Dear @normanlamb, thanks for your e-mail. Could I bring the transgender community to your attention?

It was very nice to get an e-mail from the Minister of State for Health, especially so soon after we met in Saxmundham, And I couldn't agree with him more that we should, as a society do more, if we can, to reduce suicide rates in this country.

Which brings me to the transgender community. I understand, from friends, that the suicide rate, particularly amongst young transgender people, is very high, far higher than that of the population as a whole. They are often poorly treated by the NHS, due in part to a lack of awareness but also due to insufficient resources to deal with their quite specialised needs.

It would not cost much to change that, but would make the world of difference to those who are vulnerable and, often, isolated. Ensuring that they receive treatment within the guidelines set out, enabling them to be treated overseas if that helps - the cost differential need not be that great - would prevent the needless waste of human life that delays and/or denial by medical professionals sometimes provoke.

I don't know too much about my friends amongst the transgender community, and have only a hint of their day to day experiences, fighting for the treatment they need. They will doubtless have a list of more specific suggestions that would be appreciated, and I hope that they will be given an opportunity to put them to you and your colleagues in the Department of Health. But it strikes me that we could do something that helps them and achieves your laudable goal at the same time.

Just a suggestion, Norman, but I would be grateful if you could think about it...

A night out with Norman Lamb in Suffolk Coastal

Having been invited to attend a public meeting in Saxmundham last night, organised by the PPC whose selection I managed a few months ago, it seemed churlish to refuse, especially as the guest speaker was Norman Lamb. And besides, it's always helpful even if all you are doing is boost the numbers.

James Sandbach, for it was he who organised the event, lives in Saxmundham and had promoted the event locally and, it became apparent, very effectively too, as the chairs that had been set out quickly filled and extra chairs had to be fetched - I vaguely remember a David Steel story which included that line - as interested local residents streamed through the doors, filling the hall.

It had been arranged that Norman, who was coming from London, would be picked up at Ipswich station, and conveyed by fast car (fast being an entirely relative concept here in rural Suffolk) to the meeting. What perhaps hadn't been allowed for was that it takes about forty-five minutes to get from Ipswich Station to Saxmundham and so, as the start time for the meeting approached, I was detailed to await Norman's arrival outside, in the company of the Press (BBC and the East Anglian Daily Times) and a small group of protesters campaigning to 'save mental health services in Norfolk and Suffolk' some of whom were clearly there to be seen by the media and who left when Norman arrived - perhaps if they listened to him, they might be better informed?

Norman Lamb, answering questions

Time passed, and James kicked off the meeting in the expectation that Norman would make it before he ran out of speech and, just in the nick of time, a car pulled out and Norman leapt out of it. Stopping only to give a brief interview to the BBC, he strode into the meeting to be introduced by James and spoke to the assembled audience without notes before taking a series of pre-written questions from a cross-section of the audience, including quite deliberately, some from those of the protesters that had actually decided to take part (I know that because Julia, James's wife and a local GP, and I selected them).

He got through a lot of questions, and got a pretty good response from an audience which was anything but hand-picked, including Liberal Democrat activists from at least four constituencies. All too soon though, the entertainment had to end, and Norman received a thoroughly well-deserved round of applause from most of the audience (you can't please everyone, can you?).

It was a bravura performance, and I suspect that those people who had come to the meeting with an open mind will have concluded that, whilst they might not agree with him on every point, Norman genuinely wants to achieve better outcomes for patients suffering from all kinds of ill health, be it physical or mental, and that equality of priority for mental health funding is something that he has, and will, work hard to obtain.

Much kudos must also go to James and Julia, who put an awful lot of work into organising the event, and to Marian Andrews, who chaired the meeting. Hopefully, people will spread the word about the event and perhaps speak kindly of Liberal Democrats and, in particular, James. He will have a tough struggle to keep the yellow bird of liberty flying in Suffolk Coastal, especially given our poll ratings nationally, but it won't be for lack of hard work and imagination.

@BaronessRos in the Lords - Hospitals: Voluntary Sector and Emergency Readmissions

The House of Lords does choose to do things with almost glacial slowness sometimes, and then, having chosen to move, does so so quickly that members are unable to keep up. And so it was in this instance, as Ros notes in her opening paragraph...

