Interview

Opposition guaranteed

As New Labour’s modernisation of the NHS falters, what big ideas do the Conservatives have in store? Shadow health minister Liam Fox spoke exclusively to healthmatters

Liam Fox can afford to smile. Labour’s mid-term blues have hit the government hardest where it hurts the most – on the health service, traditionally Labour’s strongest suit. And their current pasting over NHS waiting lists, funding ‘aspirations’, professional mutinies and media manipulation is clearly a source of some quiet satisfaction to Dr Fox, the Conservative shadow secretary of state for health.

‘How come, in the world’s fifth biggest economy at the beginning of the twenty-first century, something as predictable, as cyclical and as common as flu can bring the health service effectively to its knees?’ he asks incredulously.

The obvious riposte – 18 years of under-funding by Conservative governments – isn’t part of Dr Fox’s answer, though funding is. ‘We spend too little on health care in this country’, he agrees. ‘I think that we have gone, in the last couple of years, below the level which gives us any slack at all.’

And the Conservatives would spend more on the NHS? ‘Yes, we do need to increase our expenditure, otherwise our health outcomes will remain unacceptably low,’ he says. ‘I don’t see any point in changing the tax basis on which the NHS is run – but I do see that one of the biggest gaps we have is in the proportion of our post-tax income that we are willing to spend on health.’

Previously a general practitioner, and MP for Woodspring since 1992, Liam Fox is surprisingly pragmatic about the NHS for a Tory politician, given the ideologically charged climate of the past decade. Perhaps having front line experience of the health service helps. But, being a Tory, he is a natural supporter of the expansion of private care, albeit rather modestly.

‘For a small range of private expenditure we would want to hope that people will be willing to spend more of their own income,’ he argues, suggesting that ‘people who could afford, or whose companies provide them with, these resources are off-loading the NHS’.

‘One of Labour’s most vicious acts right at the outset was to abolish the tax relief on private insurance for the elderly, which has only succeeded in making NHS queues longer.’

But Dr Fox won’t be drawn on how the Tories might seek to expand private spending on health. At present the only clue to Conservative health policy is their ‘Patient’s Guarantee’ (see the box opposite), part of William Hague’s ‘commonsense revolution’ package. This implies that more NHS patients should be treated in the private sector, with the taxpayer footing the bill, to meet guaranteed waiting times – something Tony Blair also seemed to give the green light to in a recent debate with NHS staff, despite existing Department of Health guidance that NHS care in private hospitals should be seen as a last resort. But perhaps the government is now considering anything that might help reduce waiting lists. So what do the Tories think of Labour’s high profile electoral pledge on waiting lists?

‘I think they were foolish to make it. I think they are even more foolish to keep it in place’, says Dr Fox. ‘They’ve conceded the distortion it’s creating.’ And one has to wonder whether Labour health minister Alan Milburn might be inclined to agree.

‘Waiting times would be a far better way of dealing with the problem than waiting lists. Lists are meaningless because I couldn’t care less how many people were in front of me or behind me on a list. All I worry about is the time I wait – and we will move to a waiting time based system,’ he adds.

Of course, there is still always the risk that as waiting times fall more patients are referred for treatment, pushing waiting times up again. Demand for health care seems to be limitless – and alongside the quest for lower taxation, this forces the issue of rationing healthcare up the agenda as never before. But who should make such decisions, and how? These are questions politicians would much rather avoid: the Patient’s Guarantee, for example, pushes the responsibility on to doctors.

But Dr Fox broadly supports the role of Labour’s National Institute for Clinical Excellence (NICE) in assessing new drugs and technologies before they are used in the NHS, though he has his reservations about the decision to discourage doctors from prescribing Relenza, an anti-flu drug, on the NHS.

‘NICE has been set up in the wrong way, I think. If you are going to consider the cost-effectiveness of something you need to consider its cost-effectiveness over your whole area of spending. For example, if the cost of the flu outbreak to British industry is of the order of £8bn and by spending £100m on Relenza you could dramatically reduce that, then overall that becomes a cost benefit.’

