Conservative Draft Manifesto 2010: Dissection Part 14

An analysis of the Conservative Draft Manifesto 2010.

"we will allow everyone – on retirement – to protect their homes from being sold to fund residential care costs by paying a one-off insurance premium of £8,000."

Many people have pointed out that this policy has problems. The average annual fee for residential care homes is £18,000, where constant medical care is needed, then the care required is from a nursing home and the average cost is £25,500 a year. There are regional variations, of course, and in the last few years fees have exceeded the rate of inflation. A one-off payment of £8,000 looks like remarkable value-for-money. 

But that is the problem. It means that most people who pay this insurance fee must not go into residential care for there to be enough money to pay for those that do. Those that do not go into residential care will stay in their own home and will need care there. This scheme can only work if it includes provision for care in the home of the elderly. The Conservatives make no mention at all about care of the elderly in their own home. So we can only assume that the Conservatives expect that the elderly will have to pay for their own care. 

Update (18/2/2010): Even Andrew Lansley does not believe that £8,000 is enough:

The Liberal Democrat health spokesman, Norman Lamb, said that his Tory counterpart, Andrew Lansley, had accepted before going on a BBC political show this Sunday that Conservative plans would see people offered three voluntary insurance schemes.

One, which the Tories have already outlined, costing £8,000, would be for those who wish to be covered in the event they had to go into a care home. The second, said Lamb, was a new admission: a one-off payment of £10,000 to secure care for people in their own home. The third was a "cheaper, stripped down package for critical care at home". "Having options within a voluntary scheme has potential perverse consequences. What happens if you want to switch out from one scheme to another?" said Lamb.

There is abundant evidence that under the Conservatives the vulnerable will be forced to pay extra. The so-called Conservative Easy Councils, local authorities that have made savage cuts in council tax, have done so by increasing charges for services including social care. In effect, these councils have targeted the most vulnerable in our society to pay for the council tax that benefits the rich. So if the choice is for an elderly person to have to pay themselves for help in their own home or to get free residential care, they will have no choice at all: they will choose the latter. This is the fear of the Association of Directors of Adult Social Services and the Kings Fund who say that this policy from the Conservatives will mean that people will go into residential care too early.

There is also a philosophical issue. When I asked an elderly neighbour about care for the elderly she told me that she was brought up to save for her retirement, and so it was a natural assumption that any assets that she had – including her house – would go towards paying for her care if she needed it. In fact she, and those people of her generation, was very forthright about the issue: she did not want her children to be paying for her care, and her house was hers and so ultimately she know that this would pay for her care. But, she told me, if she didn't need care then she was happy for her children to inherit her house. This is the sort of self-reliance that should be encouraged.

The Conservatives, however, seem somewhat obsessed with the idea of inherited wealth. This has been clear time and time again when they argue somewhat unjustifiably for an increase in the IHT (Inheritance Tax) threshold. The Conservative obsession infantilises the adult children of the elderly, suggesting that they are not capable of living their own lives without the inherited wealth of their parents. This is nonsense, of course, but it is the only conclusion that can be drawn from the Conservatives obsession with enabling children to inherit as much as possible from their parents. The Conservative social care policy is more evidence of this Conservative obsession over inheritance because the justification is "to protect their homes from being sold to fund residential care costs". The whole point of a policy on social care should be to ensure that the elderly retain their dignity and receive the care they need; inheritance should have nothing to do with the policy.

Conservative Draft Manifesto 2010: Dissection Part 13

An analysis of the Conservative Draft Manifesto 2010.

"we will weight public health funding so that extra resources go to the poorest areas with the worst health outcomes through a new 'health premium'."

One of the most important principles of the NHS is that care is given according to clinical need. When you abide by that principle, it also means that you have to target resources at the places with the most healthcare need. While poverty often means less healthy, the cause is a public health issue: eat more healthily, take more exercise.

It is internationally accepted that most healthcare resources are used in the last five years of life - regardless of age at death. It makes sense to target resources at the areas of need and conversely, affluent areas often have a higher proportion of the elderly than deprived areas, and so this means that they may actually need more NHS funding. Targeting poorest areas for acute NHS funding (as opposed to public health funding) necessarily means reducing the acute NHS funding to other areas and this may well mean reducing the funding to the areas that actually need the funding.