Baroness Scott of Needham Market

To ask Her Majesty’s Government what assessment they have made of the role of the voluntary sector in reducing emergency re-admissions to hospital.

Baroness Scott of Needham Market (LD):

My Lords, it is about a year since I first tabled this Question for Short Debate. I was inspired to do so by reports from the Royal Voluntary Service which described the impact of its Home from Hospital schemes. I regret that, having waited all this time, the Motion was in the end tabled at very short notice, which prevented many Members who would have liked to participate doing so. Given that it appeared on the Order Paper only on Wednesday and that the speakers list was closed on Friday, that comes as no surprise. I am particularly grateful to both Front Benchers and my noble friend Lady Thomas, who will speak in the gap. For the record, I give an assurance that the modest speakers list does not reflect the level of interest in this matter.

I am not one of the usual contributors to debate on health matters, so I thought long and hard before venturing into this area, but I do know about the voluntary sector, and here I declare an interest as chair of the National Volunteering Forum, and it occurred to me that I should table the Motion precisely because I do not come at this from a health expert’s perspective. We have all agreed that the time for silos is over.

It seems a long time ago now, but in 2010, the Secretary of State for Health took measures to manage emergency readmissions, which had risen, in part at least, because hospitals were reducing the length of stay. Despite this, about 19% of emergency readmissions—about 190,000—occurred in 2012-13. The evidence shows that people from lower socio-economic and vulnerable persons groups are at a higher risk of avoidable emergency readmission.

The Government and the NHS have made a good start on getting to grips with this problem by creating individualised discharge plans and ensuring that hospital-led discharge teams provide continuity of care. Of course, the better the integration of primary, secondary and social care, the better the contribution by prevention, early diagnosis and self-treatment. However, as Simon Stevens noted in the NHS Five Year Forward View,

“voluntary organisations often have an impact well beyond what statutory services alone can achieve”.

Last week’s report on patient-centred care from the Royal College of General Practitioners makes specific reference to the role played by community groups and the voluntary sector in achieving self-management of health conditions. Also last week, the NHS published Stephen Bubbs’s report into the commissioning framework for people with learning disabilities and autism, in which he, too, notes the role played by the voluntary sector in the sort of community-based support which reduces both initial admissions and readmissions. It is an area that I am beginning to know well as a fairly new patron of ACE Anglia, which provides just that kind of advocacy and support to people with learning disabilities and autism living in my area. Of course, they are all right. Voluntary organisations can help with early intervention by spotting problems early on and by helping to join up fragmented services. They often bring specialised and local knowledge and, precisely because they are not from the statutory sector, they tend to be trusted.

Provision of hospital-to-home services in a range of contexts can often give patients the time and space they need to make a recovery and avoid readmission to hospital, with all the trauma that that entails. The British Red Cross gave an example of Mrs Jones, a widow in her mid-80s suffering from dementia. Discharged from hospital but needing treatment for a urinary tract infection, staff referred her to the BRC, which arranged for a volunteer to meet her in hospital and then visit her at home to make sure that she completed her course of medication. It ensured that the social services team was aware of her needs, and that she felt supported. She not only recovered well at home but, because of the ongoing support and encouragement she received, her quality of life actually improved on a long-term basis.

AGE UK Cornwall carried out a pilot scheme where volunteers worked closely with patients to identify their needs and offer support. It acted as a key link with the NHS and social services. Under that scheme, emergency readmissions were reduced by 25%. The Midhurst Macmillan Service is a specialist palliative care service covering a 400 square mile area of rural England across three counties. By offering a host of roles from shopping and gardening to emotional support for the patient and their family and liaison with the NHS, the scheme is aimed at reducing the number of hospital admissions. Although they are not strictly emergency readmissions, nevertheless, its work is very successful: 73% of its patients died at home or in a hospice rather than having to be admitted to hospital.

In its recent report, Going Home Alone, the Royal Voluntary Service highlighted its own scheme in Leicestershire which showed that a package of support reduced emergency readmissions by half, from 15% being readmitted in 60 days to 7.5%. It was not rocket science. Contact was made with patients before they left hospital, and someone went home with them and made sure that the house was warm and lit, and that some food was available. They offered support to collect prescriptions, make follow-on medical appointments and liaise with the statutory services. Many of these actions are so simple, but make so much difference. However, like many simple things, they are not always easy.

