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Siding with patients

Martin Rathfelder considers the election choices in health

The Government and the opposition are falling over themselves to pledge loyalty to the NHS and its continuing growth. According to the Conservatives 'Few things matter more to our country than the NHS it's an institution that binds the nation together.' Just Nye Bevan's attitude. Health is said to be more important than housing, transport and maybe even education, so it must be protected from the cost of paying for the recession. The main health issue between the parties seems to be their judgement about what promises the voters will believe.

Will voters see any difference between the parties on health coming up to the General Election? Labour has pushed ahead with an internal market, more choice, and brought in more private sector providers to challenge the consultant monopolies, ignoring shouts from the Left that it is dismantling the NHS. Although some Tories would like to do just that, the Cameroons feel more vulnerable in this area and they may prove to be more cautious than Labour has been. The official Tory line is to do what Labour is doing, but better.

Labour can proclaim big triumphs mostly achieved by the blunt instrument of targets the 4 hour wait in casualty, the 18 week wait for treatment and a host of measures to improve primary care. These targets are not popular with clinicians, and abolishing them would not cost money, but they are popular with patients. Patient satisfaction among people with recent experience of healthcare is the highest it has ever been, and has been climbing upwards steadily. Targets are easily understood and have done a lot to curb poor practice and shift power in the direction of patients. The Tory proposal to abolish them and replace them with outcome measures does not sound like a vote winner except with doctors. Outcome measures are not a bad idea in themselves, but it will be a long time before they are developed enough to be used to hold the NHS to account. After all, the long term outcome is that we are all dead. Tony Blair fought elections on the slogan 'More Hospitals, More Schools', not 'more health' or 'more education.' We are spending three times more now on the NHS than we did in 1997 but improvements in health since then have been comparatively modest, and at least partly attributable to improvements in education, housing, etc. Life expectancy is still rising at about three months a year, as in most developed countries, and has been doing since 1840.

There are real problems in defining efficiency in health. We are all in favour of efficiency, but what is it? According to the recent McKinsey report efficiency could be improved if the doctors who spend an hour with each patient improved their service by only spending half an hour with them. And of the 25 minutes in each hour hospital nurses spend with patients they complain that only 15 minutes is spent on physical care as opposed to psychosocial care. But would the patients involved share this view of efficiency?

Real efficiency in health probably comes from public health measures. The smoking ban is the best thing to happen in public health since piped water and will do more to improve the health of the poorest than any amount of hospital building. There are plenty of other issues which need to be tackled like increasing the unit cost of alcohol and altering transport policies in favour of walking and cycling - which address the causes of ill health, but Labour has been a bit timid in this area, and there is no sign that the Tories would be any more decisive. Politicians don't like to talk about rationing. They don't like to talk about death. But both are inevitable. Sarah Palin, bless her, has exposed the scandal of the NHS death committees. http://www.facebook.com/notes.php?id=24718773587

As she reminds us, some 45 years ago Ronald Reagan said that 'no one in this country should be denied medical care because of a lack of funds', but of course everyone everywhere is always denied medical care because of lack of funds. We can always spend more on medical care. The trick is to spend money where it does most good. The scandal, actually, is that the NHS death panels, or PCTs, as we like to call them, are not more active. We let hospitals carry on admitting people until they are full. We pay them to do it. But there is a lot of evidence that 30 or 40% of the patients in an average hospital don't really need to be there. Pressure on hospital beds is, if anything, greater in prosperous areas where people are healthier, live longer, and are more assertive. Giving more power to GPs is likely to shift resources away from the poor.

If we spend less on health care the rational approach would be to cut back on the least cost effective treatments first. The idea that NICE should force Primary Care Trusts to fund treatment at £30,000 for a Quality Adjusted Life Year is not sustainable. Gross domestic product in the UK is only about £23,000 a year. While expenditure is rising it is easy to fudge these difficult questions. We probably ought to close a couple of dozen hospitals, mostly smaller hospitals in suburban areas, and fortunately mostly in Tory areas, which are not suitable either for specialist or community services. But whether politicians of any party are prepared to adopt this sort of approach is very doubtful. Greater efficiencies could probably be achieved by clinicians than by politicians, but that would require less central direction. They have a better idea of where resources are wasted than politicians do. Andrew Lansley, Tory Health shadow, has been telling doctors that they will be running the NHS under the Tories, but devolution of power is always more attractive to parties in opposition than it is to governments. And GPs may not be very enthusiastic about taking more responsibility if that means being blamed when people are denied treatment which is not cost effective.

Andrew Lansley is best friends with the British Medical Association, probably the most powerful Trade Union in Europe. Andy Burnham is positioning himself on the side of patients. GPs have been forced to open in the evening and weekends, and now it is proposed to force them to accept registered patients regardless of where they live. This might give people a choice that interests them. At present the main choice offered to patients is about where to have surgery. Planned surgery is only a small part of the NHS, and choice is not even open to all surgical patients for a variety of reasons. People in Cornwall are unlikely to choose to travel much further than Plymouth. Specialist surgery is only available in regional centres. Few patients care much about this sort of choice. But they might be more interested in the chance to change GP, a choice Labour is proposing to introduce. The quality of service offered by GPs is quite variable and at present it is difficult to change GP if you are dissatisfied.

David Cameron plans to go further down this road '.. by extending the competition and patient choice that Labour have started - not least by equipping patients with the information they need to inform their choice and exercise more control over their healthcare.'

GPs will also have the responsibility to manage the entire relationship that a patient has with the NHS. Tories have great faith in the market. They seem to think that the power to choose 'which GP or other healthcare provider they want to use, which hospital they go to and even whether they want the privacy of a single room, rather than a ward...' will transform the essential power relationship in the NHS, from a top-down relationship where professionals are told what to do by politicians and patients are left to accept the treatment they are given, to one where patients are put first by having the power to choose the service they want, supported by the right information to make that choice meaningful.'

They don't seem to have twigged that most patients acutely ill or living with long term condition are in no position to choose anything other than the nearest provider. Or that if we were going to be choosing other providers there would have to be spare capacity, which costs money. Otherwise we will have the position we have in schools, where the institutions which are popular have a waiting list, or choose their pupils by lot.