Is the NHS safe under Dr Blair's team?

The Opposition's once distinctive stance on health has dissolved for lack of fresh thinking. Jack O'Sullivan examines a failure that the Tories will exploit in the general election

The NHS may be in poor shape, but its condition is nothing like as moribund as Labour's performance on health. After 17 years in opposition, the party no longer has a stance on the NHS that is either distinctive or convincingly deals with the problems that the service faces. The serious question is: can Labour run the health service any better than the Tories?

One very senior NHS official says privately of the current cash shortage in hospitals: "It's as bad this year as it has ever been." He should know, having dealt with the winter of 1987, when thousands of hospital beds were closed, when David Barber, a hole-in-the-heart baby, had his heart operation cancelled five times, and when John Moore, then in charge of health, was politically destroyed and Margaret Thatcher announced a policy review which resulted in the 1991 health service reforms.

You might expect this prospect to send Labour frontbenchers rushing to the despatch box with a searing critique of government failure and a thought- out set of solutions. Yet the Opposition is strangely muffled on the NHS. Gone are the days when Robin Cook harried and humiliated his then opposite number, William Waldegrave. And Labour is as short as ever of fresh ideas.

John Major's government has a more confident demeanour over the NHS. At last it has a credible Health Secretary. Stephen Dorrell looks and sounds competent. The succession of two floundering politicians, William Waldegrave and then Virginia Bottomley, to the more sure-footed and determined Kenneth Clarke (who pioneered the first tranche of NHS reforms) did little to boost public confidence that the health service was safe with the Conservatives. In contrast, the business-like Dorrell is good at short-term management. He anticipates potentially explosive issues, such as problems with accident and emergency provision and shortages of intensive care beds, and takes pre-emptive measures.

Dorrell will probably take the sting out of the looming 1987-style crisis. He got himself into a mess by winning too little during the last public expenditure round. And he is averse to going back for more mid-year : his leadership ambitions dictate that he must look tough on public spending. But Kenneth Clarke will probably rescue his ideological ally. Expect managers in the NHS to be told that there will be plenty of money in the pipeline in the next financial year - they should muddle through with a bit of creative accounting.

But the Major government's avoidance of political crisis is not just because Stephen Dorrell has learned to avoid obvious pitfalls. It is also thanks to Labour's complacent attitude, which has focused on scoring points in opposition rather than constructing a viable alternative.

In the past four general elections, Labour has played a negative game over the NHS, issuing dire warnings. It has been a cheerleader of professional groups such as the doctors, vociferous in their opposition to change. And the Government has stewed.

But what did Labour's opposition amount to? That the NHS needed more cash and that the Tories' changes would lead to privatisation.

The message rang true for voters. But it was a cynical tactic, because, in reality, Labour offered little alternative to Tory policy, an inadequacy overlooked in the hysteria about funding shortfalls and the supposedly sinister hidden agenda of the Tories.

This time around, these tactics may not wash. Labour has as good as admitted that the NHS run by Tony Blair would not be very different. There would be almost no extra money: the best that Chris Smith, Labour's new health spokesman, could offer at the party conference was an extra pounds 40m, gleaned from administrative savings, to cut cancer surgery waiting times down to two weeks. This is a drop in the ocean, given that the NHS costs more than pounds 42bn a year.

Gordon Brown's determination to leave no hostages to the Tory propagandists and protect Labour from tax-raising charges means that Chris Smith's hands are tied. This reality is reflected in a policy document, New Agenda for Health, being published today by the left-leaning Institute for Public Policy Research. "From where we stand now," it says, "there will be no significant new public money for health care in the UK."

Then there is the supposed ideological gulf, said to have distinguished the two parties. That has all but disappeared. Labour now accepts the all-important separation of purchasing by health authorities from the provision of care by hospitals and other NHS units. The party still rails against GP fundholders, but goes along with the principle that family doctors should be key figures in deciding what care hospitals should provide. There is much casuistry about the language of contracts and markets, but, under Labour, health authorities and GPs would still strike deals with hospitals.

So what has all the noise been about? The damaging impression is that Labour has been crying wolf. Worse is the fact that, after 17 years in opposition, Labour has precious little fresh to offer on how it would run the NHS.