Like most other services, voluntary organisations have had to deal with funding cuts. In many cases, when they wish to bid to provide services, they are disadvantaged against the private sector because they want to provide decent terms and conditions for their staff and are not going to go down the zero-hours contract route. In some cases, these organisations simply lack the capacity to engage in complex and expensive tendering processes.

The reorganisation of health and social care at a local level has meant that new relationships between the sector and the commissioners have had to be developed. Some health and social care providers are simply not aware of the range and extent of the work of the voluntary sector in their area and so patients miss out on the support they can offer. Then there is the vexed question of substitution. Volunteers do not want simply to replace public services which have been cut, but want to add value.

What we are now calling austerity looks likely to be the new norm. It is hard to take that on board, but we should be planning for it. Government spending should be much less reactive and give some priority to preventive spending, which involves a genuine forward look at the likely impacts of spending decisions made now on outcomes in a decade hence. Policy and funding changes which push costs off into the future are no different from borrowing, and the sooner we understand that, the better.

I am looking forward to hearing from other Members about how we can better harness the collective strengths of the statutory services and the voluntary sector. The old dividing lines have become blurred and the picture has become more complex as a result, but the need has never been greater.

Reflections on the NHS... and why we might be our own worst enemies

Yesterday, I blogged about my recent minor surgical procedure, noting how well everything went, how kind and caring the nurses were, how efficient the surgeon was. And it got me to thinking about the NHS, not something that I've had much cause to do in the past. You see, as a very infrequent user of the healthcare system - I've been pretty fortunate to remain in good health - it is the sort of thing you take for granted. It will always be there, it will be free (well, freeish), and it will cure you if you're ill, and save you when you get broken.

Its status as a national institution is such that it was showcased in the opening ceremony of the London Olympics, and was protected from cuts by the incoming government - David Cameron promised that, you will recall.

SInce then, the NHS has come under pressure. Yes, the budget has been ring-fenced, and has kept pace with inflation. However, funding a national hearth care system is more complex than simply ensuring that it has the same amount of money in real terms. Inflation in the healthcare sector is traditionally higher that it is generally, and you can't manage demand in the same way that you might otherwise. And, as we find new and exciting ways of prolonging life, whilst more and more of us adopt lifestyles that make us more vulnerable to illness, injury and disease, the demands upon the system change.

You can deal with that in a number of ways, I guess. You can simply increase the funding available, you can charge for some services, you can seek organisational savings or you can just axe some services altogether. You might attempt a combination of some or all of these. But, the problem is that if you raise taxes, the opposition attack you. If you charge for services, or reorganise, or axe services, likewise. And, if you're a politician, you might conclude that it's all too difficult and give up.

Unfortunately, like any successful organisation, the NHS has to change to face the changing circumstances as they emerge. How many expensive pieces of kit can you have, and where do you put them, how do you incentivise your staff to be more efficient whilst maintaining service coverage, how do you address the demands of local residents, who have differing priorities in different parts of the country? All of these things require thought and the ability to adapt, and yet we protest about change, condemning it as meaning the end of the NHS as we know it when we know that, after every supposedly radical (and widely opposed) change in the past, it has still been there, still dispensing healthcare to all at a cost far lower to the public purse than it does in places like the United States.

But, if we continue to have opposition parties blindly oppose change whilst not engaging with the creation of a vision for the future of such a critical public service, we risk preventing changes that could save the NHS for decades to come. Instead, we need political parties and campaign groups to come together to create a shared view of what we need as a country, rather than treating the whole thing as a football to be kicked from one end to the other whilst the rest of us look on.

We will probably need to be pretty creative about the future shape of the NHS, we may even have to make some compromises in order to secure the broad principle of free at the point of access healthcare, but with an aging, increasingly unfit population, we're going to have to do something...

Jeremy Hunt may need some better comparators for the NHS...

