Or how can “Leave it to Lansley” work alongside “Depend on Dave”?
About 10 days ago we were hearing a great deal about the ‘Letwin review’ of the Government’s health reforms. There were Government inspired quotes showing some anxiety about the long term architecture that the current Secretary of State is proposing and further worries about ‘the transition’.
All of this was compounded by Stephen Dorrell’s public worries about the finances of the NHS not being in control.
It’s often the case that the sunny uplands of plans published just after an election are clouded over by the reality of government, but this time this change in the weather has been rather speedy.
The first part of the explanation involves the money. Unless you are steeped in health economics, there is something odd for a Government that has ‘protected’ NHS spend getting into difficulties with the economics of the health service within a year. Increasing public expenditure on the NHS when all other areas of domestic public expenditure are being savagely cut would leave Conservative politicians believing that the NHS is lucky and that it will be ‘all right’. It is true that it has been better treated in relation to expenditure on other public services, but what people who have been involved in the NHS know is that even with the growth in resources that there has been, there is a fragility about the way in which the demand and supply of resources for the NHS is managed.
So from the outside – where the Conservative Party was up until May this year – the NHS looked as if it was in a really good place in terms of resources. Inside the NHS everyone knew that given it would be entering its most difficult 5 year period for some time, money would be a problem.
So a new Government comes into power and, whilst cutting every other area, thinks, “Let’s get on with the reform programme in the NHS where cuts are not an issue.”
This was a mistake. What Stephen Dorrell is saying is that the money is the biggest issue and he is right, as was the NHS leadership over the last year when it said the same thing. So the first problem for the Government is caused by misunderstanding what is the biggest issue for the NHS during this Parliament. The fact that the biggest issue is the money does NOT mean that you don’t reform. But it should mean that the way in which you carry it out is dominated by the resource problem you are going to be facing every day of this Parliament from November 2011.
The second involves the lack of politics of the current Secretary of State. He is a very clever man who has thought a lot about the structural changes that the NHS needs. He has come into his current job with a set of very clear ideas about what to do. He has got on with this by publishing an early radical White Paper which promises the development of markets in tune with modern Conservatism. His assumption is that for many people this is just common sense and will be welcomed by people who want to remove the state from their lives. His problem is that virtually nobody else really ‘gets it’. What is common sense to him needs a great deal of explaining to nearly everybody else. I will return later on to what not having a strong political narrative means for the implementation of his reforms, but here I just want to raise the issue of a very small but crucial audience, the MPs from both political parties that form the Government and their Cabinet.
In truth virtually nobody in the Cabinet knew what Andrew was on about when they agreed the White Paper. They thought, ’Leave it to Lansley’ – not a bad idea for Government unless there needs to be a political campaign and argument for change. Andrew thinks this is all technical stuff. So let him get on with it.
Unfortunately for Lansley it is not all technical stuff. Every page of the White Paper is profoundly political. And every moment, the NHS in every government MPs’ constituency is fraught with political issues. If you are going to ask MPs to go through political fire, then they really need to understand what is going on and agree with it.
In the next two years there will be two sorts of politics with which Government MPs will have to engage. The first is getting the legislation and the reforms through. That needs the passive support of most Government MPs and the active support of quite a few of them. At the moment there is little of that because they don’t know what it is they are supporting. The second is engaging with the politics of the NHS in their local constituency. Here even at the very moment the NHS is still spending the last of the big increases, parts of the country are in deficit, beds are closing and operations are being put off until April. MPs need to know why, when we have ‘protected the NHS’, this is happening.
This is made harder for the current Secretary of State because many Government MPs really don’t understand the current structure of the NHS, let along the future one. From the New Year the Secretary of State will need the confident and knowledgeable support of the Government to explain this to everyone.
How does all this relate to the ‘Letwin Review’? Almost certainly what has been billed as a special review of health policy isn’t. It’s a cross Government committee that will look at every Bill before it is published. Every Government has such a committee because legislation not only has an impact on other Government departments but once a Bill enters Parliament it has a political impact on the Government.
So this enormous Health Bill, that no one really understands, has been reviewed, and for some people who have not been paying attention to Andrew Lanlsey’s common sense, a lot of it was a bit of a shock. So they took this review seriously and tried to make sense of it.
The outcome is the continuation of ‘Leave it to Lansley’. In part this reflects a major broad political problem for the Government. This Government, since before it was born, depends totally on momentum. It has to keep on moving forward – very fast – so that the coalition that supports it gets the feel and the importance of progress – and above all activity. This, and this activity, is why it’s so right for us to be in power. Standing around and raising questions about issues is a problem for any Government that is not secure in its majority or ideology. This is such a Government. Throughout its life there will not be a lot of idle standing around thinking.
So the speed and the necessity to move fast – which looks so strong – is in fact a sign of weakness. As a Government, 7 months in, they cannot afford to really question their health reform plans. If they do what else might unravel? So the review – for the very future of the Government – has to find that they are doing the right thing.
“Leave it to Lansley” is the policy that comes out of the review of the Bill in the same way that it was before the review The response to the Consultation that is published next week will say full steam ahead to the good ship Liberation.
There are however two important developments.
The first is that they recognise that Andrew really needs some help in politically selling the Bill to the Party and the country. The Government needs to pick up this narrative and begin to sell it in a much more organised way. I strive not to be self-congratulatory in these blogs but on 14/09/2010 I did mention the need for a compelling narrative for these reforms. What was merely important in September has become absolutely vital in December. I look forward to other Cabinet Ministers standing up and explaining this narrative.
The second is what every one calls the transition, but is in fact the money. The Government recognises that even if we can ‘Leave it to Lansley’ and his reforms for 2013 onwards, getting the NHS in an organised and coherent state by that time is very difficult. If we take a laissez-faire attitude to a reformed NHS after 2013 we certainly can’t do that for the next 30 months. There is a growing recognition that building a radical new system whilst keeping the old one on the road is very hard. Doing that when the money has run out may not be possible.
So the Government wants a lot more thought given to the transition. And it needs to move on that very quickly. That is why the Operating Plan that is published next week will be girding the loins of the remaining much derided ‘NHS bosses’ to keep the show on the road especially next year. At the top of this will be David Nicholson the head ‘NHS boss’. His task will be to ensure that there is a coherent NHS to liberate from himself at some stage in the future. So for 2011/12 we can ‘Depend on Dave’.
The Operating Framework published next week will therefore offer – for the next year at least – much tighter control of the money. The Conservatives, especially for next winter, will be depending on the SHAs to be able to move money around – separate from all this market stuff – to keep the show on the road. In 2011/12 there will be a lot more of that than we have seen for a few years.
So next week we will see published a long term reform programme which says that the best NHS is a liberated NHS
And an Operating Framework which will say that the best NHS for 2011/12 is a tightly controlled one.