Fresh perspective: Liberal Democrats outline new health policies

by Andy Cowper, editor, Health Policy Insight
It’s been difficult to write about Lib Dem health policies in recent years for a couple of reasons. Firstly, there haven’t been many worth the name. Secondly, since Evan Harris, they have had a series of spokespeople on health who have not exactly impressed.

Liberal Democrat shadow health secretary Norman Lamb is changing that. His thoughtful presentation to the NHS Confederation’s Westminster lecture series outlined their new directions, which Lib Dem leader Nick Clegg re-emphasised in a recent Kings Fund meeting.

Chairing Lamb’s lecture, NHS Confederation policy director Nigel Edwards wryly observed that the fate of the best ideas is to be stolen by others. Does this sincerest form of flattery await Lib Dem policy on top-ups – perhaps very soon?

The future’s Orange (Book)

The electoral arithmetic is starting to look brighter for Westminster’s third party than it has for decades. True, the Conservatives enjoy a daunting lead in opinion polls, but the election is not tomorrow. Events and smart tactics have been benevolent to them – yet the degree of swing needed to put them straight into power still feels unlikely.

As Labour fails to escape the sitzkrieg over polyclinics, and the Conservatives have announced the bulk of their policy platform in 2007, attention is inevitably now focusing on the Lib Dem suggestions.

In his busy office in Portcullis House, Lamb reiterates the Lib Dems’ principal new themes: a right to top up NHS care; defined entitlements for patients, backed by a waiting guarantee (whereby the PCT will fund private treatment if providers cannot offer access within a set timeframe); direct elections for 2/3 of the PCT boards; individual budgets for patients with long-term conditions; and a locally variable income tax which could fund this.

HPI: Have you costed your waiting guarantee?

NL: “We haven’t - at this stage it’s about the principle of the issue. We met health economists in Denmark, and discussed how a similar system has worked there. In Denmark, they started with a three-month wait triggering the entitlement. This year, they’ve reduced it to two months, and they’ve seen a substantial step change.

“The experience of this gradualist approach has seen very few patients leach out into the Danish private sector, but we don’t have a philosophical problem with that anyway. It has not destabilised the state hospitals; it’s resulted in them improving their efficiency substantially and doing it on time. The people we met described it as the single biggest driver of state sector efficiency improvement they knew.

“We’re looking at extending this to mental health as well as acute care, and the potential costs of that. There’s always costs of any guarantee: as Labour’s found with 18 weeks. This is partly about improved efficiency, but especially in mental health, the capacity issue is serious. There are not enough therapists at present, and incidentally I’m told those being trained up in cognitive behavioural therapy (CBT) training under Layard proposals won’t be able to deal with the more acute mental health needs.

“Providing more CBT is good in itself, but not sufficient to the scale of the problem. There’s a danger of seeing the box as ticked, and of neglecting people with more acute mental health problems, whom these low-cost CBT therapists won’t help. These people with more serious mental health problems have rights to care, and can pose a danger to themselves, and to the wider community.

“If you were to introduce a 12-week wait to access as a long-stop, given that a lot of people wait more than a year, there will be two consequences. Firstly, a lead-in period. You could not impose this straight away, we’re so under-provided, so we’d have a gradualist basis (as in Denmark), reducing the maximum waiting time in the entitlement step by step. Secondly, we’d have to commit extra resources to build capacity to deliver the care on time.”

HPI: Where would those resources come from?

NL: “One thing Nick Clegg touched on and I’m starting to develop, is about efficiency. Health economists like Nick Bosanquet, believe that it should be possible to achieve efficiency saving of perhaps 10% of total NHS spend. That frees up billions, even if you only achieve 5%! That efficiency dividend can be invested in priority areas. We want to develop ideas in our autumn conference of principle of equal treatment for mental health patients, who face massive discrimination in access and in the quality of accommodation, compared to other patient groups.”

HPI: How will you decide the length of time it’s appropriate to wait for an NHS-funded treatment?

NL: “We’ll use clinically-based, condition-specific criteria. The issue raised at our Kings Fund meeting about access times for diagnosis were interesting, but we wouldn't want to lose the concept of entitlement – for example - to access to diagnosis within two weeks for a breast cancer patient (which is a target at present; not an entitlement). We know that a lot of people whom GPs define as not high-risk of breast cancer who are referred but not within 2 weeks - and a significant proportion of this group are then found to have breast cancer.

“So that target’s not very effective, as long as there’s a slow-track outside 2 weeks: a classic perverse consequence of targetry, which makes those perceived ‘low-risk’ patients wait longer and ends up leaving them at more risk than if there were no target.”

HPI: Do you think NHS capacity and commissioning is up to delivering on your entitlement?

NL: “I always think it's right to set stretching challenges for organisations, to stretch and challenge rather than allow complacency, and that’s why I don’t buy the Conservatives’ policy proposals that waiting time targets and or any measure of access are not important: they would ditch all of them and focus only on outcomes. Outcomes are very important, but part of the problem for a patient suffering from cancer is the stress and trauma they go through. A modern service should be able to deliver quickly, which in itself improve outcomes. Guaranteeing access is more effective than a blunt bureaucratic target.”
Commissioning is not strong, it’s weak and we have a long way to go improving the quality of commissioning. The focus has been on providers in recent years and they’ve mostly got very good at becoming more efficient and now we have a series of acute foundation trust hospitals with surpluses in FTs, which is not necessarily in the wider community’s interests.

“We need real effective commissioning for value for money in PCTs. Current organisations may struggle to meet an entitlement to access treatment, but that is no reason why we shouldn’t introduce it and require them to meet it.”