Reading my morning newspaper, I note that Jeremy Hunt is suggesting that the NHS must copy banks and budget airlines by using the internet to give a better service whilst cutting costs. And yes, there is no doubt that the internet does offer opportunities to increase efficiency and open up new possibilities for patients, but are banks and budget airlines really the sort of organisations that you'd want to see the NHS aspire towards?

One envisages a Ryanair-style website, where you start off with what looks like a simple transaction and then you find yourself confronted with a plethora of choices, do you want an anaesthetic for your surgery, or extra convalescence time, or clean surgical instruments, that sort of thing. Perhaps, taking a cue from the banks, you could be offered spare body parts that you don't need because you've already got one, and when you do try to use them, they tend not to be compatible with you.

And it is ironic that, as Jeremy makes his suggestion, elsewhere in my copy of The Times, there is news of a report from the Financial Ombudsman Service, noting that the number of complaints made to it about banks last year reached record numbers.

However, he makes a point which exposes a slight lack of understanding of how public services work, in that he notes that retail banks have cut a third of their costs by persuading us to do the work they used to do themselves. He is right, but he misses the point that, by doing so, the economic costs of transactions have not necessarily fallen, as the work, instead of being done by a trained professional, is being handled by an inexperienced, untrained amateur, who is likely to spend rather longer doing it.

I'm also not necessarily convinced that I have benefited financially from the arrangement either, as fees haven't fallen and senior employee salaries have increased.

So, yes, encourage the NHS and, for that matter, the rest of the public sector, to use the internet more intelligently by exploring new ways of operating by all means. But just don't forget that it's not the same as a retail transaction, in that most dealings with public services are seldom voluntary, and there's seldom a choice, because, ultimately, you're dealing with human beings with all of the irrationality and foibles that come with them...

NHS Reform: Shirley rides to the rescue...

So, Liberal Democrat Conference has voted to debate the leadership favoured alternative in the emergency motion ballot, by a margin of 309 to 280. And the majority, small that it was, includes me.

There's no doubt that such a margin demonstrates how important the work of the Lords has been in revising what was a very poor piece of legislation. And, whilst the public debate has centered on what was in the original bill, I would rather have us debate what we now have, rather than what others would like us to believe.

I'm intrigued by the protests. They have been emotional, many entirely genuine. However, I feel it only right that  Conference has the opportunity to hear for itself what has been done to reflect the concerns expressed in Sheffield last spring.

And tomorrow, we'll see if Conference thinks that it is enough...

NHS Reform: everybody's shouting, but is anyone paying attention?

If, as Andy Burnham claims in Liberal Democrat Voice, this weekend sees the last opportunity to 'save' the National Health Service, then I find myself in the eye of the proverbial storm. Which, all things considered, is an intriguing place to be.

If, as is suggested, most people have taken sides, then my support will be somewhat in demand, as I genuinely haven't made up my mind.

As a fiscal conservative, I look at comparative rates of inflation within the health sector and the economy as a whole, and I shudder. We will, as a society, have to decide what we are willing to provide and what we can afford to. And, with increased longevity and the additional costs that go with it, the demands on the NHS are bound to outpace growth in the economy. Such a debate will not be pretty. New 'superdrugs' and complex but lifesaving medical procedures don't come cheap either.

Therefore, finding new, more cost-effective ways of doing things is an imperative. But this isn't like widget manufacturing - people's lives are at stake.

And because of that, all changes to the NHS are emotive. Private versus public, access to treatment, questions of waiting times and rationing, all provoke an awful lot of heat and very little light, it would seem to this rural bureaucrat.

And this is where our coalition with the Conservatives makes reform difficult. Sadly, nobody trusts them with the NHS, and despite some fairly herculean attempts to address the issues that have been most difficult, we are left with some major problems;

1. The Coalition Agreement seems quite clear that there would be no top-down reorganisation. You can argue that all the change is actually bottom-up, as change will be driven by local GPs, but few people really believe that, and there are plenty of GPs who would rather not be empowered, thank you very much.
2. Andrew Lansley has the bedside manner of Dr Crippen. It has become so bad that I suspect that if he was announcing record new investment in the NHS (genuinely record new investment, that is, not the spin master version), he would still cause a drop in support for the Coalition.
3. The Opposition have every incentive to wave shrouds and none whatsoever to engage. And, as everybody loves the NHS, and nobody remembers what they did to it when they were the Government, they can get away with it.
4. The original bill was clearly drafted by people who go private, or would be happier if more people did. Given Andrew Lansley's links with the healthcare industry, one perhaps shouldn't be too surprised.

