In a recent HSJ poll, NHS managers suggested they are more comfortable with what they know, when asked their preferred secretary of state. With the government behind in the polls and change looming, it has not been a great conference season for senior local authority or PCT managers listening to the opposition set out their plans.

Alan Maynard’s column this week (http://www.healthpolicyinsight.com/?q=node/183) centres on the difficulty of getting rid of poorly-performing senior managers (and doctors) in a less costly way. The conference season suggests the political wind is turning to put more pressure on senior managers. At the Lib Dem conference, Vince Cable said anyone earning over £100k should be forced to reapply for their jobs. Last week Labour promised / threatened stronger local performance. Yesterday’s Conservative conference promised less local spending, coupled with assurances of intent to hold local managers to account over improvements in care. The last few weeks threaten much greater pressure on local managers.

With central politicians talking up expectations, it will be local managers that local people will look to deliver services. If experience falls short of expectations, there will be a serious political battle over who is to blame: central politicians for not delivering enough resources, or local managers for not making enough of the resources they receive?

THE CONSERVATIVES POSITION THEMSELVES AS BETTER AT MANAGING THE PENNIES AND ERADICATING DEBT

George Osborne said that he would stop Labour spending money like there was no tomorrow. His words were very political. Recalling the winter of discontent, he suggested we should learn our lesson never to trust Labour with the public finances. His main suggestion is explosive (and massively praised by Peter Riddell and the Times today). The Conservatives would put the piggy bank out of reach of ministers, to avoid them raiding it. Not just Labour, this would trust no government with the public finances.

The implications of this for our political society are far-reaching. It would leave government with little potential to change economic rules or spend on the basis of future return. It would leave central government with a highly managerial role, regulating and pressuring local managers to deliver central targets.

In relation to health, George Osborne ridiculed PFI deals and said they could no longer be hidden from balance sheets. Interestingly, he said he would cap advertising budgets in the public sector. This may not be as radically different as it sounds – there is a similar cap in place on the money that NHS trusts can spend to advertise their services. But depending how ‘advertising’ is defined, the move could hit legitimate attempts to increase awareness by promoting information.

This is a point worth raising in the light of the recent hoo-ha over the size of the ‘communications’ budget held at NICE. The Conservatives briefed the media that NICE spent more money on advertising itself than it did on evaluating new drugs. A weary-sounding Andrew Dillon (chief executive of NICE) explained that the budget included the promotion of guidelines and work to encourage their adoption – important activities that might be limited if the cap on ‘advertising’ is interpreted broadly.

The Conservatives’ promise to prevent tax raises by spending less money has not been taken at face value. On the Today programme this morning, Evan Davies accused David Cameron of failing to respond to the new economic reality. “Cutting consultancy and advertising, these are policies from a different world. Do you really believe £1bn can be pulled out of budgets and that this will make a difference?” Cameron said that everyone was having to tighten their belts, and that government should do the same. Fifteen minutes later, Nick Robinson opined that “the Conservatives seem to be struggling to keep up”.

TORIES PLACE PRESSURE ON LOCAL AUTHORITIES TO REDUCE SPENDING AND FREEZE COUNCIL TAX LEVELS

George Osborne’s pledge to freeze council tax has grabbed all the headlines. The promise could change the dynamic of central and local government solutions. The small print of Osborne’s ‘partnership deal’ is that freezes will only be achieved where the local government agrees to cut spending. In return, central government will give the savings from cutting the consultancy and advertising budgets in central government.

The Times’ today reports that ‘local government organisations said that town halls would have to make swingeing cuts in services to qualify for the freeze. Critics also pointed out that the poorest third of families would benefit less than middle-income households.’

However, Sir Jeremy Beecham, leader of the Local Government Association's Labour group, said: “The Tories' short-lived claims to be a party of social justice have fallen at the first hurdle. Local councils must be able to help people struggling with housing, people caring for vulnerable relatives, or those looking to wipe out gang violence. Slashing a billion pounds from council budgets [over two years] will put vital programmes at risk.”

If the local authority feels it cannot cut spending, they will be cast as inefficient by central government who may point to the experience of Conservative local administrations who are spending less. As they did throughout the 1980s, local authorities will pin the blame for spending freezes on central government. In response to these accusations, the Conservatives will say that they are taking tough decisions to pay back debt that was built up by Labour.

Osborne’s stance is political rather than economic. Local government experts hailed the move as politically astute. “It's a palliative rather than a brilliant reform, but it hits at one of Labour's weaknesses,” Tony Travers, of the London School of Economics, said. “The Conservatives can now go into the next election saying, ‘Vote Labour you will pay 5 per cent council tax. Vote Conservative and you will pay zero.”

LANSLEY SAYS IT’S TIME FOR LOCAL PEOPLE TO HAVE THEIR SAY

Lansley says the Conservatives “will ensure that the voice of patients is listened to through the creation of a national consumer voice HealthWatch”.

A simple proposition is at the heart of the Conservative plan, says Andrew Lansley. ‘If responsible professionals have the freedom to respond to informed and empowered patients, services will improve’. There is little detail, however, on how the Conservatives would wish PCTs to respond if professionals were not responding to what patients want from services".

He does want a response, however. “Let us resolve again today to keep today to keep campaigning for a local say over NHS services. For community hospitals, for GP-led services and against Labour’s cuts and top-down polyclinic plans’.

