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Bruce Anderson

Bruce Anderson: He's not back at square one but Cameron has lost many of his NHS gains

Tim Montgomerie has made a powerful case. In Opposition, David Cameron almost succeeded in neutralising the NHS as a political issue, and a chronic negative for the Tories. Even so, a wise Tory government would surely avoid raising the salience of health matters. Despite de-toxification, Tim thinks that this is bound to work to the Labour party's advantage - and it is not as if the voters were demanding radical reform. So, in the favourite phrase of that shrewdest of Tory Whigs, Robert Walpole, "Quieta non Movere". For the benefit of his squirearchical neighbours, Walpole would translate that as "let sleeping dogs lie".

There is an irony. Tim is a Christian. Although the least priggish of men, he does believe in grounding his political beliefs on moral foundations. Yet here he is, abandoning any attempt to see the health debate in moral terms and resting his argument solely on political expediency.

The Prime Minister disagrees and will not back down. He too made a powerful case, in yesterday's Sunday Times. He reasserted his own personal commitment to the NHS. When he does that, he is always persuasive, because his views are based on experience and come from the heart. He insisted that the NHS needs to change in order to improve. At its best, it is outstanding, but it is not always at its best. There is waste and too much is spent on bureaucracy. Mr Cameron used some impressive statistics. "If we were as good in England at treating cancer as the average European country, we would save 5,000 lives a year". "In Labour's last year there was a 23% increase in management costs and the number of managers grew six times faster than the number of nurses". On one point, we can be certain. Whatever the political implications, Ministers are absolutely sincere in their desire to see a better health service, which would still be free at the point of use.

So how did we get into this pickle, and who was at fault? At present, the hapless Andrew Lansley is copping the blame. Someone in No.10 thinks that he should be taken out and shot. His Cabinet critics are more merciful. They would let him off with the sack. When a government is in trouble, Cabinet Ministers are like destroyers on escort duty, to protect capital ships. They are expendable, as Mr Lansley must be well aware. Indeed, he would already have been expended if Jeremy Hunt, his obvious replacement, had not been in charge of the Olympics. Is that a good reason to delay poor Mr Lansley's quietus? Would Britain really win fewer gold medals if Mr Hunt were moved? If Mr Lansley were a dog, the PM could be prosecuted for exposing him to unnecessary suffering by failing to have him put down. Then again, as he is beyond the protection of the RSPCA, there is a cynical argument for leaving him in place until the Bill is on the statute book so that he can soak up all the poison and Mr Hunt can start off with a clean charge-sheet and an emollient manner.

Yet Andrew Lansley is not solely to blame. Others - including the Prime Minister - must share responsibility for the strategic misjudgments. There was a basic difficulty. Mr Lansley deceived his colleagues. He led them to believe that he was in charge of the agenda. That, alas, was untrue, but one can understand why the mistake was made. In Opposition, few Shadow ministers worked harder than Mr Lansley. He saturated himself in the detail. He spent a lot of time with all the NHS interest groups: professional bodies, trade unions et al, and won a great deal of confidence. He mastered all the acronyms; he learned to speak NHS. A man who started his career in the Civil Service, he did not sound like a Tory politician. He sounded like the regional director for paper clips.

That was the problem. He was all acronyms and no politics. It is not clear whether a Bill was necessary; many of its objectives could have been achieved without legislation. The suggestion is that Mr Lansley wanted a big Bill which would go down in history: the Lansley Act. The trouble is that a big Bill needs a big politician. But if there were to be such a Bill, it had to start by answering some big questions. The PM should have said: "OK, you want your Bill. Before I agree, I'm going to lock you in a room with Oliver Letwin and Steve Hilton. You're not coming out until you have completed the following three sentences. 'This Bill is good for me and my family because...'. 'This Bill is good for Britain because...'. 'This Bill is great for the NHS because...'.

Once the formulae had been agreed, every Minister should have repeated them endlessly. As it is, hardly anyone in politics can give a concise account of the Bill's purposes. David Cameron's article began to put that right, and the cancer point is a formidable one; everybody is frightened of cancer. Although the Government could hardly say that "You are less likely to die of cancer under the Tories", a bit of dog-whistling along these lines would alleviate some of the political anxieties which Tim Montgomerie has identified. As Tim and others have argued, the danger with a high-profile Bill is that it will be blamed for anything which goes wrong in any hospital, or even for the inevitable attritions of mortality. As the Government is going to persevere, it has no alternative. It has to start selling its Bill, now.

That leads us to another interesting question; will the new measures work? Paul Goodman has drawn attention to a paradox. This Bill, supposed to cut back on bureaucracy, starts by creating new administrative structures. There is a disturbing precedent. In 1979, John Hoskyns, the then Head of the No.10 Policy Unit, concluded that the NHS lacked a central nervous system and was therefore incapable of actining rationally. Area health authority 'A' would spend £x on a given course of treatment. Authority 'B', next door, would spend £3x, with no discernible difference in outcomes. Sir John decided that the NHS needed accountants, in order to become financially self-aware. So far, so commonsensical, but the result was a grotesquely over-administered system which is still not self-aware. As has happened before with British administrative reform, a politician has a good idea. He then discovers that the franchise for implementation has been awarded - to Dr Frankenstein's laboratory. This time, the PM must ensure that this does not happen. It will not be enough to pass the Bill, sigh with relief, pour everyone a stiff drink, dispose of Andrew Lansley and let events take their course. The implementation must be rigorously monitored. In their early phase, the innovations ought to be treated like a patient in intensive care.

If that does happen and the Government's luck holds, Tim's forebodings may prove to be exaggerated. I do not believe that all the ground gained during the NHS de-toxification phase has been lost. I suspect that the NHS debate has moved on since the years when Labour found it endlessly easy to denounce the non-existent Tory cuts. That era need not return, as long as David Cameron keeps a grip on the detail while playing a major part in making the government's case. Ed Miliband did have a good PMQs on Wednesday, but that is bound to happen occasionally. One day, Scotland will win a rugger international. It would be premature to assume that a single PMQ success  will turn in to the Milipede recovery syndrome. In politics, we know what MRSA stands for: Miliband Revival Still Anaemic.


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