HPI: Does your waiting guarantee mean the end of patient choice of NHS provider?

NL: “There doesn’t have to be any conflict with choice. I accept and am positive on choice as a concept. I don’t think choice has developed significantly so far, and our proposals for patient advocates would help more people to make sensible, wise choices. For an elected health board who’s funding treatment, the patient can say to their GP, ‘I want to go to that good hospital’.

“Choice should also be the choice to wait longer to go where you want to, which gets closed down under the straightjacket of Choose And Book, where centre-of-excellence trusts with long waits get ‘greyed out’ of the CAB list. That’s very centrally constrained choice. You can empower patients to wait rationally to see a particular specialist than they may need to wait.

HPI: You’ll be relaxed about patients exceeding the maximum wait if it’s their choice?

NL: If it’s up to the patient. The entitlement only kicks in if the patient wants it to. If they are content to wait for a specialist in a particular hospital and they want to have it free but they’re content to wait, then that’s fine.

HPI: Is your waiting guarantee basically designed to address very bad waits in a few areas (audiology; mental heath; therapy and rehab)?

NL: Yes. We acknowledge recent NHS improvement and we supported the new investment. And there’s an optimum maximum waiting period, under which it would not make sense to push it down and to guarantee operations within 4 weeks: sometimes things can happen to change the diagnosis and the judgment of most suitable treatment. Sometimes it’s sensible to wait to develop the diagnosis. It shouldn’t be seen as a straightjacket. I think it’s particularly powerful in mental health, and it’s not the only lever that can be used to improve efficiency or the entitlement of patients. It’s potentially an effective lever and I don’t think when we talk about waiting targets having worked, that we can see it as a one-off job done. Without investment and without a drive for maintaining improved efficiency, it could drift up again: you can never take your eye off the ball.

“I think this is a more sensitive tool than blunt waiting time target, which give patients no particular rights. If 6% of patients don’t meet the target, nothing happens: there’s no sanction”.

HPI: You’re not concerned about any distorting effects from a greater focus on activity and maybe less on outcomes?

NL: We asked about this in Denmark. Their main messages were of no significant distorting effect and the overall improvement and resource efficiency massively over-compensating for any minor distortion.

HPI: What has been the take-up in Denmark?

NL: A report found that about 2% tip over the two months and get funded to go private. So it’s guaranteed that patients get their operation.

HPI: In your Westminister lecture, you said that equity was a key principle as a Liberal. How will you explain to a constituent that your topping-up policy does not institutionalise a two-tier NHS with a residualist service for those who can’t pay for extras?

NL: I have a constituent, a fireman, now retired. He’s not wealthy, and he’s liver cancer: apparently he contracted Hepatitis C in his work as a fireman. It’s a tragic case. His clinician at Addenbrookes says that a particular palliative drug (not approved by NICE) should extend his life. The PCT refused; he appealed under exception rules; and that appeal was refused. Under current rules, if he has this drug, he takes himself outside the NHS system for all his care. You have to ask, is that equitable? For someone of very modest means who paid his taxes his whole working life to have the NHS rug pulled from under him?

“I have a different view from those who instinctively oppose this saying that it breaks the NHS social contract. If you're very wealthy, you're fine and can pay privately: it's those of modest means who are potentially the most affected. For me, the NHS principle is that everybody has access to the NHS offer equally, without fear or favour, irrespective of income. You shouldn't lose that NHS offer because you follow a clinician's advice and buy a drug to extend your life which isn’t being paid for by the NHS. I think that is potentially iniquitous.

“We need all sorts of conditions and protocols if we do change the rules. But the principle of co-payment exists already: prescription charges, eye tests, dentistry. It’s hard to argue that this is still an overwhelming principle that must be maintained because it’s al ready been broken, and we could end up with very haphazard co-payment system. Things like car parking charges can disproportionately affect those on low incomes.

“There’s a very powerful case for it but it needs to be introduced in such a way that the NHS will not end up paying a penny extra. That must be an absolute rule: you have to pay the full costs of the extra treatment, including any extra hidden costs (like diagnostics). We can’t have an extra burden imposed on the NHS if someone chooses to go beyond what the NHS system offers”.

HPI: What mechanisms will be needed to deal with locally-elected PCT boards who campaign in poetry (overpromise) but deliver prose (under-deliver)? Is there a recall mechanism?

NL: There could easily be. We haven’t gone into mechanisms, but all PCT boards would be nationally audited, as local government is. So voters can see performance and MPs can hold them to account and be able to argue publicly why can some regions achieve things that others can’t. Use the power of the democratic process! Sometimes that doesn’t work, and there may be additional mechanisms needed.

HPI: Last week, West Sussex County Council held a vote and agreed that they want to take on the PCT functions, and have written to health secretary Alan Johnson to ask permission. Would you have concerns about local government running PCTs?

NL: “Our paper argues that if a locality’s social services authority believed they could commission healthcare effectively because they’re well-run and star-rated, then that should be voted on in a referendum by the local community. If you believe in empowering the local community, you don’t have to have a straightjacket. If West Sussex is really well-run, let them put forward the case to that community.

“I’ve been interested in the development of Care trusts such as in North-East Lincolnshire’s Care Trust Plus, bringing together health and social care, and transferring the public healthy professionals into the local authority to work alongside housing experts, regeneration experts and educationalists. Herefordshire Unitary Council has merged the county council, unitary council and PCT into one organisation. That’s what I favour, all sorts of local experimentation”.

HPI: One size does not fit all?

NL: “Yes. We’ve just seen the gross failure of that approach by the Government".