Health policy debate (HPD) - 1 to 14 March 2005
This issue of HPD is longer than usual because of the amount of political coverage sparked by the case of Mrs Dixon. Ordinarily, HPD covers professionalism, performance, plurality, incentives and innovation. But for the next few months, politics will be added to this list.
Politics
The election is approaching rapidly and already the press and political parties are in advanced training. The "battle of Margaret’s shoulder" became the first major battle of the 2005 general election.
The importance of health in the general election and the case of Margaret Dixon
Political polls in England show the state of the health service is second only to immigration in voters’ priorities. In Wales, an ICM poll found 22% of voters ‘gave health as their number one issue, followed by education with 9%. Three further issues were tied on 8% - asylum and immigration, taxes, and law and order’. [Go to note 1]
Ordinarily, the citing of health as the most important issue would be good for Labour, as traditionally it is safe territory for them. However, in the last two weeks, they have been rattled by a Conservative attack on their health policy.
Influenced by his new advisor, Howard chose to highlight an individual case to demonstrate to voters that for all of Labour’s trumpeting of its achievements in the NHS, there are fundamental problems with the system that they would change.
The case came to the attention of Tory HQ when a Conservative councillor put a leaflet through the door of Margaret Dixon and offered her mobile number if anyone had an issue to discuss. Mrs Dixon called to talk about her experience of continually having her operation cancelled. The councillor, Fiona Bruce, has since been adopted adopted as the prospective Tory candidate to take on sitting Labour MP, Helen Southworth, who has a 7,837 majority in Warrington South.
Mrs Dixon is an interesting political pawn as a Tory-to-Labour switcher in 1997. She is typical of many voters that the Conservatives want to win back.
She has complex health needs and to be operated on required a High Dependency Unit bed, which was continually unavailable, meaning her operation was cancelled several times. Her case became the basis upon which senior Westminster politicians - ‘led by Michael Howard and Tony Blair - traded blows about the extra billions Labour has invested to modernise the NHS (up from £43bn to nearly £70bn in four years) and the disputed impact it is having on waiting lists and treatment.
As The Guardian‘s Michael White noted, ‘Conservative strategists think the Dixon case has crystallised public fears about an over-bureaucratised NHS. Labour HQ thinks that by latching on to one case Mr Howard has made a typical miscalculation in searching for headlines. [Go to note 2]
Conservatives attack on health - and win the early rounds
The case of Mrs Dixon gave the Conservatives a chance to attack and to the surprise of many, win a skirmish with Labour on health policy. A Sky News phone poll (on 8th March - the day Reid and Blair held a press conference on health) showed a majority (57%) had more faith in Tory plans for the health service than in the government’s.
Although Margaret’s shoulder was operated upon on March 16th her story will not go away quickly. It’s sub-themes will form battle lines in the coming weeks.
For example, a feature in the Sunday Times said that Mrs Dixon’s case ‘seemed to go to the heart of a key election issue: after all the extra billions poured into the NHS has the service got any better or is the money, which is set to cost each man, woman and child in the country £1500 a year, being wasted?’
Blair asks voters to judge him on the performance of the NHS
Two days later, speaking at Labour’s spring conference in Dundee, Tony Blair said: "To say our NHS today is worse than it was in those Tory years, to see Michael Howard, who sat for ten years in that Cabinet as they cut it, starved it of resources, sneered at its values - to see him take the case of someone in pain and use it to run down and denigrate the whole of our NHS, should make any decent, right- thinking person turn away in disgust."
"I say this to the people of Britain: shortly you will make a choice. Rightly, the NHS and its future will be at the heart of it. "If you believe the NHS today is worse than it was when Mr Howard and the Conservatives ran it, don’t vote for me. Vote for him. Put me out of Downing Street. Put him in."
After the speech, Blair emailed Labour members to remind them that "Labour is the party of the NHS, always was, always will be". [Go to note 3]
The Conservatives continue to attack
The Conservatives continued to attack. They undertook a quick survey of hospital finances and the measures being taken to reign in overspends. In line with recent Health Service Journal surveys they found they 'hospitals are freezing recruitment, closing beds and postponing operations in an attempt to prevent a forecast overspend across the NHS'. [Go to note 4]
This reality contrasts oddly with the picture the government are trying to portray an NHS that is improving and will prove embarrassing in the run up to the election.
Michael White said the Conservative strategy was typical of its new adviser - Lynton Crosby - who has helped John Howard to 4 election victories in Australia. Tory MPs are quoting ‘the aincient Chinese military strategist Sun Tzu: ‘attack the enemy where he is unprepared and appear where you are not expected - ie a Warrington hospital’. However, Labour officials were describing the Tory attack as tactically clever but strategically stupid - because it would inevitably focus media attention on Conservative proposals to pay half the NHS tariff toward private treatment’. [Go to note 5]
But are they right to be so confident? Not according to Polly Toynbee who asks: ‘what is going wrong' for Labour?’
'Labour looks ambushed by the ferocity, speed and dirty tricks of a Tory party that has suddenly woken from its torpor. Just look at the Tory website for attack, compared with Labour's timid offering. Where is the rapid rebuttal force that used to defend Labour? Where are the friends and allies in every field that used to jump to its defence?'
