There are two things about the forthcoming general election that
make it special for anyone interested in politics. One is the economic
situation of the UK
and the other is the massive influx of new, inexperienced MPs, with so many
retiring or fatally damaged by the expenses scandals of the past two years.
Though the recession may officially be over, that’s not true
for public services, where the worst impacts are yet to be felt. Local
authorities and NHS trusts (or health boards, if you’re in Scotland or Wales) are only just beginning to
feel the impact of the collapse of their investments, the strain on their
pension schemes and the imminent reduction of some of their central-government
funding. Essentially, whatever promises any of the political parties are
making, they will be subject to complete revision once the winning party gets a
good look at the state of the Treasury. This lack of money will distort, if not
simply negate, any election promises.
Whoever takes the reins of power in Westminster this year will have to manage
their way through a serious level of cutbacks in public service for at least
the next two years – and that will likely mean reductions in both statutory and
community services for people with HIV. Not just national government but also primary
care trusts (PCTs), health boards and local authorities will be looking to
prioritise what they – and local residents – see as must-do services, and we
all know how low down that list HIV and sexual health services can come,
despite the best efforts of both THT and NAT (National AIDS Trust) in lobbying.
Because health is a devolved responsibility, with the
Scottish Parliament and the Welsh Assembly making decisions in those countries,
some (though far from all) of what follows relates specifically to the English
NHS. But it’s worth remembering that all MPs at Westminster have a vote on English health
matters, and many of the things that affect people with HIV are not in the
health brief.
In particular, the AIDS Support Grant, which comes up for
scrutiny again in 2011 after a thre-year renewal by Labour, is at serious risk.
Without it, many local authorities in England will cease to fund any HIV
social care at all. If you want those services now or in the future, then it’s
a point worth making to any candidate that you want the AIDS Support Grant renewed.
That decision will be centrally made by the Treasury and the Department of
Health.
Money will be scarce throughout the NHS, and managers will
be looking to make changes to how care is delivered in order to use their
scarce resources to best advantage. HIV services won’t be exempt from this, but
currently all three parties are keen to show that the broader NHS is safe with
them and so are not really tackling the issue convincingly. Whoever gets in
will be keen to devolve decision-making to local level, and then disclaim
responsibility for those decisions. Local MPs, however, have local influence so
it will be important that yours understands HIV, whichever country you’re in.
Whatever the party in power, there will be many shiny new
MPs with, to be tactful, variable levels of experience of the practicalities of
government. The election of 2010 is expected to see more new MPs than any since
1945. That’s not necessarily a bad thing, but it does mean that they’ll start
out with more enthusiasm than experience. It’s going to be up to all of us, as
their constituents, to train them about issues dear to us.
Health, as said, is a devolved responsibility nationally but
one thing all three main parties agree on is that even more decision-making
ought to be devolved, with health funding and prioritisation done at PCT level
or lower. All three parties want to see the NHS and local authorities working
together better, particularly in managing public health and social care. The
Conservatives are flirting with abolishing primary care trusts, the Liberal Democrats
want to abolish strategic health authorities and all three (particularly the
Tories) are keen on using GPs to commission services on an ever smaller and
more parochial basis. Would you want your GP commissioning your HIV services?
Unfortunately, we know from experience under Labour how poorly
this localism works for HIV. Stigmatised, unpopular conditions lose out in local
‘democratic’ prioritisation of scarce funds unless they have a local ‘champion’
– all too uncommon with HIV. Sexual health funds have notoriously been
plundered in the past few years to make up deficits; and only unpopular
national targets seem to have any leverage in getting most trusts to do the
right thing by any area of sexual health. Local election of members of the
public onto PCT boards, as suggested by the Liberal Democrats, sounds great –
but will those members of the public be sympathetic to the issues of people
with HIV? Sadly, so far they’ve often not been unless people living with HIV
are prepared to get involved.
