The Tories, as fixated as Labour on hospitals rather than health, are missing a trick. With a bit of imagination, they might this week have joined the growing chorus asking why money should be poured into the national health service when it doesn't buy better health. Potentially, the choir's leader is the occupant of No 11, Gordon Brown.
The chancellor's final position will depend on his banker-with-a-conscience, Derek Wanless. Having last year given the Treasury a robust case for big increases in NHS spending, the former chief of NatWest is now polishing a second report for the chancellor, providing arguments for doing the opposite: spending less - at least on doctoring and nursing. The Wanless watchword is more "health", less health spending. This suits the Treasury because, looking ahead, it knows that the current rate of growth in health service spending is unsustainable, even with tax increases.
With his conclusions due next February, Wanless is examining that huge dimension of our physical wellbeing that is not surgeries, clinics and hospitals. Instead it's lifestyle, seatbelts and sun cream. On his agenda, too, ought to be lack of central heating, inadequate household income and danger and stress at work - all causes of "excess" demand for GP appointments and hospital treatment. And bicycles. The pressure on the NHS caused by head injuries sustained in bike accidents is far outweighed by the degree to which cycling cuts cardio-vascular problems.
Wanless himself cites smoking. Shouldn't the government, he asks, have looked at the cost-effectiveness of programmes to cut smoking before launching its great cancer initiative? You save more lives by stopping people smoking than treating them for lung cancer.
There's an individualist take on all that. Wanless, who presents himself as a citizen above party politics, may turn out to be ideologically heterogeneous. If we had to face directly the financial costs of our negligence of our bodies, we should eat more fruit and veg and drink less. In fact, Wanless says he has yet to be convinced that charging for healthcare would make people take better care of themselves.
Individualism is a recipe for inequality. The more money coming into a house hold, the healthier its inhabitants. Obesity, diabetes and other conditions have a distinct social class profile. Unskilled workers are more likely than professionals to die young. Social security spending has a greater impact than health spending on "health".
Above this debate hang those teasing international figures that show the more equal the income distribution, the healthier a country tends to be. The chart shows life expectancy going up for everyone. But the two-year gap between how long people in general can expect to live and those living in the worst fifth of health authorities is also growing. Here's a paradox: programmes to cut, say, smoking could increase inequality if, as is likely, middle-class men and women drop the habit more readily than poorer people.
Since his report will have implications for nearly every department, from sport to transport, Wanless will be handing Gordon Brown a powerful tool for the redirection of policy as well as confirming the Treasury's increasing influence. Look at its recent interventions on dispersing civil servants to the regions and releasing more land for housebuilding.
Wanless may end up supporting those Labour insur gents who have lately been saying something odd. "Labour has not made health a priority," according to Anna Coote, of the King's Fund. "Turning hospitals into foundation trusts, appointing cancer 'tsars' or cutting waiting times can create an impression of a tough minister taking the portfolio by the scruff of the neck. Measures to improve health and reduce health inequalities take a long time, and seldom provide clear and measurable results within less than a decade. It would take a truly visionary secretary of state to shift priorities, focus on the long term and start building up better opportunities for everyone, especially the poor, to enjoy good health."
There is nothing new about such a diagnosis. It was set out in the Black report (commissioned by the Callaghan government and then buried by the Tories), repeated in the Acheson report for New Labour, and most recently spelled out this year in the Department of Health paper on inequalities in health. Social class is strongly associated with how long you live, disease, the chances of your baby surviving. The World Health Organisation says heart disease could be halved, and pretty speedily too, by adopting radical public health measures.
But addressing inequality means big government. And states that worry about their citizens' waistlines and drinking habits get abused as "nannies". It is more acceptable to pump money into buying expensive statins, the drug that busts arterial build-up, or to ensure ambulances career even more dangerously down city streets to get to cardiac emergencies than to encourage people to stop eating fat or to take more exercise. It may even be politically easier.
Take exercise. A "health policy" would force schools to stop selling sports fields and reinstate physical education; or force employers to provide gyms and insist they get used. If that sounds Stalinist, just work out the sums. It is hugely more expensive to taxpayers over the long run to pay for NHS mopping up than make people shape up.
