Big public service speeches are due next week from both Michael Howard and Tony Blair. A major theme of both will be choice. The right to choose has become the catchphrase of the two big parties and looks set to run right up to the next election. The Conservatives are relying on health and education vouchers to achieve this new nirvana, while Labour is requiring state services to offer a wider choice of hospitals and specialist schools to achieve its goal. What both party leaders are still failing to signal are the limits of choice. Here are some issues which we would like both leaders to clarify next week.
Choice requires spare capacity. In that sense it is less efficient and more expensive. Ask the French and Germans. These two continental neighbours have had an excess capacity in their health systems, hence their eagerness in 2002 to offer hospital beds to the UK and the tight financial squeeze that has been applied to their systems since. Just how much spare capacity are the two major British parties ready to provide? Will Michael Howard, who waxed lyrical this week on the right of parents to select a state school of their own choice, recognise that there are limits to the number of pupils that schools can accommodate? Vouchers, even if restricted to the state sector, do not solve this problem.
Second, both party leaders have emphasised the need for an efficient health service but failed to recognise the inefficiencies which choice can lead to. If more patients choose less cost-effective treatment, the health system will not be more efficient. Labour is on much stronger ground here, because of its earlier structural reforms to the NHS (inspections, audit on the clinical effectiveness of drugs and appliances, new treatment strategies) whereas current Conservative plans are a recipe for inefficiency with their criticisms of audit and inspection and their readiness to let patients use their NHS vouchers to pay (with a top up of 40% by the patient) for private care.
There is also the need to recognise the important differences between buying a car and seeking medical treatment. Gordon Brown was right to point to the dangers of seeing patients as consumers. They still lack much relevant information. They may not even know they are ill, be poorly informed of available treatments, be reliant on others to understand diagnoses, and be uncertain about the effectiveness of different medical interventions. There was no mention of any of this in Mr Howard's keynote speech on choice this week. Indeed there was no mention at all in the speech of the biggest challenge facing the NHS: not the 1.1m people waiting for one-off elective surgery, 70% of whom will be treated within three months, but the 17.5m people suffering from debilitating long-term diseases, which are incurable but with proper management can ensure that patients lead active and fruitful lives. They account for 70% of NHS spending. Ironically, this is one of the most fruitful areas for extending choice, which to Labour's credit it has been exploring: getting patients more involved in the treatment decisions of their conditions.
Mr Howard's concern for poor patients rings hollow given his party's readiness to allow patients to use the NHS voucher to buy private medical care. It is not just inequitable but carries a huge deadweight costs (with the state paying £1.5bn for private operations currently paid by insurance). There is another irony that Labour's success in reducing Britain's excessive private hospital fees (by bringing in overseas private operators) would be reversed by the subsidies vouchers provide. What both parties must recognise is that what people want is not some sharp-elbowed market or mythical choice, but a decent local school and a decent local hospital. Both leaders should concentrate on this goal.
