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A Conservative case of the jitters (Wall Street Journal Europe)

Britain's state medical program, the National Health Service, is held in such esteem by so many Britons that former chancellor Nigel Lawson once dubbed it "the English religion." Increasingly, however, it is becoming clear that it does require a profession of faith to believe that the NHS functions properly. Lines are long, and when you do get a hospital bed you risk dying through negligence. This would be great fodder for an opposition party preparing for elections. Alas, the opposition party in this election year is the Conservative party.

One of the iron rules of British politics is that whenever the subject of the NHS comes up, Tories keep quiet. Whatever they do, whatever they say, whatever they spend, the electorate is convinced that all Conservatives really want to do is close the NHS down.

Whatever Labour does, on the other hand-no matter how bad the state of the service-the public knows in its heart that Labour only wants the best for the NHS. That means that, even when the Conservatives have something to say, they don't say it. But even worse, it means that what they do say-they do, after all, have an election campaign to get through-is often worse than useless.

But by remaining on the defensive, the Conservatives not only give themselves a self-induced handicap; they also end up, in a self-fulfilling prophecy, guaranteeing that very poor public impression that they were so desperate to avoid in the first place. Even worse, the absence of a democratic debate is hurting the NHS itself.

A prime example is the current state of the debate on healthcare as Britain approaches an election. In every one of its 18 years of government, the Conservative Party increased spending on the NHS in real terms. Labour's response to this largesse was to allege that the country had only a few "hours to save the NHS,"-which would, of course, be accomplised by voting in Labour. Now, after almost four years of Labour government, the NHS is widely recognized-certainly by voters, as every poll shows-as being in a worse state than it was under the Conservatives.
Labour's response in last July's Comprehensive Spending Review was to pledge to spend add more than £5 billion to its already enormous spending plans over the next four years. When Prime Minister Tony Blair first revealed this extra spending, he pointed out that health spending as a proportion of GDP in Britain is below the EU average. Although the figure is constantly shifting, the EU average stands at almost 9% of GDP, while the UK spends only 6.8% of GDP (the US, dwarfing all EU members, spends over 14%). The pledge-or "aspiration," as it later became-was to increase UK spending on healthcare to the EU average.

But there really are lies, damned lies and statistics, as XXX GLADSTONE??? said. It is quite true that total British state spending is some 2% of GDP less than that across the rest of the EU. But almost all of that difference is made up by private spending. In terms of money spent on healthcare by the state, Britain spends only a tiny amount less than the EU average HOW MUCH???. The crucial difference-and this is not merely a statistical argument; it goes to the heart of the problems with health care delivery in the UK-is that almost all health care in Britain is delivered by the state, through the NHS.

Across the rest of the EU, however, patients are able to make use of private provision and to contribute not just through their taxes but through additional private spending (HOW'S THIS DIFFERENT IN THE UK??? PEOPLE CAN GET PRIVATE CARE IN THE UK TOO IF THEY WANT, RIGHT??). To give the Conservatives due credit, they cottoned on to this fallacy in Labour's argument straight away. The Conservative health spokesman, Dr. Liam Fox, a former NHS doctor, immediately decided that this was where Labour was vulnerable. It was aiming at an extremely misleading figure for average spending across the EU, and intending to make up the private spending gap through extra public spending.

But then the Conservatives' instinctive caution on saying anything to do with the NHS took over. Dr. Fox could have used the government's confusion over the real meaning of the EU average spending figures to open the door for a fundamental rethink of health policy and a debate on whether or not the NHS remains the most appropriate vehicle for the delivery of healthcare today. Instead, Dr. Fox chose the single worst option open to him.

You can imagine his thought processes. Given the Conservatives' unpopularity over the NHS, the last thing he must have considered doing was arguing that the NHS was indeed fundamentally broken. That, he must have thought, would only confirm the public's view of his party as hated opponents of the NHS. So how best to use the government's confusion? Well, since the real message of the figures is that other countries spend more private money on healthcare, why not simply advocate that? Bingo!

That, in one sentence, became Conservative health policy: persuade as many people as possible to take out private health insurance and offer tax breaks to those that do. You can see the attraction and the logic of it. But you can also see just how wrong headed, and self-defeating, it became as a policy.

If anything was designed to confirm the public's view of Conservative attitudes, it is a health policy offering tax breaks to those already better off. It was seen as a policy designed only to-in that phrase which says so much about why the British have put up with the creaking NHS for so long-queue jump. Nothing could also be more damaging to the cause of healthcare reform in the UK, making it appear as if the only role for private provision is to make life a little better for the wealthy.

What Dr. Fox should have done was to ask why the British spend so much less on non-state funded healthcare. The reason is simple. It is because the NHS is so different from the systems on the Continent. Other Europeans have a mixed economy of healthcare, with private providers working alongside state providers, with private funding joining together with public spending and with arrangements which draw on public and private approaches.

If Dr. Fox had been canny, he would have recognized that his party is not really campaigning for the 2001 election, but for the 2005 election, and that in three or four years' time it will be obvious to everyone that the government's extra billions have made precious little difference. The extra money will go down the drain.

After all, in all but two of the NHS' 52 years, its income has risen in real terms, and it has nonetheles never been able to cope. The country needs, Dr. Fox should have said, a "fundamental debate" on how to structure health care delivery in the most equitable and efficient manner.

So he could have prepared the ground for the Tories to reap the political rewards in by arguing today that the NHS is no longer able to cope with demands made on it. He could, in plain language, have put the Conservatives in a position to be able to say in 2005 "I told you so" and to reap the benefits of foresight. Yes, he would have had to endure jibes that such an approach was all that could be expected of a party opposed to the NHS in principle.

But he is suffering them today, with no possible gain, and certainly no long term strategic benefit. Instead, he has simply positioned the Conservatives as the party that really does seem to care only about helping the better off.
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