Leading article: In the long run, health means responsibility

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The Independent Online
Frank Dobson, Secretary of State for Health, is an admirer of Napoleon. In quieter moments he will regale you with the line-up at Marengo and tactics at Austerlitz. Like Bonaparte, Mr Dobson faces a tough winter campaign when - it is widely predicted - waiting lists will grow rather than fall, patients will be refused admission to cash-strapped hospitals and the health unions will become restive. If the doctors were to perform heart surgery on the health secretary they would find stamped on that tough muscle the same word that tormented his predecessors back to Aneurin Bevan - money.

Predictably, then, Mr Dobson's speech yesterday to the NHS Confederation was greeted as if it were a promissory note - in this case promising to try not to pay for the public's expectations of health care raised by Labour's election commitments. A mention of amalgamating health authorities and closing hospitals in his speech was taken to signal his desperate search for savings while the proposal to create "Health Action Zones" was read as a bid to get other people to do the Government's dirty work of cutting and crimping the NHS. Meanwhile, in another neck of the woods, much significance was attached to references to "hypothecation" by Patricia Hewitt who, though a fresher MP, is well plugged into Blairite policy wonk circles. In layman's speak, that means a health tax or some other device for dedicating a flow of funds into "saving the service". There are, it's undeniable, big holes in NHS finances, in the short run. They were graphically described by, among others, the Institute of Fiscal Studies before the election and have receded since. Too many health trusts ended the last financial year carrying forward deficits for there not to be anguished cries in the winter months. But health politics are a perennial round of knife-edging and wound- binding. Besides, there are substantive questions facing the NHS which do not have much to do with the aggregate budget - such as the excess in the system of a particular kind of hospital bed. The growth of day surgery and changes in treatment regimes fostered by the doctors themselves have reduced demand for "acute" beds, but not uniformly across the country. Frank Dobson could soon face the perplexing task of justifying keeping beds going in London (where patient demand has been rising, whatever the health planners intended) while closing them down elsewhere.

Any health secretary in a government which thinks itself worth at least two terms in office would be derelict in his duty if he did not, even at this early stage, start thinking hard about the medium to long run. And that, though his critics may have missed it, is just what Frank Dobson started to do yesterday. Health Action Zones could turn out to be ineffectual talking shops where, not for the first time, the medics dominate and other interests get pushed to the margins. But they could become a means by which a health revolution is accomplished. That is big talk, but the new government's emerging health thinking does appear ambitious. Since its inception the National Health Service has of course been nothing of the kind. It has been the national disease and accident service. Health - what we all need if we are to stay out of doctors' surgeries and hospital wards - was relegated to local authorities and marginalised doctors. When, not long after Margaret Thatcher came to power, Sir Douglas Black reported that public health was adversely affected by life chances, he was stating the obvious. But the obvious consequences for "national health" were ignored. Now Tessa Jowell has dusted off the work and if the Department of Health - by all accounts not yet the most coordinated of Whitehall departments - can pull its arms and legs together there is at least the prospect of renewed attention to the simple truth that people by and large make their own health, within the economic and social circumstances in which they find themselves. Being healthy is, for most of us, a life choice.

Health Action Zones could be much more than vehicles to give him cover for closing down unwanted acute beds. They could, for example, start thinking about public health and what it takes to improve it. Yesterday we reported on the front page extrapolations of recent trends in the incidence of cancer. They made for a scary headline. Even if we re-weigh the figures for demography (old people have to die of something, so proportionately more old people must mean proportionately more cancer death), cancer cases will grow. But a trend is not a fate. The incidence of cancer reflects, in part, life-style choices: to smoke, to lie in the noonday sun, to eat unhealthy foods. Those choices are ours. However successful Frank Dobson might or might not be in wresting funds from the Treasury, whatever progress is made in gene therapy, however fine the screening nets for breast or bowel cancer, it will still be down to us to raise or lower the risk of certain cancers by our own actions. By "health maintenance organisation" the Americans mean a plan guaranteeing access to care by dint of having paid a subscription cum insurance premium. What if Frank Dobson's zones became health maintenance organisations in the common or garden sense, Weight Watchers writ large, community mechanisms to foster healthy behaviour? Only if people start to "own" their health rather than contracting it out to the NHS will those cancer trends not be realised. There is another benefit, admittedly not one that is going to bail Frank Dobson out in the short run. It is money. The more public health we enjoy - health as a personal, family and community responsibility - the less need there will be for the NHS to be continually racked by crisis.