'Every day the Tories are first in with a punch on the nose, a flyweight frisking around the ageing champ'. Is it because 'eight years is many dog-years in government, while voters' political memories are goldfish-short'? The awful truth is only just dawning on Labour that what things were like eight years ago doesn't cut much mustard, except with we political archivists. Those waiting for an operation for eight months care little that they would have waited 18 months back in Tory olden days.'
'The cheek of the Tory campaign springs from believing they are at last free of their past'. 'So they feel disgracefully liberated to hit and run on myriad public sector failings, leaving Labour lamely sulking that things were even worse once'.
'Labour steadied their nerves with reassurances that all would change once the fight moved on to Labour terrain, the NHS especially. Now the Tories have marched through the night to mount a dawn raid on Labour's NHS camp too'.
'Even the NHS doesn't feel like completely secure home turf'.
'The NHS still has far to go - but it would take gross Labour campaigning ineptitude to let voters think the Tories would do better. It should be easier than this to turn the tables on Howard's health policy: it will take £1.2bn deadweight cost out of the NHS budget as a free gift to all those already buying private operations. There's no knowing how many more billions the NHS will lose if other better-off people take up the voucher. It's a shocker of a policy, breaking the principle of the free NHS'. [Go to note 6]
Rattled Reid launches aggressive offensive against Conservative policy
Labour were rattled by the Conservatives seizing the initiative on health policy debate, but insisted that ‘Mr Howard has played into their hands by raising the NHS up the agenda’. They believe they will win the argument if they could focus voters' minds to contrast their use of the private sector to enhance NHS capacity with the Conservatives aim to use the NHS to increase the private sectors market share. [Go to note 7]
To many this may seem like semantics, but for Reid this is a vital distinction. At a press conference on 8th March he said the Conservatives when in government had not merely been responsible for cancelled operations but also for "cancelled lives". Furthermore, the Conservative policy was illegal. He said it would breach the first clause of the act that founded the health service.
John Reid challenged Michael Howard ‘to come out from behind his "human shield" and explain how using taxpayers' money to help the better-off get private operations will help the NHS- or its patients.’ "Have the guts to come out into the open and debate your indefensible policy. You won't, of course. You daren't. Because you know that it's a policy of cuts and charges that is unfair, immoral and contrary to the very principle on which the NHS was founded".’ [Go to note 8]
Reid appeared on Newsnight that night after a long day and immediately barked at Jeremy Paxman for referring to him as a "Labour attack dog" in his introduction. He objected to being patronized.
Odd then that two days later cabinet ministers were calling Howard an "attack mongrel".
Odd too, was Reid’s outburst. Private Eye asked: ‘Was it really, as he claimed, that Jeremy Paxman had hurt the feelings of this delicate ministerial flower by calling him an "attack dog"? Er, not quite.’
‘What roused poor sensitive Reid to fury was the discovery - too late - that the shadow health secretary Andrew Lansley was also on the programme. As soon as the broadcast was over, Reid’s minders complained furiously to the BBC that he’d been "set up" explaining that he would never have appeared if he’d known that a Tory would be allowed to join the debate’.
‘All most puzzling, since the Newsnight item was inspired by a press conference earlier that day at which Reid had called for a debate’
Reid later rallied in the programme and focused on the Conservatives "patient passport". He said it was "illegal" and asked Lansley, "Yes or no, will you change the legislation that the NHS is founded upon?" When Lansley said "no", Reid said: "well you’ve just thrown your flagship policy down the drain". (Initial legal advice obtained by HPERU suggests that Reid is right. The Conservatives would have to amend sub-section 1 of the NHS Act to introduce its patient passport.)
As The Times explained, ‘Clause one of the 1948 Act which founded the NHS - amended in 1977 - states that treatment "shall be free of charge except in so far as the making an recovery of charges is expressly provided for by or under any enactment, whenever passed". [Go to note 9]
The NHS will play a key role in the general election
In the Health Service Journal, Alastair McLellan complained that the pre-election campaigning is not throwing much light on the more substantive issues facing health service reform.
‘There is little debate, for example, about practice-based commissioning or payment by results - probably because Labour and the Conservatives are in broad agreement about the direction of travel, and the issues are deemed to complicated by the national media for general consumption’. [Go to note 10]
On the contrary, Alice Miles argued in The Times, the initial debate presents a lot to think about.
The Conservatives would respond to Reid’s charge of privitisation by saying, ‘yes, they do want to encourage more people to use the private sector in order to develop it as competition for newly liberated NHS hospitals - but that after the first £1.2 billion it will start representing a saving to the NHS as it saves half the cost of all those operations it would otherwise have funded'.
'There is plenty here for the parties to argue over - about whether Labour's use of the private sector introduces any competition or simply represents a short-term measure to cut waiting lists but leaves the monolithic health service fundamentally unchanged, for instance.' [Go to note 11]
After the Reid/Blair press conference, Michael Howard repeated his call for a TV debate with the prime minister. The Tory leader said: "John Reid calls for a debate on health. I say bring it on. I have consistently called for a debate with Mr Blair and I repeat it again today."
As Michael White noted:' In the War of Margaret's Shoulder, only the upcoming election will reveal the real victor'. [Go to note 12]
The following week he noted some of the argument will be resolved by whose statistics the public find more persuasive, for example: how should you report the numbers coming off the waiting list?
Michael White says ‘it’s the so-called "bus queue" argument. Does an average include those who were waiting for ages and have now got a bus? Or just those still in line?’ This is essentially the difference between Conservative and Labour counting. [Go to note 13]