Andrew Lansley, secret radical - and the risks and opportunities of his healthcare revolution (Part One)

by Paul Goodman

Which public service reform will make the most waves if it goes wrong?  The answer is: health.

If few Free Schools come into being, most parents and pupils won't notice.

If Police Commissioners fail - perhaps because they may not evoke a sense of ownership, if the areas they cover are of sub-regional size - it'll happen below the public radar.

If benefit reform turns out to be costly, complex and confusing, non-claimants won't be directly affected: in any event, the Universal Credit won't come into effect during this Parliament.

Above all, any such collapses (I'm not making predictions, just exploring questions) will gain variable media coverage.  Certainly, national media outlets are keeping a close eye on Free Schools.  And local papers will take some interest in the pronouncements of the area's Police Commissioner.

But all this is dwarfed in size and scale by the coverage won by health, especially locally.

In my ten years as a Member of Parliament no issue was as likely to be grabbed by our local press, picked up and run with as health - and, in particular, hospitals.  During the middle part of the last decade, Wycombe Hospital lost its Accident and Emergency Department, and most of its Women's and Children's Services.  The changes were part of an eruption of closures taking place in largely non Labour-held constituencies.

Hospital stories mean scary tales of mothers giving birth in ambulances;  huge photos of appealing babies and toddlers; appeals by furious local fundraisers, themselves pillars of the community; irate letters from pensioners who remember when the hospital in question was built or expanded.  Our local paper ran a campaign and a petition: 40,000 people signed up.

David Cameron - not so far away from Wycombe in his Witney constituency, in a neighbouring county - would have watched John Radcliffe Hospital in Oxford (a major teaching site) devour tanker-loads of public money; puzzled over distant edicts handed down from the remote Strategic Health Authority; visited his local Primary Care Trust, and watched waves of change washing over much of the south-east.

He'd have seen the Strategic Health Authority re-cast; hospitals merge into common trusts, Primary Care Groups redrawn as Primary Care Trusts and then redrawn again as bigger PCTs; Mental Health Trusts amalgamate (Oxfordshire's was paired off with Bucks'), and Ambulance Trusts fold into each other.  The pace of change was like permanent revolution in Mao's China.

I'm sure that all this - lumped together with the polling which he'll have seen - had a decisive effect on the man who's now Prime Minister, and that he came to think that -

• Most of Labour's NHS changes must be opposed...  This was, in political terms, a no-brainer.  Local papers and people were up in arms.  So the Party opposed the Darzei proposals.  It slapped a moratorium on hospital closures.  It ran a campaign against "Brown's health cuts", showing a manic Prime Minister (as he then was) brandishing a giant pair of scissors.

• ...While the Conservatives committed themselves to the NHS wholeheartedly...  Healthcare was and is a high political priority for voters.  This expresses itself as support for the NHS, which Nigel Lawson described in his memoirs as a kind of English religion.  Labour plug away to widen the perception that the Tories hate the system.  Cameron was determined to close this weakness down.

• ...By trying, in particular, to win the support of doctors, nurses and NHS staff.  Remember the Conservative leader's enthusiastic reception by junior doctors in 2007 (see video below).  It dovetailed with a drive by Cameron to get the doctors' and nurses' representative bodies and unions on-side by cutting targets and trusting professionals.

So from early days, the Tory leader was determined to "accentuate the positive, eliminate the negative".  The "Patients' Passport", a feature of the 2005 manifesto that he himself had written, was dropped.  "Tony Blair explained his priorities in three words: education, education, education," Cameron told his first Conservative Conference as Party leader in 2006.  "I can do it in three letters: NHS, NHS, NHS."

Sometimes, these efforts seemed forced.  Last January, a pre-election poster was released declaring "I'll cut the deficit, not the NHS" (see below).  But the slogan clumsily linked the words "cuts" and "NHS" in the same sentence, and raised the question of what a Conservative Government would cut.  The poster presaged what turned out to be a deeply unconvincing election campaign.

Sometimes, however, they seemed natural.  This was because anyone who followed politics (plus a large number of those who didn't) knew that the Camerons used the NHS themselves to care for their son, Ivan - who was tragically born with cerebral palsy and epilepsy.  I've written before that many voters retain memories of his family sorrow, and that it helps shape how they view the Prime Minister.

Cameron was not above personalising the issue.  "When your family relies on the NHS all of the time - day after day, night after night - you know how precious it is," he told that 2006 conference.  "So, for me, it is not just a question of saying the NHS is safe in my hands - of course it will be. My family is so often in the hands of the NHS, so I want them to be safe there."
 
He also promised "no more pointless and disruptive reorganisations". Instead, change would be "driven by the wishes and needs of NHS professionals and patients".  Which brings us to the forthcoming NHS Bill, the Conservative manifesto, the Coalition Agreement, the NHS funding settlement - and the Health Secretary, Andrew Lansley.