As a Party, we haven't been terribly sure-footed either. The political antennae of our leadership were evidently not operating well before the initial draft came out. Someone, somewhere, should have spotted the various bear traps and sent it, and Mr Lansley, back to the drawing board.

It must be admitted that, at that stage, there was little sense still that when it came to converting ideas into deliverable legislation, the Conservative policy wonks were a menace to society due to their apparent failure to understand how real people behave in real situations. After all, we test our policies at Party Conferences, where people get up and make comments such as, "I think you'll find that the requirements of the 1885 Paper Clips (Amendment) Act are a barrier to progress in that direction." - and are often right.

As a result, the proponents of the legislation start any argument with a significant disadvantage. Having conceded the pause in the legislative programme, and encouraged people to express their fears, the Coalition fell foul of the widespread misunderstanding of the word 'consultation', a personal bugbear of mine.

There was still time to withdraw the Bill, put it out to pre-legislative scrutiny, preferably in the Lords, and see what emerged. It might not have been what those behind the original Bill would have liked, but it would have been something more circumspect and obviously coherent.

Instead, opposition to the Bill has been allowed to grow unopposed, and whilst Liberal Democrat Peers have sought to build in safeguards addressing any reasonably based concerns, the likelihood of reasoned argument getting a look-in at the public debate is either slim or none. Indeed, that might be slim leaving town as I type...

So, I'm hoping to hear the arguments, find out more about the legislation, and weigh up the politics of where we are.

But somehow, I'm not minded to do it because Andy Burnham wants me to. After all, if he and his friends hadn't opened up the NHS to the private sector in the first place, we wouldn't even be having this argument now...

Lords call for proper testing of EU health workers in the UK

In a widely welcomed report, the Social Policies and Consumer Protection sub-committee of the European Union Select Committee of the House of Lords has sharply criticised the European Union MRPQ Directive, underpinning the mobility of healthcare professionals within Europe, for its failure to protect the public from doctors ill-equipped to carry out the duties expected of them.

As a taster, here is a short video, featuring one of the Committee's members...

The report, "Safety First: Mobility of Healthcare Professionals in the EU", notes that whilst employers in the United Kingdom are obliged to recognise the qualifications of health workers, including doctors, nurses and midwives, from other EU states without question, they are barred from carrying out language testing to ensure that they have the verbal skills required to deal with patients. Indeed, there is no scope to verify whether or not an individual has maintained their skills since receiving their qualification.

It notes that the definition of key roles, such as 'general practitioner', varies in terms of its scope across Europe, with some patients seen directly by consultants for conditions treated by GPs here. In some countries, babies are delivered by gynaecologists, whereas in others, midwives are at the heart of things. The question of definition, and hence skill and experience levels, is at the core of the problem, and the Committee called for an updating of the minimum standards as currently outlined in an Annex to the Directive.

Questions relating to medical ethics were also touched upon, with the Committee noting that some groups of healthcare professionals were required to have an understanding of the issues surrounding ethical behaviour whilst others, including doctors, were not.

In brief though, the Committee made three core recommendations;

• regulatory bodies (including the General Medical Council, Nursing and Midwifery Council, General Dental Council and General Pharmaceutical Council) should be allowed to test the language skills of ALL non-UK applicants
• an alert mechanism should be implemented so that authorities can share fitness to practice information and warn each other about practitioners who have been subject to disciplinary proceedings
• the list of qualifications and skills recognised by the EU Directive must be updated

Hopefully, the Government, and the European Commission, will act upon these recommendations by 2013, although it is not likely that the impact will become effective until 2017, at the earliest.

Does freedom of movement within Europe trump public safety?

One of the great benefits of our membership of the European Union is the ability to work anywhere within it, a benefit which has allowed British professionals to take their skills to places where they are needed and valued. However, it does occasionally present problems.

