Daved and Confused
by Jonty Olliff-Cooper
David Cameron spelt out his priorities a few years ago in three letters: NHS. Since then though, Tory head office has very sensibly read the polls and said almost nothing on this massive policy area. Why? Because you cannot say Tories and health in the same sentence without thinking of cuts. But now Cameron is in the self-declared Year of Change, muzzling the issue is not good enough. That’s why on Monday the Tories unveiled 20 policies for a better NHS. And they are good ones.
Yes there is some waffle (a nebulous reference to cutting NHS administration costs by the miraculous device of “devolving decision making closer to patients” stands out) and some gimmicks too. Andrew Lansley can at last carry out his curious urge to rename DH the Department of Public Health.
But there were a number of solid, pro-poor measures too. The health premium grabbed the headlines, but the highlight was actually the heavy emphasis on structural reform. Nine out of the twenty announcements were connected to extending choice or ‘payment by results’ mechanisms. These policies were largely neglected by the press, which is probably fair enough as creating quasi-markets can seem rather wonky. But do not be deceived; these structural reforms are the big, positive and potentially very pro-poor policies that offer the best hope of improving the NHS for everyone, especially the poorest.
However, the Conservatives must be cautious. As the Demos Power Map shows, there is huge variation in people’s ability to influence their own lives. There is a strong risk that choice systems exacerbate health inequality, not decrease it, because some people learn how to work the system in their favour, whilst others are left at the back of the queue.
The Tories have to confront this. A decentralised state full of innovation and third sector providers is great, but it is much more confusing. Without mitigating measures, patient (and school) choice will hobble the weakest.
So the Conservatives need to start thinking about how to unscramble the state. This goes to the heart of a big question for the Tories: what inequality is to them; and what they will do about it. Equality is not just about income or non-discrimination. For progressive Conservatives it is about equality of assets, networks, cultural capital and character too. Equality of access is a huge part of this. After all, not knowing how to use a service is as bad as not having it at all. If we are not careful, choice in health could stretch the gap still wider.
That is why Cameron’s next speech should be on equality of access, looking at successes like New York’s 311 or the Cotswold Village Agents. Otherwise his despite good intentions, we might all be left Dave-ed but confused.
Jonty Olliff-Cooper
Thank you Cliff. I quite agree. (I had a mention of Patient Opinion in the first draft.)
This links to Demos' wider character and capability work. Check it out at http://www.demos.co.uk/publications/parenting
Joe Farrington-Douglas
Politicians and commentators on all sides have been very lazy about definitions of - and distinctions between - choice, competition, empowerment, coproduction etc. Actually what Conservative policies really talk about is competition. Of course, this is also what the Government has already been doing for the last two terms, as John Appleby pointed out (http://bit.ly/8Fmvi9).
As you both say, though, the really interesting - and more challenging - territory is raising self (and collective) efficacy, particularly for disadvantaged and unempowered service users. More marketisation won't achieve this my magic, and as you say may make it worse (or no better). Cooper and Le Grand's claims (http://bit.ly/8drp4A) of a pro-poor impact of reforms are down to targets (which Demos and Conservatives oppose) not choice or markets.
It's not a new argument - at ippr (http://bit.ly/6czWTy) we made these points some time ago - but the policies to make real equitable choice have still not hit the mainstream, so there's a good space here for Demos to apply progressive pressure.
Jonty Olliff-Cooper
Thank you for your comments Joe. Plenty for us to follow up there. I agree there is much more to make choice work.
cliff prior
The NHS was created so that health care is free at the point of delivery. So it is a social promise of equality of access regardless of wealth. Increasingly, it is information, the confidence to use it, the self esteem and motivation to want to use it, which are the key determinants of access. Even more so with personal budget and choice based initiatives.
S0 do we need a new social promise of equality of access regardless of information ability?
Yet we know that self efficacy (the confidence and skill to use information and tackle problems) is critical for a good life and good health outcomes. So the last thing we should do is undermine people's self determination in this area by creating dependency.
This is a really tough area to get right. Folk like Harry Cayton and Paul Hodgkin have been thinking this through for some time. Its not simple. But despite the intangible quality of the concept, its central to getting the next level of health improvements.