As I say, a prominent feature of Tory NHS policy has been the suggestion of no major change, formed by Cameron's political instincts, furthered by his family circumstances, supported by his constituency experience, and expressed in the ring-fencing of the NHS budget.  Cameron's instinct is to keep the NHS going much as now as a healthcare service, while closing it down as a political issue.

However, there are tensions between this impulse and a very different one - the urge to reform our healthcare system, and help prove the Government's radical credentials by doing so.  Caution, polling and wariness of the lobbies tug one way; choice, competition and the needs of patients pull the other.  Sometimes the two work together - as in the Government's scaling-back of centrally-set health targets.

But sometimes they don't, and the man in charge of making tension work creatively is an old health hand.  Lansley's been the Party's health spokesman for the best part of a decade.  Appointed in 2003, the ex-Conservative Research Department Director and high-flying Civil Servant (he was Norman Tebbit's Private Secretary) has been responsible for a single brief for longer than any other Cabinet member.

Lansley's a hard man to get right.  I found him easy to deal with, relaxed in himself, extremely helpful, and completely without the overbearing manner sometimes acquired by senior front benchers.  He was also, unsurprisingly, very well briefed - a mine of information about what was going on at which hospital.  He made an explorative foray into the 2005 leadership election, but found few takers.

However, he's seen by some of his colleagues as a bit of a grey eminence.  One old friend of mine insists, against all the evidence to the contrary, that the Health Secretary is actually a golem - that is, an artificial man created (as Jewish folklore has it) from inanimate matter.  Another tale has it that his nickname is "the Permanent Secretary". 

This is unfair, but I suspect none the less that Lansley didn't hold the Shadow Cabinet spellbound when explaining the finer details of practice-based commissioning, purchaser-provider splits, domiciliary care packages, clinical leaders, pathways to care, and so on.  His colleagues, bowing to his experience, will have believed that they were, to coin a phrase, safe in his hands.

But it's become apparent that beneath the Health Secretary's undemonstrative grasp of healthcare arcana lies an insistent commitment to NHS reform.  A major healthcare bill is due shortly, though there are now conflicting signals about how far it will go.  At any rate, Oliver Letwin has been drafted in to give Lansley's proposals the once-over.

According to legend, a golem can run amok, and be brought under control only by a wonder-working sage.   But be that as it may, I'm puzzled that anyone thought that Lansley's plans would be unambitious.  It was evident before last May that a Conservative Government would, in the first main leg of his plan -

• Empower consortiums of GPs, rather than PCTs, to carry out commissioning.  The manifesto committed a Conservative Government to "giving [GPs] the power to hold patients' budgets and commission care on their behalf" and "putting them in charge of commissioning local health services".  This is now set to happen.  So it's wrong to suggest that this scheme wasn't spelt out in the manifesto - though it certainly wasn't in the Coalition Agreement, which speaks merely of "strengthening the hand" of GPs.

Another leg of the post-election policy is to -

• Give local councils a bigger role in the promotion of public health.

The Coalition Agreement also says that -

• We will give every patient the right to register with the GP they want, without being restricted by where they live.

In short -

• Cameron promised "no more pointless and disruptive reorganisations", and the Agreement declares, near the beginning of its health section, "We will stop the top-down re-organisations of the NHS that have got in the way of patient care."

• Lansley, however, is carrying out major structural change.  An independent NHS Board will allocate resources.  The Secretary of State will become the guardian of public healthcare policy, and streamline the targets imposed from the centre.  GPs will help to plan the local NHS.  (The Agreement says "We will stop the centrally dictated closure of A&E and maternity wards.")  At the same time, competition will be used to help drive up standards: GPs will buy care on behalf of their patients; patients will choose their GPs.  I believe that this reform programme's neither pointless nor disruptive, and that it won't exactly "get in the way" of patient care - but it is a top-down reorganisation, and a big one, too.

• This reform programme coincides with a major funding squeeze.  This statement will raise the eyebrows of ConservativeHome readers, who've become accustomed to the idea of the NHS and overseas aid budgets being protected while other budgets are plundered.  And, certainly, the Government's trying to raise the NHS budget in real terms.  However, the above-inflation rise is just about the minimum possible - 0.1% for four years, and this doesn't take higher inflation forecasts into account.  The average annual NHS increase above inflation has been 4%.  There's no agreed figure for what the system requires to keep pace with cost rises, but 3% is sometimes quoted.  Under the Thatcher and Blair Governments, the real terms rise was kept down, for a single year, to one per cent.  I'm not falling for the fallacy that more spending equals better results - as Phil Collins pointed out recently behind the Times paywall, the NHS in England now has higher productivity and lower waiting times than Scotland and Wales despite spending less - but there's no precent for a increase of 0.1%, especially over four years.

Tomorrow, I'll explore the risks and opportunities posed by the interaction of structural change and the funding settlement.