A management consultant is, if they get something wrong, unlikely to kill you. On the other hand, a healthcare professional might. The recent incident where a German locum doctor accidentally killed a patient by multiplying the correct dosage of the prescribed drug by a factor of ten, highlighted this risk.

The Mutual Recognition of Professional Qualifications Directive (MRPQ Directive), agreed in 2005 and transposed into UK law in 2007, is a fundamental component of the Single Market. It allows professionals to have their qualifications, obtained in one Member State, recognised in another and thus allows them to be employed anywhere within the Single Market irrespective of where they have trained.

However, whereas non-EU healthcare professionals have to undergo language testing, EU ones don't, not necessarily ideal for a relationship as nuanced and intimate as doctor/patient.

Thankfully, whilst the Commons is pretty useless at scrutiny of European Union directives, the Lords is rather more dedicated to the task, and its EU Sub-Committee G - Social Policies and Consumer Protection has been exploring the impact of the MRPQ Directive and considering what further steps might be taken. Today sees the publication of its report and, once I've had an opportunity to examine it, I'll report back...

NHS Reform: getting rid of Andrew Lansley isn't the point

According to this morning's Times, one of the prices to be paid for securing the Coalition is the head of Andrew Lansley.

To be honest, that's a bit too easy for my taste. Don't get me wrong, I hold no candle for the MP for South Cambridgeshire, but he isn't the problem. The problem is the policy, in that it isn't wildly popular. That doesn't make it bad policy, ironically, because popular isn't always good - dangerous dogs, anyone? - but it does mean that revisiting the drawing board might be a very good idea indeed.

Firstly, strip out the entirely artificial deadlines. All they do is create an undue sense of urgency and make transition management a nightmare, a car crash waiting to happen. That's not only bad politics, but bad administration. Good policy is straightforward to administrate, so that you can make it happen.

Second, decide upon your criteria for a well-run NHS. Cost-efficiency, improved care standards and democratic accountability are not mutually exclusive, and a proper debate on the future of health provision might just make for better decision making. And that means not simply demanding the full ice cream sundae with whipped cream, a flake and a cherry on the top, it means a realistic assessment of what we need in the future and what we can afford.

Thirdly, the notion of private sector cherry-picking is something that some Conservatives do not, or do not want to, get. And yes, there do appear to be some in the Labour and Liberal Democrats who suffer from the same myopia. That isn't to say that there isn't a place in health provision for the private sector, but it makes people nervous. So, for example, why not allow private companies to run an NHS Region leasing all of the buildings and equipment from the State? Any savings could be split on a shared basis between provider and government, and the assets revert to us when the contract ends. Indeed, you could even allow said provider to subcontract bits of work, so as to open up opportunities to small and medium sized enterprises.

Ultimately though, the problem is less about policy than about fear and trust. On the NHS, people don't trust the Conservatives, and the fact that the changes appear to be all about one of the three key criteria - cost - excites suspicion. And it isn't the job of the Liberal Democrats to reassure people that Andrew Lansley has the best interest of the NHS and patients at heart, it's our job to test, prod and probe the policy, and to do it publicly. If it survives proper scrutiny, then fine.

And if Andrew Lansley doesn't like it, he can quit, rather than be sacked. That way he gets to retain his honour and his integrity, and we take a small step towards the new politics that people keep talking about.

Should we really be surprised that NHS reform has been botched?

I am not in the habit of saying, "I told you so", especially as there have been so many occasions when I didn't. However, I did take a look at Conservative health policy a year ago and noted the sea of contradictions that existed then. And, as far as I can tell, not much has changed.

This explains an awful lot, and is a precursor for future potential difficulties. You see, the Conservatives don't really get localism or at least, they don't really understand its implications. With localism, you get difference, not consistency, and you place your trust in local people. And that in turn means that they will make the choices that suit them. What is good for Barnsley may not work so well for Bury St Edmunds, and vice versa.

In an environment where politics is often about playing off one group against another, the dangers are obvious. If government devolves power to a community, and that community makes a choice that an opposition party doesn't like, who gets the blame? You can hardly blame the community, so you blame the government. The government, under fire from the media, starts to think about regulating for minimum standards. The more minimum standards are set, the less scope there is for the community to make choices, and before you know it, the benefits of localism are lost, and you've created another bureaucratic structure that is now purposeless.

