NHS reform is a never-ending nightmare for Cameron

The Prime Minister could end up with a reputation as the man who broke the NHS.

The NHS bill cleared a legislative hurdle in the Lords this week . But that doesn't really solve any of the political problems facing the government's reforms. Of those problems, one of the biggest is that the coalition doesn't seem to have a clear grasp of why Andrew Lansley's plans are causing so much difficulty.

The one thing everyone can agree on is that the plans have been appallingly presented. Lansley cooked them up in the Department of Health without much input or scrutiny from Downing Street. (So blindsided was the prime minister that the episode triggered a whole re-organisation of the Number 10 policy operation earlier this year.) According to one senior civil servant at the heart of the operation, when Cameron was first presented with Lansley's plan he skimmed the introduction and then turned to his aides in shock and disbelief and said "have you read this stuff?!" He had, until then, had no idea of the scale of what was being planned.

There was a moment, towards the end of January, when a u-turn was still an option. But Cameron feared looking weak by abandoning such a huge public sector policy drive - and, reasonably enough, worried that dropping the reforms would implicitly confirm voters' suspicions that the Tories had some hidden agenda on health. A u-turn would make it look as if they had been rumbled. The way senior figures in government tell the story, Cameron's foot hovered between the brake and the accelerator, finally choosing the latter. That now looks like a huge mistake.

The essential miscalculation was the PM's assumption that if he personally threw some weight behind the cause - deploying the powers of persuasion in which he has considerable confidence - the public mood might shift. Of course, the Conservatives did not count on a Lib Dem backlash, sanctioned from the top of the party as a device to "differentiate" the junior coalition partner (fearful of losing its identity) over an issue of famous toxicity to the Tories. Some of the Lib Dem turbulence around the NHS earlier this year was principled objection to the reforms but some is retaliation for the Tories' personal attacks on Nick Clegg during the referendum campaign on the alternative vote. The compromise package that ended up before the Lords this week was therefore a mangled monster consisting of the original Lansley plan with heaps of ad hoc Lib Dem caveats, brakes, disruptions and supposed safeguards.

And there lies the government's problem. The reform it is now trying to sell is the expression of Westminster political choreography and not a coherent response to the needs of the health service. Everyone in the NHS knows it and voters can sense it.

Cameron and Lansley have tried to sell the need for reform on the grounds that the health service cannot cope with rising levels of demand without major structural change (especially when there is no more money to fund the existing system). My own impression is that they haven't got that message across too well. One thing, however, is certain and that is their failure to persuade people of the follow-up assertion that the only solution lies in much more private sector involvement using much more vigorous competition to provide services. The Lib Dems and Labour are just as queasy about bald expressions of that view - it is, essentially, the Blairite model of public sector reform and has advocates in all three main Westminster parties.

But opponents of Lansley's plans don't need to rebut the theoretical premise on which it rests because (a) they can just accuse the government of unleashing needless revolutionary chaos in the NHS, which is plainly true and (b) they can accuse the prime minister of reneging on a pledge not to do (a), which is also true. Plus, (c) voters' mistrust of the Tories over the health service is visceral. Whatever it is the Tories are doing will raise suspicions of an ulterior motive; Cameron and Lansley have done everything possible to confirm that view by failing to sell the reforms on their own terms. You can't credibly insist that there will be no privatization of the health service when the core concept of the reforms is to promote more competition and more private sector involvement. OK, so it's not privatization in way that BT and BA were sold off in the Eighties, but it's hardly reinforcing the "national" in National Health Service.

The only way to actually persuade people that the Lansley plan is any good would be to sell the first principle of increased marketisation in health care but, implicitly, the Tories have accepted that such an approach is toxic to their political reputation. Besides, changes demanded by the Lib Dems have corrupted Lansley's vision enough that - even if it were the best way forward (which I doubt) - it can't be implemented as the health secretary envisaged. Meanwhile, there are £20bn of "efficiency savings" to be found, which will feel like cuts and inflation at around 5 per cent, which will have an impact on health budgets that will also feel like cuts. Every doctor and nurse in the country will have motive and cause to blame the government for every refused treatment and every bad outcome.

