"Well I hope the New Statesman have now got their headline," the Conservative shadow health minister Mark Simmonds said at a heated moment in the debate with the Labour Health Secretary, Andy Burnham, and the Liberal Democrats' health spokesman, Norman Lamb. "Which is that the Conservative Party is the only party to maintain and guarantee funding for the National Health Service."
Funding was one of the principal dividing lines in the debate on the NHS that took place a week before the general election on 6 May. All three parties devoted substantial sections of their manifestos to health, and the Tories revealed their commitment to preserving funding for the service in one of their early campaign posters. "I'll cut the deficit, not the NHS," proclaimed an airbrushed David Cameron from billboards around the country. Yet the subject made few headlines and occupied little airtime - especially in the leaders' television debates - during the election campaign.
Given that health commands more of the national budget than any other sector, it is surprising that the party leaders have not done more to divert the public conversation to this policy area. Budgetary concerns preoccupied each of the politicians in our debate, and the Conservatives' pledge to ring-fence the NHS budget was met with opposition.
“A major flaw in Conservative thinking is to see the NHS in isolation from other key public-sector budgets, because the NHS depends on those services for its own ability to function and be productive," said Burnham. Instead of blindly preserving the NHS budget, he argued, efficiencies had to be found.
He added that, while in government, he had been "ahead of the game" in seeking savings, despite the vast challenges involved. "We are entering a new era for the NHS. The era of expansion has come to a close and we now have to get much more for the public from the expanded system."
Lamb broadly agreed, and expressed his astonishment at the Tories' unwillingness to consider making savings in the NHS. "Mark said nothing about this budgetary challenge," said Lamb, "and that really scares me, because there's a real danger that by talking about ring-fencing you take your eye off the ball . . . Even if you have small real-terms increases in funding, the NHS still faces a massive challenge to keep within financial means."
The charge from Labour and the Lib Dems was clear: the Conservatives are unrealistic in their pledge to leave the NHS untouched. However, there was some common ground between the Tory and Lib Dem spokesmen. Simmonds said that he would seek to reduce much of the "central bureaucracy" within the health system, while
Lamb, supporting decentralisation, emphasised the importance of working more closely with local authorities and employers to improve health outcomes. Drawing on the example of the pasty-maker Ginsters, which has successfully reduced sickness absence, he said that encouraging this kind of employer action was essential as health budgets are squeezed.
One major budgetary fear expressed by the audience related to mental health care. Representatives from the charities Mind and Sane were anxious that the historical underfunding of mental health services would return. Hasty reassurances followed. Burnham promised to "complete the job" on rolling out psychological therapies, and he and Simmonds agreed on the importance of protecting the mental health research budget. But Burnham took the opportunity to reiterate the difference between Labour and Conservative policy. Pointing out the interdependence of mental health, housing, work and education, he argued again that to separate the health budget from these other sectors simply didn't make sense.
There was also disagreement over the organisation of the health service. The Conservatives said they wanted to avoid another major restructuring. "One of the fundamental things that has gone wrong with the National Health Service in the last decade is constant reorganisation - nine in ten years," Simmonds said. "We need to allow the NHS to bed down so both clinical professionals and management professionals can get on with doing what they want to do, which is to look after patients and improve the quality of patient care."
Lamb outlined the Liberal Democrats' plan to abolish England's NHS strategic health authorities, arguing that "there is nothing sacrosanct about a layer of bureaucracy in the NHS". Burnham took issue with both views. The Tory policy of outsourcing the running of the NHS to an independent board - "making the NHS the biggest quango in the world" - sounded to him like a major organisational change. And he dismissed the Lib Dem idea of scrapping the strategic health authorities as "populist". He defended the job the authorities do at a regional level on jobs, procurement and providing specialist services - though he did note that they would have to face "efficiency changes" along with the rest of the system.
The three politicians had a moment of unity when Zack Cooper, a health economist at the London School of Economics, raised the issue of the NHS as a free service.
Cooper asked why the health service had to be free at the point of access, when that only encourages people to use it more. Unless you start charging people for medical care, he asked, how will you give them the incentive to take greater responsibility for their health?
“Look, care free at the point of need is something that I cherish," said Lamb. Simmonds declared his "real belief" that the NHS should be free and available to all: "I think that is something that unifies all of us on this platform." Burnham insisted the NHS was cost-effective compared to systems around the world. "Other, market-based systems often have an incentive to over-treat, over-provide and over-prescribe. We spend per head of population about half of what America spends."
However, Burnham accepted the point about responsibility, saying that the service was sustainable only if people took greater care in their engagement with it. He suggested that people could be made aware of treatment costs - printing the cost of a hip replacement on a patient's letter, for example - as a way of hammering home the value of the service.
Simmonds confirmed that a Tory government would make people pay if they missed dental appointments. Burnham challenged him on whether this would be extended to those who missed GP appointments. Simmonds denied this was the plan.
Towards the end, the debate returned to a question raised at the beginning by a nutritionist in the audience - how to motivate people in the UK to improve their lifestyles. Burnham had earlier stated how "proud" he was that childhood obesity levels had levelled off and that nutritional standards in schools had improved. But he acknowledged the importance of raising the levels of physical activity.
“It's not a good statement about this country that we love sport but are in a relegation place in the physical activity league table," he said. Compared to those in Germany, Scandinavia and the Netherlands, rates of activity across the British population are especially low.
Burnham reminded the audience that Britain won the 2012 Olympics because the International Olympic Committee was inspired by proposals in the British bid about increasing the population's activity. Simmonds expressed the hope that, in the run-up to the Olympics, athletes would engage with young people around the country. He also promised to improve sport in schools. "Sadly, competitive sport at a school level has disappeared and we need to bring that back," he said. Burnham shook his head at the implication that Labour had failed to promote sport in schools.
In his closing comments, Simmonds restated the Conservatives' commitment to "patient-centric" care, moving away from the Blair-era focus on targets. Lamb repeated the Lib Dem call for structural reform to liberate resources lost in complex layers of administration, and warned that getting this process right was imperative to maintain public confidence in the health service.
Burnham, however, charted new territory, turning to the previously unmentioned issue of social care. "If returned, I would make the reform of social care the very top priority." As things stand, it's a big if.