Jeremy Laurance: The health debate we need is not the one you hear

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Seventeen weeks of sleepless nights and nail-biting days is a long time to wait to find out whether you have cancer.

Seventeen weeks of sleepless nights and nail-biting days is a long time to wait to find out whether you have cancer.

Labour's pledge that, by 2008, everyone with suspected breast or bowel cancer, urgent and non-urgent, will be seen by a consultant within two weeks of referral has obvious voter appeal.

It will benefit those who actually have breast cancer - about one quarter of the 40,000 new cases diagnosed each year was originally referred non-urgently - as well as those anxiously awaiting the all-clear.

But it risks clogging up surgical out-patient clinics. For every woman with breast cancer, 10 to 15 who do not have it are referred to consultants. If these women are seen more quickly, those with other, possibly more urgent conditions, will have to go to the back of the queue.

All policies that establish new priorities have a downside. The Tory plan to introduce isolation wards wherever they are recommended by the senior nurse or matron to tackle MRSA may cut the number of superbug infections - an objective which no one can criticise. But it will also mean fewer patients can be treated, waiting times will lengthen and patients may suffer deteriorating health or worse as a result.

MRSA infection rates are unacceptable - but reducing them will come at a price if Tory plans are followed.

Although the NHS comes top of most voter's concerns in the election there has been a deafening silence from all three parties on the issues crucial to its future. Cutting breast cancer waiting times, tackling MRSA and the Tory plan to build five new children's hospitals is tinkering round the edges.

What is not being discussed is what happens when the cash runs out in 2007-08? Both opposition parties have agreed to match Labour's plans to raise NHS spending in England to £92.1bn in 2007-08, an average 7.2 per cent annual real terms increase over five years, the largest sustained rise in its history.

Every economic indicator suggests that rate of increase in spending on the NHS will be unsustainable beyond that date. A debate is needed now on how the funding gap that will open up in two years is to be bridged - whether from higher taxes, increased private funding or some form of social insurance. But no party is keen to confront it.

A parallel debate is needed on the impact of the NHS market. All three parties have promoted the concept of a patient-led NHS, without spelling out what it means in practice. Up to now, the NHS has provided most of the health services paid for by the state. In future, it will increasingly manage a market in which NHS and private services will compete for business.

By 2008, patients will be able to choose any hospital, NHS or private, to have their operation provided it can meet NHS standards and the NHS tariff. We could see NHS trusts establish marketing departments to tout for business as they depend on getting patients through the doors on a "payment by results" system.

The outcome is unpredictable. Hospitals may skim the most profitable patients - those having routine operations - while neglecting the chronically ill. Primary care trusts, which will hold 80 per cent of the NHS budget, may flex their financial muscle and hold outpatient clinics in GP surgeries - potentially destabilising the hospitals.

Those are the big questions. We should be thinking now if this is the sort of health service we want and if so how to cope with these pressures. But you will not find it being debated out on the stump.

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