I've just been reading David Cameron’s latest health speech, looking for anything interesting in it.

There’s a hearty endorsement of Andrew Lansley, which is of note: “Nobody is better placed to bring about this change to the NHS than Andrew. He has an exceptionally detailed knowledge of his brief … a cast-iron determination to reform and improve the NHS … and a deep understanding of what the health service and its values mean for this country”.

There is also an interesting reference to “how by using the methods of what we describe as the post-bureaucratic age … decentralisation, accountability and transparency, we can build on the NHS and improve it for everyone”.

Cameron’s reaffirmation of plans to keep NHS spending in real-terms growth seem like a political retort to Labour’s plans to make waiting times legally enforceable rights. What an age we live in when this is the clear blue water.

Cameron on efficiency
Using the rhetorical device of rebutting opponents’ criticisms of Tory health policy, Cameron told his audience, “We are determined that a Conservative pound will go much further than a Labour pound. To bring that efficiency we need to completely change the way the NHS works”.

And what does this complete change mean? It’s your old friend and mine: “zero tolerance on waste”. Ahem.

We then get to the NHS’s need for less management: “It’s astonishing to think that the NHS spends £4.5 billion – enough to pay for 50,000 doctors – on administration alone. So we will slash the cost of health service central bureaucracy by a third during the next Parliament, cutting that bill by £1.5 billion within four years”.

Now we’ve done this bit, here and here. It’s wildly unclear what they will cut, as if the case for Google health records (which he also reiterates).

Bogus disbelief on nurse's paperwork time
Cameron also suggests that “it is an astonishing fact that nurses spend a million hours a week on paperwork”. But nurses deliver front-line care, which has to be recorded to make handovers and judgments safe. As hospitals continue to treat older and sicker people (the ageing population thing, innit?), technical medicine and good, up-to-date data is only getting more important.

Yes, it would all be much better if every clinician (nurse or doctor) had a hand-held electronic device, to record the data in real time, warn of adverse drug reactions etc … it also is perfectly technically possible. But we’re not there yet. So the job will involve a lot of paperwork.

In 2007, there were 307,628 full-time equivalent nurses, midwives and health visitors. There are probably a few more now, but those are the figures I can get easily from Hansard.

So to get to Dave's "astonishing" million hours a week on paperwork, those 300,000-odd nurses are doing about three-and-a-quarter hours' paperwork a week.

Doesn't sound too unreasonable, put that way. But maybe Dave is an easy man to astonish.

What else? More power for FTs and more FTs – how will this latter be achieved without lowering Monitor’s standards? If you support people to achieve FT status, that will cost the money you’re cutting from bureaucracy. He concluded, “The Foundation Trusts roll-out which was supposed to be completed by December last year has been brought to a standstill” – which has happened because Monitor was not getting good enough quality applications for FT status, and some trusts are simply too financially challenged to be able to apply.

More competition. There’s no compelling evidence it really works, and a fair amount that it doesn’t.

But here we go: “we must bring in competition. Labour were evangelists for market mechanisms, but in the end they rarely left what they saw as the safety of the monopoly.

“The Conservatives understand that competition isn’t a dirty word – in fact it is the key to better healthcare for everyone. With a Conservative government any service provider from the private or voluntary sectors will be able to compete on equal terms for a NHS contract. What we will demand from them is that they provide services at least within NHS prices and at the right quality of standards. What they will get from us is a stable, transparent and pro-competitive framework with clear payment and commissioning structures.

“That way, we can increase competition, drive up standards and drive down costs.
And to make this competition really mean something, commissioning by GPs won’t be stalled – it will be propelled forward … we will give GPs real control over their budgets, letting them negotiate contracts with service providers so they get the best deal for their patients and allowing them to re-invest any savings they make”.

Power to the people over the professionals
But Dave wants us to know this: “Freedom for professionals will not mean a free rein to do as they please, unaccountable to anyone. No: instead of answering to the bureaucrats and the politicians, they will be answering to you, the patient. Instead of bureaucratic accountability there will be democratic accountability.

“The boss won’t be some pen-pusher at a distant PCT but the woman who needs a cataract operation, the parent of the child in A&E, the man given physiotherapy as an outpatient after a stroke.

“That’s because all the information on hospitals’ performance will be published online, in detail, from the success they’ve had with heart transplants, to cancer survival rates, to how patients rate their quality of care.

“Not only will all this information be online for everyone to see – but it will be backed up by real patient choice about where they go to get their treatment. Choice and transparency – it is such a powerful combination.

“When patients not only have the power to choose where they get treated but also the information to make an informed choice, then hospitals and GPs that don't provide good care will have to raise their game.

“This is why our plan to scrap targets will not result in higher waiting times. The reality is our focus on outcomes will enable doctors and nurses to deliver the best treatment for patients at every stage of their care, not just a narrowly defined part of it”.

Oh dear. Where to start? Patient choice is already happening to much lower levels than was anticipated, as this story in Pulse revealed. The Kings Fund interim findings on choice are not encouraging. The Picker Institute's study from May, reported in HSJ, found that choice is not driving up standards or indeed having particularly significant impact.

Cooper and Le Grand’s recent BMJ paper found only that “It would be inappropriate to conclude that, for instance, increased choice and competition led to improvements in equity. What we can assert with confidence, however, is that the introduction of choice and competition, as well as the other post-2000 government reforms, did not lead to the inequitable distribution of waiting times across socioeconomic groups that many people had predicted”.