The problem with this policy is that it is misplaced. Funding should be targeted at the areas with the most need, and not to areas which are chosen for political purposes. One of the principles of the NHS is that healthcare should be according to clinical need, and this Conservative policy shows that it pays no attention to that principle.

This policy looks like a headline grabbing policy with not much thought behind it.

"In the long run, we will introduce a new per-patient funding system for all hospices and other providers of palliative care so that proper support for sick children and adults can continue."

Palliative care is a huge issue and there needs to be a lot more thinking in this area. End of life care is an emotive issue and it has knock-on effects to other NHS services, for example, the availability of beds in hospitals.

The 2009 Conservative health policy document does not have any details about this policy so it is unclear what is actually planned.

"[we will] give patients with chronic illnesses or a long-term condition access to a single budget that combines their health and social care funding which they can tailor to their own needs."

This policy was discussed in the Darzi Report ("High Quality Care for All" and "Personal Health Budgets: First Steps"). Clearly it is a Labour policy in progress, and yet another policy that David Cameron intends to take as his own with no acknowledgement of the origin.

Conservative Draft Manifesto 2010: Dissection Part 12

An analysis of the Conservative Draft Manifesto 2010.

Improving the Nation's Public Health

"we will turn the Department of Health into a Department of Public Health"

Orwellian, or what? This is spin. The Department of Health know that their work is for the public, so what is the need for a name change? It seems quite amazing that a government that says that it will be an austerity government on a scale that we have not seen for 60 years will want to waste money on a re-branding exercise. There are zero benefits to the public from this policy.

"we will provide separate public health funding to local authorities"

It is unclear why local authorities are expected to be experts on public health. In fact, the Conservatives probably do not expect them to be, and the devil, as they say, will be in the details.

So if local authorities do not have this expertise, where will they get it from? It is easy to assume that a Conservative government would expect local authorities to use this money to purchase public health solutions from the private sector. This is not new money, it is just money re-directed from the current NHS public health budgets towards predominately Conservative-controlled councils. In the 2009 health policy document the Conservatives say "As part of the national strategy for public health, we need to ensure that the corporate responsibility of business, and the ability of businesses to contribute to the promotion of healthier living, is fully and successfully engaged". This sounds very much like a hint of private sector involvement.

The public health budget is about £3bn (about 2.5% of the NHS budget) and if the Conservative policy will result in that money being channelled from existing NHS providers to private sector providers then that will be a huge back-door privatisation. This is consistent with Conservative policy in the NHS which is to cut the state involvement as much as possible and transfer the funds to the private sector.

Conservative Draft Manifesto 2010: Dissection Part 11

An analysis of the Conservative Draft Manifesto 2010.

"[we will] allow new providers to deliver maternity care - especially services like ante- and post-natal support."

The new providers in this sentence gives a clue about the reasoning behind this policy: it is the failed Conservative Patients' Passport policy which was covered in an earlier post. The intention of the Conservatives is to move services away from NHS providers to private providers. Since the public purse has clearly invested large amounts of money over the last decade in NHS services it is incomprehensible why a Conservative government would not want the public to use those services. Perhaps the inclusion of businessmen with private healthcare interests in the Conservative shadow cabinet may explain why the Conservative health policy appears to be so much in favour of private healthcare.

"…allow us to give one million more people access to an NHS dentist and give every five year old a dental check-up"

This is a laudable aim. In the entire manifesto this is the only policy that shows any support for the NHS or for patients.

"we will remove the rules preventing welfare-to-work providers and employers purchasing services from Mental Health Trusts so that many more unemployed people and at-risk workers can be helped."

This is a difficult point to assess. The NHS is a free at the point of delivery service, so patients that need mental health treatment will get that treatment without the intervention of either welfare-to-work providers or employers. The Conservative party needs to explain why these services must be purchased when the NHS is free at the point of delivery.

This specific policy is not mentioned in the 2009 policy document, so it is unclear what it means. The only section in the 2009 policy document on mental health is also fairly thin on details, the significant section says:

"We will make patient choice a reality within mental health through our 'any willing provider' policy, and seek to reduce dependency on powerful and expensive drugs with a focus on alternative therapies."

