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If the Liberal Democrats want to run health policy, they should take responsibility for it.

By Paul Goodman
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In the long years between the unravelling of John Major's Government and the stitching-together of David Cameron's coalition five Conservative MPs left the party and joined Labour: Alan Howarth, Sean Woodward, Robert Jackson, Peter Temple-Morris and Quentin Davies.  Each defection said more about personal circumstance than anything else, but they were interpreted in varying degrees as a sign of the times - that the political ascendancy remained with Labour, and that the Tories were an opposition-plagued party with paltry leadership and shrivelled morale.

Cameron and George Osborne have always wanted to turn the tables on Labour.  Their enthusiasm for recruiting John Hutton and Frank Field to review pensions and poverty respectively had at least as much to do with destabilising the Opposition as improving public policy.  The post-expenses scandal experiment with new candidates and open primaries was another sign of post-modern leadership - in which activist commitment to the Conservative Party as, say, an Association Officer or a local councillor can be a roadblock to advancement rather than a springboard.

Rachel Sylvester's column today claiming that Number 10 would like to exchange Andrew Lansley for Alan Milburn therefore has the ring of truth about it.  It's true that Sylvester cites only one source, and his or her declaration that the Health Secretary "should be taken out and shot" may be the product of frustration rather than calculation.  But were the Prime Minister to be offered the chance of neutralising the NHS politically while denting Labour's morale simultaeneously, I bet he would take it (though such a move would pile discontent higher among the promotion-hungry).

However, it's doubtful whether even as commitedly New Labour a figure as Milburn would stuff his party in such a way.  In any event, writing about such a move makes it less likely to happen: perhaps Sylvester has just preserved a Cabinet place for a Conservative, and should thus take an honorary bow.  But whether she has or not, Cameron has excellent reason not to single out Lansley - or any Cabinet Minister - and sack him or her outside a wider shuffle.  Firing an individual Cabinet Minister would mean drama and speculation - lights, cameras, music and action.

The Prime Minister hates anything of the kind - at least where personnel are concerned - and with excellent reason.  The gratitude of those who are promoted in reshuffles is always less than the sum of the resentment of those who are fired.  Cameron grasped this long ago, and believes that the Tim Loughtons and Nick Gibbs and Charles Hendrys and Anne Miltons should have the chance first to further and then to practice their expertise.  If he had won a majority my unprovable guess is that he would have moved almost his whole front bench to Government more or less unchanged.

He is therefore unlikely sack Lansley outside a wider Cabinet shuffle.  This would thwart the destablising lobby game of Who's Next - of hunting for the next possible Cabinet victim to be singled out when the going gets tough.  The Health Secretary is not being well treated.  His plan to introduce mass GP fundholding was well-known in opposition, and Cameron did nothing to stop its introduction.  In his early days as Prime Minister, he was Hilton as much as Osborne: in other words, he acted as though the Government should be maximalist rather than minimalist.

The universal credit, free schools, GP fundholding, elected police commissioners, public sector pension reform, localism, the Big Society (and in particular the local running of public services by the people who provide them)...the image was of transformative enthusiasm rather than practical realism.  Although much of this programme is still in place, the post-AV referendum obstructionism of the Liberal Democrats has put parts to some of it - and in particular to Lansley's original scheme.

First, the bill was introduced.  Then "concessions" were made.  Soon afterwards, under Liberal Democrat pressure, the Prime Minister announced a "pause".  Further concessions were introduced and the bill substantially amended.  Now, as Sylvester points out, the Lords are poised further to twist the bill out of all original recognition.  The simplest solution would be to drop it (and accept that Lansley may resign).  But poetic justice and practical politics point to a more feisty solution for Cameron.  He should keep the bill and stick with the Health Secretary till the reshuffle.

Then he should hand over the Act (as it will be) plus the coming NHS crisis - complete with patients parked on trolleys, ambulances marooned outside A & E wards and NHS managers closing wards while pleading bankruptcy - with his compliments and very best wishes to a new Liberal Democrat Health Secretary plus an entire team of Liberal Democrat health Ministers.  And turn the Business Department over to a Conservative Secretary of State who, unlike the present incumbent, is enthusiastic about enterprise and deregulation.


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