And if NICE was to conclude that a new drug was less cost-effective than an existing treatment, should the NHS refuse to fund it?

‘That’s entirely a suitable ministerial decision,’ says Dr Fox, apparently contradicting his party’s Patient Guarantee, which asserts that ‘a clinician not a politician’ is the proper person to make decisions about priorities.

Just as under the last government, primary care under Labour has again become an area of rapid and often controversial policy change, producing running battles with the medical profession. Labour lost no time in ending fundholding, replacing it with primary care groups (PCGs), and with primary care trusts soon to emerge. But, surprisingly, Dr Fox doesn’t hold a great deal of nostalgia for the heady days of GP fundholding.

‘Fundholding in some areas was extraordinarily successful. It was most successful in areas where you already had GPs who were innovative and creative anyway,’ he admits. ‘I don’t think that fundholding applied universally would be any more successful than PCGs would be.’

He is also unwilling to give Labour’s collectivist alternative to GP entrepreneurialism much support. ‘PCGs may work in areas – for example inner cities – where you have disparate groupings that never worked together before,’ he says, ‘but I think that in many rural areas, for example, it will simply create resentment from people who were working perfectly well being forced into structures and straitjackets they didn’t want’.

So if he were to find himself a future secretary of state for health, would he restore fundholding and wind up PCGs? ‘What we will do when we return to office is we will look and see what’s working,’ says the pragmatic Dr Fox.

Other changes, of course, are also afoot in primary care. The 1997 Primary Care Act – one of the last of the Tory years – set the stage for the development of what are now called personal medical services pilots, leading to an expansion in the number of salaried GPs, local rather than national contracts for some practices, and in some cases nurse-led primary care. A vigorous debate is now being held among GPs on the future of ‘independent contractor status’, with many convinced that – as in the 1940s – Labour would like nothing better than to see a national salaried service. Does Dr Fox think that the historical fudge of independent contractor status has had its day?

‘I very much hope not. I think independent contractor status has been an integral part of our primary care set-up and a lots of doctors like it. However, not all doctors want that.’

But doesn’t independent contractor status make it hard to manage a national primary care service? This suggestion provokes an impassioned response from one who was a GP in his former life.

‘I think that all of these changes are about control. The thread that runs through all departments in this government is the prime minister’s control freak mentality, which is just to control everything from the centre – and I think that simply does not work in primary care.’

And other Labour primary care policies, aimed at improving access and giving the public a better impression of their first contact with the NHS, have also met with resistance from GPs. NHS Direct, the nurse-led telephone helpline, has split the profession down the middle, into wide-eyed evangelists and hard-bitten cynics.

‘We piloted NHS Direct in office,’ says Dr Fox. ‘We were the ones who started it, and I have no problem at all with NHS Direct as long as it is giving quality assured information.’

But surely it undermines the unique relationship between patient and GP which has been at the heart of British primary care? ‘Except that patients have always been willing to consult the practice nurse, or ask the chemist or get other sources of information.’

Labour’s new walk-in centres, however – so far 36 have been announced and are due to get underway in coming months – are a different matter. ‘I do see walk-in centres as interfering with our tradition of practising medicine and I think they offer the potential for the fragmentation of care.’

‘Were you to have some way of carrying your medical records on a card, or a proper national database, then there would be less risk of that. But there’s a definite risk of abuse in the system, of patients using it for second opinions or going to another doctor with a condition they don’t want their own doctor to know about.’

One suspects, however, that the Tories will wait and see how Labour’s sweeping changes to primary and immediate care services turn out, because the government’s clear calculation – based on pretty good odds – is that despite professional scepticism they will prove immensely popular with the public. If that is the case, then careful politicians like Liam Fox will make sure they are in a position to say they supported them all along.