Localism, so popular with politicians, also increases the
postcode lottery of variable health care – an evil which all parties are
stoutly against. ‘Doublethink’, as George Orwell defined it, “the
power of holding two contradictory beliefs in one’s mind simultaneously, and
accepting both of them”, is alive and well across all the main British
political parties.
As a lay person trying to find out what the parties
officially think should be done about HIV from their policies, you’d have a
hard time. Though over 90,000 people in the UK are currently infected and
numbers continue to rise, domestic HIV is not a big ticket item for any of the
parties. Labour’s website has their policy on public health, but neither HIV
nor wider sexual health figure in it. The LibDems have a handy pocket guide to
their policies, but neither this nor the health page on their website mention
HIV or sexual health. Interestingly, both parties find time to mention other
public health threats like obesity, alcohol and smoking. The Tories follow the
same format, although they do link to their overarching health policy document,
which talks about HIV and sexually transmitted infections under public health.
They also have a newer public health policy, ‘A Healthier Nation’, which talks
a lot more about HIV.
If you cast your
net a little wider, there are some interesting ideas about, which will have an
impact on people with HIV, or on its continuing spread. The Liberal Democrats,
for example, want to abolish prescription charging, which impacts increasingly
on people with HIV as cost pressures force specialist clinics to push patients
back to their GPs for everything bar prescriptions for antiretrovirals. Labour has
also promised to remove prescription charges for long-term conditions, but have
failed so far to do this for anything except cancer – because of the costs
involved.
Of course, this
reflects the reality of being in government as much as anything else. It’s much
easier to promise things when you’re not the one currently having to balance
the books though, to be fair, the LibDems are also the only party prepared to
admit they are in favour of increasing taxation to pay the bill for their
promises.
It is vital that newly elected MPs
appreciate that some of their constituents really care about HIV.
With the outcome
of the election on a knife edge, it’s tempting for politicians to worry as much
about not saying things that might alienate people, as putting forward positive
policies. That means that HIV and sexual health, as ‘tricky’ subjects, are
likely to get little attention unless interested parties ensure they are raised.
Of the three main
UK-wide parties, the Conservatives have undoubtedly published the most detailed
plans for health (and a number of other areas). This isn’t surprising, since
they have a serious shot at power but no recent government record to stand on (and
in some areas probably wouldn’t want to be remembered for their previous
history anyway – Section 28, I’m looking at you). Interestingly, on HIV itself
they do have a strong record due to their response in the 1980s which, under
Norman (now Lord) Fowler, was swifter and more pragmatic than many other
European countries despite wider Conservative policies inimical to discussing sex,
and homosexuality in particular.
Though they
regularly attack the current Labour Government on sexual health issues, even
the Conservatives don’t have many concrete answers on HIV. Their latest policy green paper sets out the
problems well, but doesn’t offer the detailed strategies for change that they
do for smoking, drinking and obesity. But they do offer increasing emphasis on
public health including ring-fenced public health funding, slanting that
funding towards the most deprived areas of the country, a linking of funding to
results and a more “mixed economy of care” involving private and voluntary
sector groups as well as the NHS. The latter is in clear contrast to the
current Health Secretary, Andy Burnham’s, off-the-cuff promise that NHS service
providers would always be favoured.
However, all too
frequently the parties use jargon to sound more different than they are. Both
the LibDems and the Tories berate Labour for their use of targets, much hated
by PCTs, and claim they wouldn’t use them. But the LibDems would have “patient
entitlements” and the Tories would have “standards”. Is there a difference?
The relevant
question is, how enforceable will any of these be? For HIV, targets and ring-fencing
and directives are often the only way we get anything done – everyone knows,
for example, that we desperately need to increase testing rates for HIV and
they know how it could be done, but without central government diktats,
everyone’s just milling around saying what a good idea it is. Many people hated
the national target of 48-hour access to GUM (sexual health) clinics, yet it
undoubtedly led to major improvements in access and services.
But the issues
that relate to HIV go a lot wider than the health brief. Social care, benefits,
employment and legal protection are all relevant and for some people, gay
issues, immigration, ageing and overseas aid are policy areas that we care
deeply about, whether it’s for ourselves or others.
