Whoever you vote for, the government gets in

This article originally appeared in HIV Treatment Update, a newsletter published by NAM between 1992 and 2013.
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Lisa Power of the Terrence Higgins Trust (THT) looks at what voting for the three main political parties in the UK might bring for people with HIV and those who serve them.

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.

Glossary

consent

A patient’s agreement to take a test or a treatment. In medical ethics, an adult who has mental capacity always has the right to refuse. See also ‘capacity’ and ‘informed consent’.

interaction

See ‘drug interaction’.

strain

A variant characterised by a specific genotype.

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.

THT, NAT and other groups are working hard to influence the future of HIV with parliamentarians, but it takes constituents to make an issue stick. If you want inspiration about what to talk about with candidates, THT and NAT have agreed some main priorities they’ll both work on (see www.tht.org.uk and www.nat.org.uk) and there are lots of tips about tackling candidates on the ShoutLoud website (www.shoutloud.org.uk), put together by all the main sexual health organisations. You can also get campaign updates, including tipsheets and information on your local candidates, from guy.slade@tht.org.uk.

And, after the election, if your MP only does one thing about HIV, it should be to join the All-Party Parliamentary Group on HIV/AIDS (www.appg-aids.org.uk) because that will keep them updated about developments. So if you want any of the things above to happen (or some of the bad things not to), get stuck in – talk to your local candidates, tell them what you care about and tell them your vote may depend upon it. And hold them to it later.