The debate over the NHS in this year’s general election campaign has already become an exchange of insults, doubtful assertions and unreliable statistics of the kind that voters find so edifying. But despite the noise, both parties are avoiding real discussion of the subject, albeit for different reasons.
Being by far the most trusted party on the NHS, Labour have put the health service at the centre of their campaign. But they look set to focus on GP appointment times, spending the proceeds of their Mansion Tax and, of course, attacking the Tories’ record. There is no sign of the harder thinking on the choices needed to make the NHS sustainable in the longer term of the kind that the previous Labour government was prepared to grapple with. They know these choices are grim and unpopular, not least with their own voters, and have decided not to trouble the electorate with them at this stage.
The Conservatives are reluctant to talk any more than they have to about the NHS for the more obvious reason that they feel no such conversation would end well for them. As I have found in my latest research, which included a poll of over 20,000 people and day-long discussions with 80 members of the public, fewer than three in ten voters think they have the best approach to the NHS, eighteen points behind Labour. The Tories are thought less likely to regard the NHS as a priority than Labour, the Lib Dems or (in Scotland and Wales) the SNP and Plaid Cymru – though David Cameron is the only leader thought more likely to care about the NHS than his party. They fear everything they say will be twisted and distorted, and the distortions will be believed.
Some will blame the Lansley reforms for this state of affairs, and it is true enough that they did not help. When I asked what they thought was the reason for the reforms, the single biggest response was “to save money”. More thought they were “part of a plan to privatise the NHS” than to cut bureaucracy or give more choice and control to patients.
But it is not as though these reforms tarnished an otherwise gleaming Conservative reputation on the NHS. In fact the reverse is true: in the absence of any clear explanation of how the changes were supposed to benefit patients, people fell back on their assumptions about Tory motivations.
This is a consequence of the failure to complete the decontamination of the Conservative brand. The party’s modernisation will be complete when it is trusted to sustain and reform the NHS. The tragedy is that in opposition, by campaigning confidently on the NHS the Tories managed to neutralise Labour’s advantage. Though the party may never overtake Labour on health, the NHS does not have to be its perpetual political millstone.
All of which means there is no immediate prospect of a grown-up conversation about one of the most important domestic issues of the time – which is a pity, because we need one. People really do care passionately about the National Health Service. At my research day, views on the NHS were at least as strongly held and expressed as at similar events I have held on Europe and immigration.
My poll found three quarters of those who had used the NHS recently saying they would recommend the service they had received to their friends and family, and a similar proportion believed the NHS is “as good as or better than health services in most other European countries”.
But although people were more likely than not to think spending on the NHS had risen in the last five years, they were much more likely than not to think the service had deteriorated. I found the fact that NHS funding had doubled under the last government – which was news to most people – underlined a view that money was not the whole answer, even if there were any to spend.
Though many are anxious about the NHS on its current course, there is no enthusiasm for reform. My research uncovered five strands of opinion towards the NHS. The “Concerned Status Quo” segment are worried about the future but resistant to change; “Armchair Realists” see a need for reform in principle, but are less keen in practice; “Cautious Reformers” believe extra funding has been largely wasted and are more comfortable than most with private providers within the NHS; “Founding Idealists” oppose private sector involvement and are less likely to think the NHS faces serious problems; and the “Entitlement Protection” segment believe the main problem is too many people using the NHS who have not paid into it.
For most people, the biggest long term problem in the NHS is too much waste and bureaucracy. Rising costs resulting from an ageing population and more expensive treatment are next, followed by too much interference from governments. Though most think under-funding is a problem, it comes relatively low down the list.
While most people’s personal experience of the NHS is good, doom-laden media reporting leads them to believe they must be lucky: 78 per cent thought “the quality of service offered by the NHS varies significantly between different areas and different hospitals”.
Wide recognition of the NHS’s problems does not mean there is any agreement on the way forward. By far the most popular proposals for raising funds or freeing up resources in the NHS were charging for missed GP appointments (which if it were ever introduced would surely raise only a minuscule amount), making bigger cuts in other areas of government spending and cutting back on non-clinical staff – though as my research also found, people are inclined to overestimate hugely the number of managers and administrators.
Just over half thought the government should consider using more private companies in the NHS “when they can provide high quality services more cheaply” – but a fifth of the population, including nearly a third of Labour voters, thought the private sector should not be allowed to provide NHS services “even if this would save money and improve treatment for patients”. More than a quarter thought that if a firm could do an operation for less, paying it to do so represented money leaving the NHS and going to the private sector, rather than a saving for the health service. Even many of those who had no problem with private involvement in principle feared that shareholders would ultimately be prioritised over patients.
I found that being able to choose where or by whom they were treated was a relatively low priority for the public. People were also sceptical about the value of information and choice in driving up standards, as compared with central targets. They were divided over whether publishing detailed information about hospitals, surgeons and survival rates would “raise standards and enable patients to make more informed choices”, or “might be misunderstood by patients and lead them to make choices that are not right for them”.
Only a minority thought the best way to raise NHS standards was to give patients choice “so hospitals have an incentive to innovate and provide the best care”; 60 per cent thought the best way was “for the government to set standards and targets that all hospitals must meet”. Simultaneously, they also demanded a uniform service across the country, and that decisions should be taken by health professionals at a local level to meet the needs of particular areas.
Ultimately, only just over half the public expect that in ten years’ time the NHS will continue to offer a full range of health services to everyone, to a high standard. Three in twenty think that in 25 years the NHS will have disappeared altogether.
We found that discussing the practicalities of the future of the health service is hard because the subject is laden with emotion: one of our participants described the NHS as “the soul of Britain”. Talking about potential reforms, even when aimed at ensuring the sustainability of the service in the long term, feels to many like an affront and makes them defensive.
That is why a proper conversation about the NHS is so important. It’s a shame there’s no sign we’re going to get one.
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