Notice the use of the term "any willing provider". This is another example of the re-introduction of the failed Patients' Passport.

Mental health services are extremely important, and the implication that they should be the responsibility of employers (or for the unemployed, welfare-to-work providers) is a frightening indication that the Conservatives want to make this area of health only available for payment on demand. The policy also does not mention self employed people, who, of course, do not have an employer. Will this mean that those people who are self employed will be denied mental health care?

Conservative Draft Manifesto 2010: Dissection Part 10

An analysis of the Conservative Draft Manifesto 2010.

"We will reform NHS Direct and introduce a single number for every kind of urgent care to run in parallel with the emergency number 999. We will give people access to a doctor or nurse when the local family doctor's surgery isn't open, and we will stop the forced closure of A&E wards."

Much of this already happens. The promised new phone numbers are not a great innovation, and it is difficult to understand how it will work. Are patients expected to perform some kind of self diagnosis before calling for help? That is what the NHS Direct operators are for.

There are already provisions for out-of-hours doctors, so again, it is unclear what the Conservatives plan. The 2009 health policy document suggest that the changes they propose are to make PCTs and GPs jointly responsible for commissioning out-of-hours service (currently, this is a responsibility of the PCT). This is not a huge policy shift, and it is not clear what benefits it will give.

The final point is interesting "we will stop the forced closure of A&E wards". This is more emotive language from the Conservative policy writing team. Rather than telling us what they will do, they use emotive language to denigrate what Labour is doing. Read that phrase and try not to think that Labour are closing all A&E departments. The good news is that this is not the case, and it is not the Department of Health determining whether the few A&E departments under threat should close: those decisions are being taken locally. Furthermore, this is yet another example of the Conservatives indicating that they will interfere politically in the NHS, when they say that they want to make health decisions local. This plan is clearly an example of where the Conservatives plan more centralisation of power.

"we will introduce local ' maternity networks' to ensure that mothers can safely access the right care, in the right place, at the right time."

The Royal College of Midwives state that this is already happening, they say that "the Government is committed to midwifery- led services, to women having choice, to user-involvement and to reducing unnecessary interventions and health inequalities". Further, the RCM say "It, therefore, is difficult to see exactly what is different in the Conservative Party's promise for maternity services".

This is yet another policy from the Conservatives that effectively says "we will continue to do what the Labour government is already doing".

Conservative Draft Manifesto 2010: Dissection Part 9

An analysis of the Conservative Draft Manifesto 2010.

"We will reform the way drug companies are paid for NHS medicines so that any cost-effective treatment can be made available through the NHS with drug providers paid according to the value of their new treatments"

This is a huge new policy. Let's examine in detail what it means. First, "any cost-effective treatment" what does this mean? Currently NICE determine which drugs are cost-effective according to the outcome of the treatment (in terms of extra life the drugs provide, and the quality of life). The Draft Manifesto calls NICE "unaccountable bureaucrats" which is an emotive and unfair term given to medical experts who carefully evaluate efficacy of treatments. The phrase is used to tap into the public unrest over the finality of NICE decisions: if NICE say that a drug is too expensive and ineffective then the NHS will not pay for the drug. The Conservatives suggest that they will allow the Health Secretary to overturn such decisions, not based on science, but based on politics. At this point I have to remind you of another pledge in the manifesto that says the Conservatives aim to have "less political interference in the NHS". They are clearly being inconsistent here.

It seems very odd that during the time between writing the 2009 health policy and the Draft Manifesto (about a year) the Conservatives have changed their opinion of NICE. In the 2009 policy document they say "The NHS Board will also be responsible for publishing guidelines for NHS commissioners, based on advice from NICE which will set evidence-based standards of care…", "NICE should provide commissioning guidelines for urgent care, providing evidence-based criteria for patient access and a basis for local contracts" and when it comes to determining the cost of treatment "NICE should be involved in this process, working with drug companies to set fair prices for new medicines". In other words, in the 2009 policy document the Conservatives treat NICE as a experienced, professional organisation central to their policies. But in the 2010 Draft Manifesto the Conservatives call them "unaccountable bureaucrats", not a way to make friends, and certainly not a way to build a good working relationship.

