Cameron’s pledges on the NHS don’t go far enough

Given the pressure the prime minister is under to deliver significant changes to the Health and Social Care Bill, his keynote speech yesterday fell rather flat.

Mr Cameron made five guarantees to safeguard the NHS, and neatly sidestepped most of the concerns that medical professionals, Liberal Democrats and many in Labour have.

His pledges – to keep a lid on waiting times, to protect funding, prevent privatisation and make competition work for patients, keep care integrated and keep the service ‘national’ – are to be welcomed in and of themselves, but are part straw men and part diversion tactic.

Firstly, the straw men, which Mr Cameron erects on a false premise simply to knock down. In proudly pronouncing that there will be no NHS privatisation, the PM boldly strikes down a policy that was never on the cards; it was never likely that the bill, as drafted, would lead to the NHS being sold off.

The bill did advocate greater private provision of certain services, a continuation of the previous government’s pro-market philosophy, but it amounted more to marketisation than privatisation – and even there the PM appears ready to water down Monitor’s role from being a pure competition watchdog to supporting the integration of care.

Much the same could be said for ‘keeping the service national’; insofar as the nationwide provision of healthcare free-at-point-of-use was concerned, it was never under threat anyway, although many suspected that the bill represented an attempt to retain just the NHS brand, as a ‘kitemark’ to be applied to entirely privately-provided services.

If by this guarantee the PM meant restoring the onus on the secretary of State’s duty “to provide or secure a comprehensive health service, not just to promote one”, one of the key demands for amendments made by Liberal Democrat conference in March, then there’s some substance to it, but it remains to be seen whether this is the case.

On waiting times, there is already some data to suggest they’re going up – although as always I’d urge caution in assigning causality to the opportunity cost of reform as there’s a significant seasonal element to year-on-year waiting times. As yet it’s too early to say whether scrapping the 18 week target has affected waiting times, and given a patient’s right to treatment within 18 weeks enshrined by the NHS Constitution remains in place scrapping this performance target may prove irrelevant anyway.

On to funding, which Mr Cameron says is will rise. There is little doubt that by imposing requirements on hospital trusts to find ‘efficiency savings’ to the tune of several percent of their budget per year, the NHS still faces its tightest financial settlement for decades. Lib Dem MP John Pugh has compared driving through the reforms at the same time as cutting funding in real terms as “trying to turn around an oil tanker whilst dismantling its steering system”; it’s as hard to disagree as it is to see where the extra money will either come from or go to.

Finally, the one pledge that we can welcome unequivocally in its rhetoric is that to keep care integrated – something that Paul Burstow has passionately campaigned for, particularly with regards to social and mental health care. The PM’s words are comforting to those concerned that widening the scope of private providers would lead to fragmentation, with less cooperation between services and institutions working in silos with individual remits; his words may be of comfort, but the threat of fragmentation remains, not least if commissioning consortia are to have arbitrary boundaries that aren’t aligned with local authorities that will be responsible for public health and social care – rhetoric aside then, it’s difficult to see how the bill as it stands, would lead to anything other than less integrated care.

Which means it comes down this: no matter how many I-heart-NHS speeches the PM and his Health secretary make, no matter the stubborn insistence on sticking to ‘red lines’ from their backbenchers and the dubious support from former Labour government advisers, will Cameron and Lansley deliver the significant changes demanded by their Lib Dem colleagues and recommit the bill to parliament? Anything short of this would be just rearranging the deckchairs.