David Cameron needs to wake up to the fact that he has allowed a process to get underway whose long term outcome could easily be an historic reputation for him as the man who broke the NHS.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

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The dog at the end of the lead may be small, but in fact what I’m walking is a hound of love

There is a new, hairy face in the Hovel.

There is a new, hairy face in the Hovel. I seem to have become a temporary co-owner of an enthusiastic Chorkie. A Chorkie, in case you’re not quite up to speed with your canine crossbreeds, is a mixture of a chihuahua and a Yorkshire Terrier, and while my friend K— busies herself elsewhere I am looking after this hound.

This falls squarely into the category of Things I Never Thought I’d Do. I’m a cat person, taking my cue from their idleness, cruelty and beauty. Dogs, with their loyalty, their enthusiasm and their barking, are all a little too much for me, even after the first drink of the day. But the dog is here, and I am in loco parentis, and it is up to me to make sure that she is looked after and entertained, and that there is no repetition of the unfortunate accident that occurred outside my housemate’s room, and which needed several tissues and a little poo baggie to make good.

As it is, the dog thinks I am the bee’s knees. To give you an idea of how beeskneesian it finds me, it is licking my feet as I write. “All right,” I feel like saying to her, “you don’t have to go that far.”

But it’s quite nice to be worshipped like this, I have decided. She has also fallen in love with the Hovel, and literally writhes with delight at the stinky cushions on the sofa. Named after Trude Fleischmann, the lesbian erotic photographer of the Twenties, Thirties and Forties, she has decided, with admirable open-mindedness, that I am the Leader of the Pack. When I take the lead, K— gets a little vexed.

“She’s walking on a loose lead, with you,” K— says. “She never does that when I’m walking her.” I don’t even know what that means, until I have a think and work it out.

“She’s also walking to heel with you,” K— adds, and once again I have to join a couple of mental dots before the mists part. It would appear that when it comes to dogs, I have a natural competence and authority, qualities I had never, not even in my most deranged flights of self-love, considered myself to possess in any measurable quantity at all.

And golly, does having a dog change the relationship the British urban flâneur has with the rest of society. The British, especially those living south of Watford, and above all those in London, do not recognise other people’s existence unless they want to buy something off them or stop them standing on the left of the sodding escalator, you idiot. This all changes when you have a dog with you. You are now fair game for any dog-fancier to come up to you and ask the most personal questions about the dog’s history and genealogy. They don’t even have to have a dog of their own; but if you do, you are obliged by law to stop and exchange dog facts.

My knowledge of dog facts is scant, extending not much further beyond them having a leg at each corner and chasing squirrels, so I leave the talking to K—, who, being a friendly sort who could probably talk dog all day long if pressed, is quite happy to do that. I look meanwhile in a kind of blank wonder at whichever brand of dog we’ve just encountered, and marvel not only at the incredible diversity of dog that abounds in the world, but at a realisation that had hitherto escaped me: almost half of London seems to have one.

And here’s the really interesting thing. When I have the leash, the city looks at me another way. And, specifically, the young women of the city. Having reached the age when one ceases to be visible to any member of the opposite sex under 30, I find, all of a sudden, that I exist again. Women of improbable beauty look at Trude, who looks far more Yorkie than chihuahua, apart from when she does that thing with the ears, and then look at me, and smile unguardedly and unironically, signalling to me that they have decided I am a Good Thing and would, were their schedules not preventing them, like to chat and get to know me and the dog a bit better.

I wonder at first if I am imagining this. I mention it to K—.

“Oh yes,” she says, “it’s a thing. My friend P-J regularly borrows her when he wants to get laid. He reckons he’s had about 12 shags thanks to her in the last six months. The problems only arise when they come back again and notice the dog isn’t there.”

I do the maths. Twelve in six months! That’s one a fortnight. An idea begins to form in my mind. I suppose you don’t have to be a rocket scientist to work out what it is. But no. I couldn’t. Could I?

Nicholas Lezard is a literary critic for the Guardian and also writes for the Independent. He writes the Down and Out in London column for the New Statesman.

This article first appeared in the 28 April 2016 issue of the New Statesman, The new fascism