The rapid turnover in Shadow Health Secretaries is one reason for this failure. Since Robin Cook moved on in 1992, David Blunkett, Margaret Beckett, Harriet Harman and now, over the past few months, Chris Smith have beaten the Labour drum. None has shown much sign of innovation beyond catching up with the Tories on the structure of the NHS. Compare Labour's idle performance over health with, for example, its tenacity in seizing the agenda over crime policy.

All of which has left the Government with an opening to destroy any Labour election challenge on the NHS. "The Tories are planning to go for them in the run-up to Christmas, because they don't think Labour has a policy," says one health expert.

In his conference speech, John Major indicated the new strategy when he promised that the health service could expect generous funding (as it always does under all governments as a general election approaches). Next week, the Prime Minister will himself take the lead in a White Paper on the NHS, which will declare that the health service is "part of the fabric of Britain ... it must continue to be there when we need it." The document highlights that since 1979 NHS spending has risen annually on average by 3 per cent in real terms. Real annual increases in tax-funded spending will continue under the Tories, the paper states. And the old threatening language of markets and competition, which voters felt so uncomfortable with, has been excised, as it has been for several years from ministers' speeches.

The White Paper slaps down the right-wing argument, put forward by Sir Duncan Nichol, the former NHS chief executive (now working in the private sector), that the NHS is becoming unaffordable because of the inflationary effects of technological progress and caring for more elderly people. Medical advances may well bring savings as well as fresh costs, says the document hopefully. The ageing population, it adds, may not have as costly an impact as once feared: the rate of increase in numbers of very old people is slowing. Many elderly people live for many years with "mild to moderate health problems".

The White Paper's vision smacks of wishful thinking. All is not, in fact, rosy, as demonstrated by the panic currently gripping the system because this year's funding is a few hundred million pounds short.

The Government is avoiding the big issues. It has failed to show leadership in rationalising the NHS. Most health experts are convinced that there are too many hospitals, duplicating activities. Why, for example, should Leeds have both St James's hospital and Leeds General Infirmary, each with department heads who double-up the same roles? But, after the rows over the closure of London hospitals, politicians are running scared.

There is also an urgent need to make sure that the health service is not only cheap but effective. It is extraordinary how, nearly 50 years after the NHS was founded, we know so little about which treatments really work. Professor Michael Peckham, former director of NHS research and development, has estimated that pounds 1bn could be released by eliminating ineffective procedures.

Today's IPPR document calls for an "NHS Effectiveness Index" to identify health outcomes of treatments. Chris Smith recently indicated that Labour is now more interested in "effectiveness" than altering the structure of the NHS.

But policy innovation remains much slower here than in the United States. There, Alain Enthoven, the Stanford University professor who inspired Margaret Thatcher to reform the NHS, has suggested changes which, if applied to Britain, could dramatically alter medical practice. His research in the US suggests that Britain could get by with a quarter of the hospital beds currently used, given the opportunities of day surgery and primary health care. In the US, whose insurance-based system has traditionally been slack on cost control compared with the NHS, hospitals are being closed in a much fiercer rationalisation than has happened here.

This news will not warm the hearts of many health professionals. And doctors will not be happy with a recent study in the Journal of the American Medical Association. It argues that plenty of their work could be done by nurses. If best practice were followed, the study said, the US could, by the year 2000, manage with about 150,000 fewer doctors - 25 per cent less than at present. Similar reductions might be available here. Alan Maynard, Professor of Economics at York University says: "Britain could also be facing a radical overhaul in the way we use our medical workforce."

Meanwhile, US doctors are tightly controlled by strict treatment protocols, currently based mainly on controlling cost, but which will increasingly reflect research on which treatments produce the best outcomes.

Finally, there is the issue of rationing: who gets what. Like it or not, hard decisions will have to be taken about how the NHS sets its priorities. "We need some national leadership on these issues," says Chris Ham, professor of health policy and management at Birmingham University.

One option, he says, would be to follow the example of New Zealand and establish ground rules, based on effectiveness, setting out the type of patients who should gain access to treatments that cannot be afforded for all. So far, politicians have shrunk from this prescriptive role for fear of the electoral consequences. They prefer to turn a blind eye to locally determined decisions.

All of this reflects how political debate about the NHS has died long before the problems have been solved. It may be that the Conservatives, if they win the general election, will rediscover the vigour that characterised their management of the NHS in the early Nineties. But there is now a large doubt about Labour. Will the party have a good answer if voters ask, for the first time in decades: "Is the NHS safe in Labour's hands?"