Tom Smith returns with a discussion of the day's political and policy vogue.

It is a demonstration of how quickly politics is changing that the Lib Dems position on healthcare has shifted hugely over the last year. Less than two years ago the party was leftwards of Labour in its social policy. After a recent about-turn, the party wants to cut taxes, limit public spending and, as revealed by Norman Lamb yesterday (www.healthpolicyinsight.com/?q=node/171), use financial incentives to encourage people to become more engaged in their own health. Increasingly, the Lib Dems are becoming sceptical of ‘state’ solutions to poor health and shifting the onus onto individual behaviour.

WHY ARE THE LIB DEMS BECOMING MORE SCEPTICAL OF GOVERNMENT?

It is important, of course, to retain a healthy scepticism about the words used by politicians. As Simon Jenkins pointed out in last year’s political book of the year, despite Margaret Thatcher’s often repeated mantra about relying less on the state, not only did public spending increase during her three terms of office, but there was also a massive centralisation of the instruments for managing public services.

In any case, there appears to be a narrow divide between those who want to see less public spending and those who are willing to cut back on public services. A poll for the BBC’s Daily Politics show today shows that 48% agree and 47% disagree with the statement ‘Overall taxes should be reduced even if that means cutting back on public spending’.

Although the vote is close, the important factor is the trend. As the FT pointed out last Thursday, in the 2005 election many more disagreed with the statement. The numbers agreeing has increased strongly.

The key question is whether public opinion is being pushed by the espousal of a more state sceptical position, or whether changing public opinion is giving rise to a greater confidence on the part of the Conservatives and the Lib Dems to be more anti-government in their state rhetoric.

Vince Cable – who is seen as being on the left of the Lib Dem party caused some controversy in an interview with the Independent the other day when he suggested that the NHS budget could be reduced – perhaps by scrapping SHAs and cutting back on the NHS IT programme.

"The situation has changed. There is a very strong sense of disenchantment that much of the public spending has been desirable but a lot of this money has not been productively spent."

In his speech to Conference, Cable robustly defended the idea of tax cuts. He challenged the accusation that this was a shift to the right if he and his party wanted to see tax cuts for people earning little more than the minimum wage. It was right to put more money in their pockets. He also said that too many well-off people were avoiding tax.

Writing in the FT today, Philip Stevens says that no matter what politicians say, whatever the colour of the next government it will be forced to raise taxes . ‘Higher taxes may be deferred, but not avoided’.

AN END TO TOP-DOWN “BULLYING”

Speaking to the Daily Politics yesterday, Lib Dem peer Lord Razzall said the terrain of the debate is shifting away from the level of state spending. The issue now, he said, is the not the amount spent, but how that money is spent. The logic is that taxes could be cut and services maintained, if money was better spent.

More generally, there does seem to be a shift in social attitudes to government spending and less faith in government’s ability to manage services and finances.

The money spent by the NHS is coming under greater scrutiny. Norman Lamb yesterday cited the £50 million that Gordon Brown spent on his ‘deep clean’ programme to try to combat MRSA. Recent reports suggest this money failed to combat the problem. The deeper charge is that it was the wrong thing to try and do in any case; that the £50 million was good money thrown after bad. Lamb cited the Lancet which “within days had rumbled [Brown]; they condemned the plan as ‘pandering to populism’ and ‘bound to fail’.”

Expensive policies and initiatives that are driven by headlines have become a regular part of our media diet. These are fuelled by a fuelling a shift in political stance from the opposition – that they are sceptical that the state is capable of fixing these kinds of problems.

The second political charge that the opposition is making stick – in addition to financial mismanagement – is that government (not just Labour) has limited competence in imposing solutions on local areas. He criticised the forcing of polyclinics on local PCTs.

“They micro-manage, measure and monitor anything that moves and lose sight of the fundamental importance of care. Look at the facts. Over the last eleven years health spending has increased threefold, vital after the years of Tory neglect. Yet the NHS is still failing too many people.

A PERFECT STORM

I doubt it was a coincidence that Norman Lamb employed a phrase used in the recent Reform report, advocating insurance. He said the NHS was facing “a perfect storm” – pressures for more money in healthcare and a declining willingness to fund it. His solution, implied by words, is the need for more money in the NHS from alternative sources than taxation.

Lamb said, “no government can solve these problems just by throwing more money at them” – “we have to find a way of navigating our way through this perfect storm”. He includes the dilemma over copayments in this and said it couldn’t be right that people who paid for drugs were denied care. He said that 10% of the NHS budget could be saved in efficiencies, with the money better spent The achievement of significant savings by the introduction of efficiencies is a claim commonly made but never achieved.

How would the Lib Dems try to save money? They would “abolish strategic health authorities” and “axe NHS quangos”.

'Isn’t it better that local people have a greater awareness that PCTs are responsible for local health services when a recent survey showed that the majority believed PCTs ran local refuse collection services?'