The risk for local managers is that the Conservatives will build up local expectations at a time when they are lifting expectations, despite the need to cut down on government spending. Lansley’s speech said people should expect very much more from their service – the latest cancer drugs, without paying top-ups, and a choice of a single room for all within five years.

SINGLE ROOMS FOR EVERYONE

'Andrew Lansley said that Labour’s target culture was to blame for many of the problems in the NHS and then in his next breath he announced that within five years every patient would have the choice of a single room'

It was interesting that Andrew Lansley said that Labour’s target culture was to blame for many of the problems in the NHS and then in his next breath he announced that within five years every patient would have the choice of a single room.

• Every patient will be given the opportunity choose a single room when booking an operation in hospital
• Every hospital will have the single rooms they need to isolate infected patients
• All mothers in maternity care will have access to a single room
• All mental health patients will have single rooms
• No patients will be in mixed-sex accommodation

The Guardian says this will mean the proportion of beds in single rooms rising from 28% to 55% over the next five years. In real terms, this is an increase from 45,000 to 100,000 beds at a cost of £1.57bn, or £300m per year. The Conservatives say this will be paid for by reallocating money in the capital funding budget, which last year was underspent by £2bn.

The FT today reports comments from Kings Fund chief economist John Appleby on the plan. He says, “the promise raises the same question as Labour’s pledge last week of free prescriptions for cancer sufferers. Is this really the top priority for NHS cash?”. He went on to say that “the relative lack of progress on single rooms in recent years comes down to cost. There may be more of a case for spending on diagnostic technology rather than single rooms.

Speaking to the Daily Politics yesterday the BBC’s chief political correspondent, Nick Robinson, said the speeches at the Conservative conference showed that politicians are still trapped in the rhetoric of boom. While making it clear they understand there are new consequences from the economic crisis they still promise tax cuts generally and expensive initiatives particularly, at a time when every economic expert says that taxes will have to go up.

The Times’ political editor, Peter Riddell, today describes the Conservative economic plan the most important publication from the right in 30 years, but conceded that the council tax announcement was ‘still a distraction from the main “cupboard is bare” message ’.

ANDREW LANSLEY ADOPTS A POLITICAL STANCE

Andrew Lansley’s health speech said the Conservatives will ‘give people more control over their lives’, ‘build stronger families and a stronger society’ and develop ‘a safer, greener, healthier Britain’ – a clear and simple set of challenges ‘every bit as vital as Margaret faced thirty years ago’.

As well as tipping his hat to the reforming right, he was keen not to alienate the conservative left. “The values of the NHS are just as relevant today as they were in 1948”. “We must not move towards inequality of access”.

Andrew Lansley’s speech yesterday avoided controversial depths. Lansley did not attempt to steal the headlines from George Obsorne by broaching any detailed policy proposals on the difficult challenges before us.

He asked relevant questions. ‘Why is Britain the leading centre in Europe for cancer research, yet one of the last places where our NHS patients have access to new cancer medicines? Why is a drug like cetuximab, for bowel cancer, available in every other European country, but denied to patients in this country?’ “I am determined all this will change. And we have a plan for change”.

The plan involves a lot of familiar sounding moves: people choosing their GP, having better information, a personal budget for people managing long-term conditions.” As Labour minister Ann Keen said, "there seems to be little new here. The government is already encouraging choice for patients and a diversity of providers within NHS tariffs.”

The Times’ David Aaranovitch was even more scathing in his column today, answering his own question: ‘What is Tory policy for the future of the NHS? To nuzzle the ears of the doctors and to stop targets. That's it. While we are being reminded of what an extravagant old roué Gordon Brown is, perhaps we should recall the recent Tory slogan: “Stop the NHS Cuts”. More money, no targets.’

ANDREW LANSLEY SKIRTS AROUND THE ISSUE OF TOP-UP PAYMENTS FOR DRUGS

He says that their pricing proposals for drugs will mean the NHS will gain better value-for-money and access to the latest cancer drugs in the NHS. “Patients who need life-extending drugs should expect the NHS to provide comprehensive care, not leave them to pay for top-up drugs”.

The Conservatives’ basic stance on top-up payments was covered in a text box embedded within a Sunday Times article reporting another test case from a woman fighting the bill she has received for her NHS treatment after she opted to spend privately on a drug.

According to the Sunday Times, ‘the Conservatives have backed the right of patients to “top up” National Health Service care by buying treatment at private hospitals’. Andrew Lansley, told the paper that “it is clearly wrong that any patient should be denied access to NHS treatment. Access to private treatment should not affect entitlement to NHS care.”

The crucial point here is that NHS and private treatment should be kept separate, delivered in different institutions. The Tories will allow top-up treatment as long as it is carried out away from NHS premises. This position suggests the Conservatives are keen to avoid the nightmare scenario of having two patients in adjacent beds receiving different care, because of their differing access to financial resources. The top-up debate presents an impossible dilemma and the out-of-sight out-of-mind policy is a pragmatic holding response to a pressure that won’t go away.

GENUINELY DIFFERENT POLITICAL NARRATIVES

For a long time, people have complained that Labour and Conservative policies are essentially the same in many areas. It is true to say that the centre of both parties share a similar approach, but in recent weeks, intensifying in recent days, the main political parties are developing quite different narratives on how to find our way out of trouble.

The Conservatives will scrap fiscal rules and cut spending, though not by nearly enough suggest the commentators. Labour on the other hand believe that the markets need liquidity and therefore government’s should keep spending.

It will be difficult to tell which of these narratives hold sway. We are as divided here as Congress is in America.