Then there is that interesting phrase "drug providers paid according to the value of their new treatments". What does that mean? Well, the 2009 policy document explains this in more detail; it says that their policy will "allow the NHS to only pay according to the benefits the drug brings to patients". This is an innovative idea: the NHS will dictate to drug companies the price of their products! Do you think it will work? If your answer is no, then I agree with you. This is a type of command economy that failed miserably in the Soviet Union, but seems to be popular with Cameron's Conservatives. The answer to the spiralling cost of drugs is competition so it is interesting that Cameron is rejecting the free market in this area.

The 2009 policy document uses the ludicrous fiasco over Lucentis as an example of how this value-based pricing "works". They say:

"For example, the drug company Novartis recently agreed to provide Lucentis, a sight-saving drug which did not yet have proven long-term cost effectiveness, on the NHS by having the NHS pay for the first 14 injections of the drug, and if the patient needed any more after that, Novartis would pay"

This statement hides a lot of important information, so let's review the story behind Lucentis. The drug research company Genentech developed a bowel cancer drug called Avastin (bevacizumab). This drug is given intravenously and one phial of Avastin costs around £300. It was discovered that people who were given Avastin and had Wet Macular Degeneration (Wet AMD, a form of progressive blindness) found that the degeneration of their sight halted. Tests showed that a tiny amount of Avastin injected in the eye stopped the degeneration. Hitherto Wet AMD was untreatable, but now there was a cheap, easily applied treatment. One phial of Avastin is enough for 300 treatments (so that is £1 per treatment). Avastin is not a cheap drug when it comes to treating bowel cancer, but because of the quantities involved, it is a cheap drug when it comes to treating Wet AMD.

In response to this threat to their profits Genentech took Avastin and modified it to remove the cancer treating active component to produce Lucentis (ranibizumab). Tests have shown that there is no extra benefit from Lucentis, and that it is no safer than Avastin. Novartis (who licences Lucentis from Genentech) charges £1000 per treatment for Lucentis. That's a thousand times more than the same treatment with Avastin. The CEO of Novartis is on record saying that the cost of Lucentis does not reflect production costs or development costs, but is merely calculated as to how much people will pay to keep their sight. This is totally against the principles of the NHS and no politician should support this behaviour from Novartis. Sadly, David Cameron, through his value-based pricing policy is supporting and encouraging this behaviour.

NICE negotiated a partial deal with Novartis where the NHS pays for the first 14 injections (£14,000) of Lucentis and Novartis would pay for the rest of the treatments for that patient. Different patients need a different number of injections, but the general opinion is that patients rarely need more than ten injections. In other words, the "deal" negotiated by NICE simply pays Novartis whatever they want. Why didn't nice negotiate that the NHS paid for fewer treatments? No idea. Why hasn't David Cameron or his health team noticed that the NHS has been ripped off in this deal? David Cameron is a clever guy, so my only guess is that he supports haemorrhaging NHS cash towards the private sector.

Why, you ask, doesn't the NHS use Avastin? This is where the story gets even more cynical and your opinion of big pharma will plummet more. The reason is that it Avastin not licensed in the UK for treating Wet AMD and NICE cannot recommend that the NHS pays for a non-licensed drug. Why isn't Avastin licensed? Because Genentech will not put it forward for licensing. NHS clinics do use Avastin to treat Wet AMD (in the US this is called "off label"), but they have to find the funds to pay for it (at £1 per treatment that is not a problem). I have been told by an eye specialist that his clinic gives patients the option of being treated with Avastin or Lucentis, and about half choose Lucentis.

Furthermore, Genentech is not a company that the government should be using as a shining example. They use disgraceful sales techniques in the US which will have the effect of Medicare (the US government healthcare fund for pensioners) being unable to fund treatment for Wet AMD. Have a read of some of the blog posts of Irv Arons to get a taste of what this company does. For example, eye specialists in the US obtained Avastin from compounding pharmacies, companies who safely divide up a phial of Avastin into the doses need for Wet AMD treatment. However, to protect the sales of the far more expensive (but just as effective) drug, Lucentis, in 2007 Genentech announced that they would no longer supply compounding pharmacies. It is estimated that Genentech could make an addition $800 million a year if Avastin is no longer used to treat Wet AMD. Dirty tricks, indeed.