Some of the recent stories featuring NHS waste do miss the mark, and it is not the case than any spending on non-clinical issues is a waste. Over the last few days there have been mocking reports that the NHS is spending money on rebranding – changing the name of West Suffolk Primary Care Trust to West Suffolk NHS, for example. But this spending could help to increase local accountability. The amount spent is very little in NHS terms – just £6,000 – and the benefits reaped could make it worth it. Isn’t it better that local people have a greater awareness that PCTs are responsible for local health services when a recent survey showed that the majority believed PCTs ran local refuse collection services?

GREATER ACCOUNTABILITY OF HEALTH SPENDING

Norman Lamb moved from talking about ways to save money onto ways to increase local accountability.

One position on which the Lib Dems have been consistent is the need to strengthen local accountability. Spending a little money on raising awareness of PCT responsibilities should aid this process. Lamb told the conference that ‘our proposed health boards would have a legal duty to deliver value for money in securing high quality care for the community they serve.’

Some of the media stories featuring NHS waste do miss the mark, however, and it is not the case than any spending on non-clinical issues is a waste. Over the last few days there have been mocking reports that the NHS is spending money on rebranding – changing the name of West Suffolk Primary Care Trust to West Suffolk NHS, for example. But the amount spent is very little in NHS terms – just £6000 – and the benefits reaped could make it worth it. Isn’t it better that local people have a greater awareness that PCTs are responsible for local health services when a recent survey showed that the majority believed PCTs ran local refuse collection services?

“We'll dismantle the wasteful and centralised NHS bureaucracy and give power to local communities - to introduce proper accountability for the first time. Primary Care Trusts - health boards as we call them -or local authorities if people so choose – efficient in performance and accountable to the people they serve.”

There is not much detail on the how local accountability would be strengthened. There is a tribute to the Swedish system but as it has been observed, with its subtly varying regional systems, Sweden is an empirical mine for practically any policy initiative.

This summer, while in Sweden, I was keen to learn about ‘local democracy’ and the Swedish experience of electing Health Boards. As it was told to me, the story is not particularly positive. Health Boards feel remote from voters and the process is highly politicised. The decisions taken are relatively minor, and are tantamount to moving existing resources around. This is one of the reasons for the local-political charge in health discussions. As here, they are often couched in terms of town versus city and local facility against local facility.

The Lib Dems would introduce a similar system here, but if it is to be more engaging, it will need to avoid certain pitfalls.

TOWARDS MORE LOCAL FINANCE

Again, there is not very much detail, but Lamb pledged that the Lib Dems would move away from Payment by Results. In fact the lack of detail is surprising. The clue may be the opposition to ‘centrally imposed’ payment by results, perhaps meaning that they would permit local tariffs and the consequent price competition.

We'll move away from centrally imposed tariffs – so called 'Payment By Results'. This rewards hospitals for admitting more and more patients racking up large surpluses as a result. The real objective should be to avoid unnecessary hospital admissions - caring for people better, closer to home.

CHARGES FOR MISSING APPOINTMENTS

Norman Lamb’s speech ‘suggests’ rather than proposes the idea that people who “persistently” miss appointments should be charged £10 to cover the administrative costs this imposes.

The cost might fall disproportionally on the poorer members of society. This may not be a reason to introduce such a charge. There may be some benefits from making the public more aware of the relationship between their actions and the costs of the NHS. If it were explained that NHS resources are precious and must be managed in order to achieve maximum gain and if it were understood that everyone shares a responsibility to sustain its universal care, free at the point of use, then such a charge

While it may be a clear political position, reinforcing the idea that people should be responsible for their own actions, the difficulty is in how this policy would work? Who would collect the money? Who would bank it? GPs would not be keen to charge their patients (though they might be more keen to have the money). If PCTs were to impose the charge, they would rely on GPs to inform on the offenders.

FINANCIAL INCENTIVES TO BE HEALTHY

One of the more eye-catching initiatives from the Lib Dems, though not widely covered in the press, is the idea of using incentives and the tax system to incentivise individuals to lead healthy lives and make healthy choices.

'Lib Dem’s health policy is designed to catch the eye. It is less a worked-through policy; more a set of aspirations, around not wasting money, reducing the size of the state, moving the burden of responsibility onto individuals'

Norman Lamb is not big on specifics, but mentions three examples. First, that ‘incentives could be offered to encourage employers to provide fitness facilities or gym membership to overweight people who can’t afford the normal fees.’ Second, ‘Health boards could follow Nova Scotia’s lead by offering a tax back payment for each child enrolled in sports or activity clubs.’ Thirdly, schemes could learn from South Africa where attendance at screening clinics is incentivised.

‘Using locally raised resources, why shouldn't Health Boards create direct incentives - tax-back payments - particularly focusing on disadvantaged communities?’

It is clear that the Lib Dem’s health policy is designed to catch the eye. It is less a worked-through policy; more a set of aspirations, around not wasting money, reducing the size of the state, moving the burden of responsibility onto individuals.

More than anything, it is symptomatic of the change in politics, the shift to the right, the declining weight of the collective view and the rise of an individualised politics.