NHS at 60: Targets and cancer in the Conservative Party Health Green Paper

With the National Health Service (NHS) turning 60 this week, here’s an analysis of the recent Conservative policy paper on health from our occasional correspondent, François Briatte a researcher from the University of Edinburgh. Find out more about his work, from his website.

Intute: Social Sciences features more resources on the topics of the NHS, health policy and health services, plus there are plenty of resources in the Intute: Health and Life Sciences collection.

On June 24th, the Conservative Party released the sixth part of its Responsibility Agenda programmatic series, a policy green paper titled Delivering Some of the Best Health in Europe: Outcomes Not Targets. The document emphasizes two interconnected aspects of health policy and politics in the United Kingdom, which are briefly surveyed below with the intention of showing how health issues are treated in the British political debate.

The Green Paper starts by reinforcing the politicisation of health policy around the use of new public management techniques, and specifically targets, as tools of government. Outcomes Not Targets effectively summarises a persistent, if not unoriginal and somewhat déjà-vu, line of criticism used by the Conservative Party to oppose health policy under the New Labour governments led by Tony Blair from 1997 to 2007. The intensive use of targets in health policy since the publication of the Saving Lives White Paper in 1999 and the NHS Plan in 2000 is particularly under attack in the second section of the Paper (pages 9-14), which presents targeting as a weak management technique with adverse consequences for patients and not cost effective and offering poor value for money. Targets have been given parallel academic attention by Gwyn Bevan and Christopher Hood, who examined targeting in the NHS and particularly the NHS star rating system. An insider view has also recently become available with the publication of Michael Barber’s book Instruction to Deliver, which covers in great detail his years as head of the Prime Minister’s Delivery Unit.

Instead of “top-down process targets” that submit health professionals to governmental overview, the Green Paper commits itself to horizontal, post-bureaucratic accountability from staff to patients directly:

A focus on outcomes will replace Labour’s idea of accountability – a top-down relationship between politicians and professionals – with modern Conservative accountability – a side-to-side relationship between patients and professionals. It is the right approach for an age in which centralised structures with a monopoly of information no longer work: the post-bureaucratic age (page 7).

To some extent, the reorientation of the NHS towards patient choice since 2006 has pre-empted the argument exposed in the Green Paper that targets are not the proper driver for change and improvement within the NHS. Concomitantly, the Conservative Party has criticised the frantic succession of NHS reforms as pointless as well a source of organisational confusion among both staff and patients.

Second, the Green Paper also shows the predominance of cancer within the politicisation of health policy outcomes. The Green Paper mentions cancer care on ten of its 45 pages, as opposed to four mentions of respiratory diseases and three mentions of cardiovascular conditions, and no mention at all of conditions like diabetes, obesity or HIV/AIDS. Cancer is also mentioned both in the first and the last lines of the Paper as a means of illustration to more general comments. By this simplistic yet rather straightforward means of measure, it seems fair to state that cancer is central to the Green Paper’s approach to disease and its management within the NHS. Similarly, cancer appears as the most prominent disease in David Cameron’s accompanying speech at the Royal College of Surgeons.

The actual content of the Paper accentuates this trend, as the authors of the paper repeatedly refer to comparative cancer survival rates in Europe provided by the EUROCARE-4 study published in August 2007. The results of EUROCARE studies, which show that all parts of Great Britain as well as Denmark are performing less well than other Western countries in tackling several types of cancer (including the most common forms), already produced an impact on British health policy in the years 1999-2000, as mentioned in a previous post on the Cancer Reform Strategy. Identically, Denmark enacted a national cancer control strategy in February 2000, following the publication of the EUROCARE-2 results in 1998.

As they seem to be conscious of the political impact carried by the EUROCARE data, the authors of the Conservative Green Paper on Health have stressed that particular aspect of epidemiological information in their writing, at the risk of overgeneralization from cancer survival to the general state of the NHS. Such a tentative extrapolation appears in the opening lines of the paper, on pages 5-6, when the authors claim that Britain’s health outcomes – for example, five-year cancer survival rates – remain poor compared with those of other European countries. While that statement might be valid, the only tangible evidence provided in the Green Paper is based on cancer survival rates only. Another factor of extrapolation comes from the fact that EUROCARE data analyses trends in cancer survival only up to 2002 for patients diagnosed with cancer in the mid-1990s, hence providing no measure of progress in the later years.

The instrumentalisation of cancer care in strategies of political opposition is hardly new to the Conservative Party, and is not limited to English Conservatives (cancer care is also a recurring topic in speeches by Jonathan Morgan AM, Welsh Shadow Minister for Health and Social Services). Cancer care was already central to the Conservative Health Manifesto of 2005, when the Party was led by Michael Howard. The Manifesto emphasized the fact that British survival rates for respiratory diseases and some types of cancers were among the lowest in Europe (page 3; in a later development on page 9, the authors of the Manifesto confuse cancer mortality and cancer survival). The Manifesto also used cancer as a means of illustration to criticise the waiting times targets set by New Labour, by claiming that the Government cancer target for ‘urgent’ referral has meant other patients, including 10,000 women subsequently diagnosed with breast cancer, waited longer to be seen by a consultant (page 7). In both the 2005 Health Manifesto and the 2008 Health Green Paper, cancer is hence given an exemplar status in the political debate of health policy.

How the two issues underlined in this brief note – targets and accountability on the one hand, cancer care and survival rates on the other – relate to each other seems a suitable topic for further analysis, especially the manner in which a sectoral aspect of health policy (here cancer control) articulates with the more general configuration of the British health system. My own research is based on such premises and I would be very interested in learning about other students of health policy with a similar approach.