New decade; same message: the Tories’ manifesto for the NHS

Cameron's NHS vision embraces “decentralisation, accountability and transparency”. But it misunderstands inequality and says nothing about standards.

“Don’t be shy about the NHS” is clearly David Cameron’s New Year’s resolution. Chapter one of the his Draft Manifesto 2010 sets out “our Reform Plan for the NHS”.

Top of the in-tray for clinicians and NHS managers is sustaining recent improvements on less money: £20 billion less predicts its Chief Executive. How can NHS quality and productivity be enhanced in parallel? Short of sacking support staff, Cameron says nothing about this.

Instead, his vision embraces “decentralisation, accountability and transparency” with much more competition, and a bonfire of targets. Much of this is not new but fails to address a key question: what NHS standards will exist under the Tories? There is no concept that patients as consumers become weaker with minimum standards or targets removed, and funding squeezed. Perhaps Cameron also feels vulnerable on social justice, as he and his spinners make a big feature of a new commitment: “on public health … we will weight funding so that extra resources go to the poorest areas with the worst health outcomes”.

Focussing on outcomes and inequality is good news for the left, however. Cameron’s argument on the causes of inequality is wafer thin. A first year sociology student knows that health status depends on much more than direct health service spend: the challenge is that many solutions lie outside the NHS, linked to aspirations, educational achievement, employment, lifestyle, sense of community and housing. Hence amongst developing nations for example, the USA spends double on health services in terms of purchasing power compared to Greece, yet has lower infant mortality and life expectancy.

A wealth of research highlights these wider influences on people’s health. The Spirit Level by Richard Wilkinson and Kate Pickett was a seminal book of 2009, emphasising the link between unequal health and income inequality. The Department of Health has commissioned WHO advisor Michael Marmot to propose strategies to reduce health inequalities from 2010, reporting pre-election.

Cameron has now revealed his hand on the NHS, and the “small state” solution is emerging. Aggressive competition and an innate preference for tax cuts and low spending cannot sit easily with a national service driving reduced inequalities.

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