It is clear that the Lucentis fiasco shows how immoral pharmaceuticals can behave, and the Conservatives support such appalling behaviour at the cost of the NHS.

The Conservative 2009 health policy document says:

"We should encourage the NHS to use whichever medicines are clinically effective, and agree to pay the drugs companies according to the therapeutic benefit and innovative value."

That is exactly the rationale that makes the cost of Lucentis one thousand times more expensive to the NHS than Avastin!

This is the standard which a Conservative government will use to determine how companies are paid for drugs. Far from making more drugs available to all, it will actually pay drug companies more money unnecessarily. This behaviour makes David Cameron look like a spiv acting on the behalf of drug companies: a drug dealer in the very worst sense.

Conservative Draft Manifesto 2010: Dissection Part 8

An analysis of the Conservative Draft Manifesto 2010.

"We will end the scandal of mixed-sex accommodation and increase the number of single rooms in hospitals, as resources allow."

First note the emotive language, the implication is that Labour has changed hospitals to a "scandalous" state where sexes have to mix. You get an image of vulnerable old women being leered at by dirty old men in raincoats, and all of this been forced on patients from an uncaring Labour government. This is arrant nonsense, of course, mixed wards go back far longer than the current Labour administration and existed when the Conservatives were in office and running down the health service. It is Labour government policy to change over to single-sex accommodation, and two thirds of hospitals now have single sex accommodation. It is also Labour policy for hospitals to supply more single rooms: in 2001 the government issued guidance that all new hospitals should have at least 50% single room capacity.

Labour has always wanted hospitals to have single sex wards and, if possible, single room accommodation. However, the big problem, as always, is cost. The Conservatives recognise this with that weasel phrase as resources allow. Changing to single sex accommodation requires capital spending on existing wards, and changing to single room accommodation often means complete rebuilds. Labour has supplied capital funding to upgrade hospitals to these new standards, but they recognise the immensity of the task. The Conservatives do not appear to understand the size of the problem. They are simply promising jam tomorrow.

Let's examine the problem. The old style wards in the UK are often known as Nightingale wards: they are large rooms with rows of beds along the two long walls and typically a nurses' station at one end for monitoring the patients. Toilet and washing facilities are typically at one end or other of the ward and so to use these facilities a patient has to walk past other beds. In a mixed-sex ward such a patient will have to walk past patients of either sex. When patients need privacy curtains are drawn around the bed. Such curtains do not block sound, and often gaps appear between the curtains. They are simply no solution to dignity.

A more up to date solution is bays where the ward is sectioned off enclosing six or eight beds. Again, curtains are used to provide some privacy from other patients in the bay. It can be argued that each patient gets more privacy because patients from other bays (nor hospital workers visiting other bays) will not need to be in another bay. Since each bay has fewer patients it is more possible to make them single sex. Converting a Nightingale ward to a ward with bays reduces the number of beds because the partitions take up space. In addition, to prevent patients walking past patients of the opposite sex when visiting the toilet or bathroom, there has to be provision of extra toilets and bathrooms (preferably these facilities should be for the use of a specific bay) and this takes up more space.

For single room accommodation, it makes no sense for patients to share bathrooms since the idea is to keep the patients separated. This means rooms have to be en suite and so for single room accommodation even more space is taken up. It is easy to imagine that each bed in single room accommodation will take up at least twice the space as a bed in a Nightingale ward.

Therefore, a provision to provide single-sex or single room accommodation will reduce capacity significantly, and this will mean building more wards and more hospitals. The cost of this will be billions. There is no costing in the Conservatives' proposal, so one can only assume that this policy, from an austerity government, is an unobtainable aspiration. David Cameron was pressed on this issue on the 7 January on the BBC's Today programme and he agreed that he would "have to be tough and pull back" from the Conservative "guarantee" of 45,000 single rooms. He then said that it couldn't be a "pledge", instead he said "it is an aspiration". I think we will find that a lot of the Tory promises will become "aspirations".

The Conservative 2009 health policy acknowledges that the Labour government has provided capital funding to upgrade accommodation, but they do not pledge any extra funding and David Cameron has admitted that their promises are unobtainable. In other words, the Conservatives will carry on exactly the same as the Labour government in this policy.