Nothing government ministers can do or say, however sincerely, seems to dislodge Labour's hold on health - not even recollections of the Winter of Discontent, or the fact that of the 49 years' existence of the NHS, the Tories have presided over 35. Under the Tories as much as under Labour, health spending has risen continuously, despite Mrs Thatcher and all she might have wished. But the Budget of November 1996 marked a change. The Tories have committed themselves to a real reduction in health spending that is to begin (officially) in 1998 but (practically) could be felt on the wards and in the surgeries by this autumn. In January Labour formally signed up to the plan, at least until April 1998. Perhaps it is no wonder health has been - to use Tony Blair's phrase - a "sleeping issue".
By that he could mean three things. The first is that the phoney election campaign has so far proceeded without any shroud-waving. It was remarkable last week how new waiting-list statistics were, though politically embarrassing for the Conservatives, passed by without much loud Labour comment. Labour could flag up health deficiencies at any point it chose but - see below - it may well choose not to.
When he spoke at the weekend, Labour shadow Chris Smith fired a shot across the bows of all those NHS trust chairs who have been appointed on the whim of Conservative secretaries of state. He is entirely within his rights, and would have been even if he had not promised (rather vaguely) to advance the principle of merit by advertising such positions in the future. There is no need to be squeamish. The archipelago of appointed government, which includes those trust positions, is not suddenly going to sink out of sight after the election. Labour ministers will have posts to fill, and if they did not occasionally glance at the party affiliations of their appointees, well, they would be saints.
But if Mr Smith thinks this is relevant to health care or spending, he needs to think again. It is, in fact, almost as irrelevant as his grand promise to find pounds 100m worth of transferable funds by delayering NHS bureaucracy. Come the election, we are going to see a mighty exercise in "badge engineering" as, for example, nurse-managers are miraculously reclassified as nurse- practitioners without a single extra patient getting treatment.
Mr Blair may mean that health is a sleeping issue in the sense that neither Mr Smith nor his predecessor Harriet Harman have come up with any compelling new formula for effective health management. The Thatcher-Clarke reforms - GP fundholding, the quasi-market - are neither pernicious nor notably efficacious. GP fundholding has, in a limited number of places, improved health care for patients; elsewhere there is, as yet, no evidence of its positive effects. Labour proposes tinkering - a bit less market here, a bit more dirigisme there. Tinkering with NHS administration is what health secretaries do as a proof of their existence; provided it is not too ambitious it is probably relatively harmless.
It does not substitute for fresh Labour ideas on health care. (It is one as pertinent in private sector systems such as the American as it is here.) Health costs are constantly pushed up by expensive new therapies, giving rise to questions about who deserves what treatment: are there any distributive principles on which patients, professionals and politicians can agree?
Mr Blair certainly means the NHS is a sleeping issue in that he has no wish, this side of the election, to tell home truths about spending. Labour has enough astute academics inside its tent; he certainly knows the score. Unless - starting at once - there is a huge break with the 3 per cent per year upwards trend in real-terms spending that has run fairly consistently for decades, Labour is set to preside over a growing gap between health demands and budgeted cash. That gap will, within 18 months, amount to some pounds 5bn, enough to create quite a bit of political flak from doctors, nurses and patients, let alone all those local figures Chris Smith has indicated he wants to appoint to NHS trusts. (That is three pence on income tax, for those souls still living in the era before the Iron Shadow Chancellor.)
The question is not whether that long-run health spending trend should be broken - it probably ought to be, insofar as it is based on professional judgements shielded from external scrutiny. The fact is, it cannot be halted within the timetable to which Labour has acceded. In the longer term things look brighter; the financial consequences of demographic change for the NHS are not so dramatic after all. Labour's problem with health is short run. Health will stop "sleeping" as soon as the election is over and dawn breaks over those hospital beds. The Blair government could switch money into health, but that would mean deeper spending cuts elsewhere. Or else it means presiding over some kind of revolution in public health provision, smashing a spending consensus which even Mrs Thatcher ended up endorsing. To vote on health this spring looks like having to choose between competing claims for who is most likely to succeed in squaring circles.Reuse content