as a whole. It is not credible to oppose every change of the past 15 years and the proposal for an ‘efficiency unit’ within the DoH acknowledges the importance of effectiveness and efficiency.

But the document is also full of ‘motherhood and apple pie’ with wish lists which partly reflect the particular interests of Labour’s health team. Some strange proposals — such as breast screening for younger women — would need rigorous appraisal before being accepted as policy.

There is some bureaucrat-bashing in the document and, of course, there are real concerns over probity and the apparent growth in management. But the NHS has been undermanaged in the past, leading to wasted resources and poor value for money. GP fundholding is rather uncritically set up for abolition without any comment on the important lessons learned through fundholding and other forms of practice-based commissioning.

Health 2000 dances around the issue of the purchaser/provider split and proposes a system of ‘service level agreements’. It needs to be explained how these differ from the types of contract that ‘mature’ purchasers are already negotiating. Some commentators have interpreted the document as retaining the split, and this needs to be spelt out in detail. Indeed, one of the weak points of Health 2000 is the lack of detail. It may be a consultation document but some detailed policy options will have to be developed. Past experience suggests that waiting until election victory is a mistake and I can’t understand why a year’s consultation without a timetable was accepted.

The document has some notable omissions. The Labour Party has been in favour of democracy in the NHS for a long time, but no clear options are put forward for introducing democratic accountability at regional government, local unitary authority or neighbourhood level.

We need to hear more about ‘public sector management’ which can demonstrate efficiency together with managerial competence, probity and democratic accountability. This could be the middle way, to which the document alludes, between a rigid bureaucratic system and market chaos.

As with other Labour Party documents Health 2000 shys away from financing and ducks any commitment to raise the proportion of GDP spent to health to that of comparable OECD countries. Backlog maintenance needs investment and low pay needs tackling if we are to get the economic, efficient and quality service we all want.

The pharmaceutical industry and prescribing costs escape close attention. Prescribed drugs account for 10% of NHS expenditure and the Pharmaceutical Price Regulation Scheme permits a return of 17-21% of capital employed in providing drugs to the NHS which must have been fairly comfortable through the recession. The details of much of the negotiations remains confidential and Labour must form a view about the regulation of the multinational pharmaceutical industry and its relationship to doctors, pharmacists and the NHS.

Finally, we need to see more on the empowerment of people both as citizens and as NHS users. Patients’ and carers’ rights and responsibilities need clarification. One of critique of the rise of a consumerist view of health care is that individuals and society are producers of ill health/health. Professional and patients should be partners, rather than the patient being a consumer. The vision that Health 2000 Mark 2 develops should be of more involvement by users, with open exchange of information, within a democratically accountable system.