The notion of localism underpins the 'Big Society' concept, but the desire to shrink the size of government is in stark contradiction to those Conservative strands of thinking that are paternalistic in nature or suspicious of empowering people that aren't like them. That isn't to say that all Conservatives are paternalistic, or that they distrust ordinary people per se, it's just that being socially conservative presents them collectively with a number of philosophical dilemmas.

The problem of creating a free market in healthcare overlooks a societal presumption that the NHS is the health provider of last resort. If the private sector cannot, or will not, provide a particular treatment, the public assume that the NHS will. This is not the basis of a free market. It must also be assumed that, in a free market, there will be a degree of surplus capacity, and in a sector where the element of choice is not so clear cut, who pays for that surplus capacity? Indeed, why should the private sector be expected to create it? No, far better to have the certainty of long-term contracts, which effectively limit the options of 'customers' (I'm sorry, I really hate the word, but 'patient' doesn't quite cut it).

Andrew Lansley's NHS reforms smack of a 'back of an envelope' calculation, and every retreat and every compromise simply demonstrates just how poorly thought out the original concept was. If the Coalition partners are going to emerge from the current cycle of budget cuts with any credibility intact, each of them is going to have to display a much more transparent and coherent approach to the changes that our economy and our country needs.

And whilst I still believe that the Liberal Democrats policies coming out of Government are fairly robust, the same cannot be said of the Conservatives...

Conservative health policy - can you spot the contradictions?

The recent announcement by the Conservatives that they will provide cutting edge cancer drugs to those that need them is, as usual, pretty good politics. Yet it is another spending commitment which indicates that, whilst flashy rhetoric is a strong point, financial management and an understanding of basic bureaucracy is still sadly lacking. I was, however, moved to see what else the Conservatives have to say on health...

There are some apparent contradictions between their stance on devolved decision making and their stance on access, for example;

• they will 'devolve decision-making closer to patients'
• they will 'create an independent NHS Board to allocate resources to different parts of the country and make access to the NHS more equal'

I think that most liberals would support the former, but if you're devolving power at one end, why give power over resource allocation to an independent body? Who sits on such a body? How is it accountable and to whom? Or is this just another quango, of the type the Conservatives have sworn to abolish?

Indeed, by allocating resources from the centre, and standardising access - because that's what 'making access more equal' means - how does that reflect devolution of decision-making? Surely, if your patients decide to allocate resources in a particular manner, unless they all make the same decision, access will not be equal.

Moving on though;

• they will 'scrap all of the politically-motivated process targets'
• they will 'measure their success against those countries with the most effective systems of healthcare'

Not all of the politically-motivated targets then, or at least, the introduction of a different set of politically-motivated targets. And, in any case, what does 'most effective' mean? Is that in terms of survival rates, is it in terms of cost? And that is an important question. If you're a cancer patient, the most effective treatment is the one that cures you. If you're controlling the budget, it's the one that saves most lives at the lowest cost. Both are the correct answer, and each is irresponsible when looked at through the eyes of the other.

The implications of a market in healthcare appear not to be understood either. The Conservatives will give everyone the power to choose any healthcare provider that meets NHS standards. Whilst that, once again, looks very attractive, it assumes the existence of spare capacity in the health system. That spare capacity costs, as spare beds need to be kept in good condition even if they're not being used. Also, if customers gravitate towards the best, you will need to find additional resources to allow those providers to extend their level of provision. That means additional expenditure, and with inflation in the health market consistently running above that in the economy as a whole, and the burden of geriatric care moving in one direction only, it is hard to see where the funds will come from.

Yes, the Conservatives offer to cut one-third off of the cost of NHS administration. Yet they promise an 'information revolution', making detailed date about the performance of trusts, hospitals, GPs, doctors and other staff available online. In principle, that's a great idea. However, you need an army of staff to gather that data, the very staff who are to be culled in vast numbers. Add the commitment to compare a performance with our neighbours, and you build into the system great swathes of bureaucracy, causing people to count things, and not actually delivering any healthcare. They will also link GP pay to the quality of the results they deliver. Again, more number crunching, more staff needed to do the monitoring.