Social care is
undoubtedly going to take a battering in the current economic situation, and
there’s little to choose between the three main parties. All of them are in
favour of better co-ordination between health and local authorities, and all
three are pushing personal care budgets, an idea that’s been around for more
than a decade without anyone working out how to do it well and efficiently. The
Conservatives are keen on ways of increasing self-reliance through new
technologies, such as the greater use of new technology to allow people to live
independently.
Education shows
more differences, with the Conservatives visibly unwilling to support compulsory
sex and relationships education (SRE), illustrated by their current opposition
to lowering the age at which compulsory SRE would start to 15 (as the
Government wants, in order to ensure every pupil gets at least one year of it)
or even lower (as the LibDems want). Though the Tories have moved a long way
from their 1980s attitudes to sex education, they still show a reluctance to enforce
teaching of the basic sexual life skills. On the other hand, they are keen on
increasing numbers of school nurses able to give advice on sexual health.
LGBT (lesbian,
gay, bisexual and transgender) issues are an area where the past shows clear
differences, but future promises are less distinctive. Labour are extremely
proud of their equalities record, having presided over a lot of change for LGBT
people, from equalisation of the age of consent to civil partnership, equal
rights to goods and services and the repeal of Section 28. Their
anti-discrimination measures have also been important to disabled people of all
sexualities.
Many Labour
politicians of my acquaintance are completely bewildered as to why so many gay
men are therefore ungrateful enough to vote Tory, given the party’s poor past
record on gay issues. But times, and parties, change and there are increasing
numbers of openly gay people within the Tory party. Undoubtedly many old-timers
within the party are holding their tongues in hopes of being elected, but the
same could be said of many to the left in Labour who ‘behaved’ in order to get
Blair elected – and then found themselves unable to backtrack.
Conservative
public health policy talks clearly about individual and social responsibility
and about making funding more dependent on results. If they win, there will be
a strong focus on these issues and it will be interesting to see how that
translates into HIV. There may well be challenges to how current services, including
health promotion, are focused, but don’t expect a return to eighties-style ‘Just
Say No’ campaigns; their policies are about ‘nudging’ people into social norms.
Payment by results will take the foreground, though.
Migration and
border controls are a difficult area and one whose interaction with HIV can be
volatile. Shortly before the last election, Michael Howard, for the Tories,
made a sudden proposal to introduce border controls based on health and, when
this proved less popular than hoped, linked it explicitly to people with HIV.
Hopefully, now even the US
has admitted this is an unworkable policy, that won’t happen again – but I’m
willing to bet someone will try and suggest it. Both the Tories and Labour are
big on policing our borders and managing immigration, whereas the LibDems have
taken on board the pragmatism of allowing asylum seekers to work instead of relying
on handouts.
People with HIV
are living longer and are increasingly likely to need care services in their
old age. At time of writing, this is a battleground between Labour and the Conservatives,
with accusations of false accounting, scaremongering and unrealistic plans.
Again, the bottom line will be – whatever they promise, the economy will come
first. Money will have to be found to pay for elder care and some will come
through charges in one form or another.
The other big
area for people with HIV, given that 47% are unemployed, is benefits and
support to work. Labour’s review of Special Needs and recent proposals to
change some benefits have not endeared them to many people who are (or were)
dependent on these, but it is unlikely that the other parties would act
substantially differently if in power. Traditionally, Labour have offered more schemes
to enable people to get back into work, but these have not always proved the
success hoped for. The LibDems want to simplify the benefits system – something
I think we’d all agree on – and to give debt advice to the unemployed through Jobcentres.
That’s only a brief
overview of some of the policies currently being promoted by Labour,
Conservatives and the Liberal Democrats. As said at the start, whoever wins the
election – and that includes the possibility of a hung Parliament with the
LibDems holding power – the economy will take precedence and could well throw
many plans and promises straight out of the window. In a situation where only
the highest priorities will get attention, it is vital that newly elected MPs
appreciate that some of their constituents really care about HIV.