There is a lack of consistency here that may well be exposed, and if the Conservatives don't show some fiscal discipline soon, the currency markets may well take the decision out of their hands.

Will you still need me, will you still feed me, when I'm eighty-four?...

One aspect of yesterday's 'Ask the Chancellors' debate which drew my attention in particular was the brief, but heated exchange on personal care for the elderly. As someone in his mid-forties, it is an issue which I expect to exercise me more as old age and infirmity approach.

My parents are part of that generation whose call upon the NHS and local government provided social care is beginning to put genuine pressure on the resources of both. They were told that they would be looked after, and that's what they expected. On the other hand, my nephew and nieces will probably grow up knowing that such provision will not be possible. For those trapped in the middle, the future is a worrying one.

What I found so disappointing was the desperate efforts by Alistair Osborne and George Darling to avoid saying anything on the subject that might upset anyone. Ruling out what George insists on calling a 'death tax' was effectively admitting that it is all too difficult, and yet someone is going to have to face up to the problem eventually, or bankrupt the country.

With an ageing population, the cost of providing care for the elderly, regardless of where, increases, and that cost must either be borne by a working population which is shrinking in relative numbers, or by raising the age whereby one qualifies for financial support, or by reducing the level of care provided by the State. Indeed, I suspect that I will see a combination of all three.

And therefore, the idea of signing over a sum from my estate is actually quite attractive. Effectively, with the flat rate option, one gambles that one will get value out of the deal, a notion no more ludicrous than a contributory pension. Of course, the devil is in the detail, but it was an idea that, as one of a range of options, offered genuine freedom to those wishing to provide for the cost of their care in later life, a government backed equity release scheme if you like.

I very much suspect that the idea will return to haunt Labour and Conservative politicians before too long. It will be interesting to see how they respond when reminded how hasty they were to discard such an option in 2010...

Postcode lottery - or a new localism?

Let me make one thing clear - I share the view that infertility is a terrible thing, blighting lives and denying people the opportunity to do something many take for granted, i.e. raising a family. Unfortunately, the debate today, whereby women are encouraged to complain about the lack of access to IVF treatment in their area, raises a question, the answer to which is going to be unpopular, whichever way you cut it.

It is claimed that access to IVF treatment varies depending on where you live, and this is clearly true. However, this is based on choices made by Primary Care Trusts, something that, as a liberal, I support. It should be the right of a Primary Care Trust to cut its limited cloth according to what is felt to be best for the community as a whole. In some areas, cancer is a priority, in others care for the elderly. You cannot prioritise everything.

I am fascinated by the suggestion that service and access levels should be the same across the country. If you asked these same people to comment on the increasing centralisation of government, they would be the first to complain about interference from Whitehall. Ah, the joy of contradiction... so, we can obviously expect the Conservatives to be in favour of standardised access...

So, should we seek standardised access to healthcare on a national basis, or do we encourage Primary Care Trusts to reach out to the communities they serve to determine what is most desired in terms of service and access levels? The answer, in my mind, is a combination of the two. There should be nationally set guarantees of minimum levels of access and service, with Primary Care Trusts free to invest in additional, top-up services based on the perceived needs of their communities. But this all hinges on proper community involvement - they're our services, we should engage in the debate.

I was, I admit, somewhat annoyed by the comments made by a woman interviewed by the BBC, stating that "I've worked all my life and I've paid my NHS contributions, so why can't I have IVF treatment on the NHS? It's due to finances, oh yes, and my weight...". She's two stone overweight (her claim, not mine), and such circumstances increase significantly the risk that IVF treatment will fail - wasting NHS funds and denying someone else access to treatment. If healthcare is to be rationed due to limits on the amount of funding (your choice, Mr and Mrs Public, you can pay more tax if you want...), then clinical factors are the best and only fair criteria to apply when deciding the appropriateness of treatment.

I don't have children myself, never wanted them, and don't particularly like them (although I make an exception for my own family - they're all angels...) but admire anyone who has the desire and patience to bring them up themselves - it isn't easy. But there are children out there in need of adoption, and they deserve an opportunity too...