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 economics of outrage: Why you haven't seen the end of Katie Hopkins

Her distasteful tweet may have cost her a job at LBC, but this isn't the last we've seen of Britain's biggest troll. 

Another atrocity, other surge of grief and fear, and there like clockwork was the UK’s biggest troll. Hours after the explosion at the Manchester Arena that killed 22 mostly young and female concert goers, Katie Hopkins weighed in with a very on-brand tweet calling for a “final solution” to the complex issue of terrorism.

She quickly deleted it, replacing the offending phrase with the words “true solution”, but did not tone down the essentially fascist message. Few thought it had been an innocent mistake on the part of someone unaware of the historical connotations of those two words.  And no matter how many urged their fellow web users not to give Hopkins the attention she craved, it still sparked angry tweets, condemnatory news articles and even reports to the police.

Hopkins has lost her presenting job at LBC radio, but she is yet to lose her column at Mail Online, and it’s quite likely she won’t.

Mail Online and its print counterpart The Daily Mail have regularly shown they are prepared to go down the deliberately divisive path Hopkins was signposting. But even if the site's managing editor Martin Clarke was secretly a liberal sandal-wearer, there are also very good economic reasons for Mail Online to stick with her. The extreme and outrageous is great at gaining attention, and attention is what makes money for Mail Online.

It is ironic that Hopkins’s career was initially helped by TV’s attempts to provide balance. Producers could rely on her to provide a counterweight to even the most committed and rational bleeding-heart liberal.

As Patrick Smith, a former media specialist who is currently a senior reporter at BuzzFeed News points out: “It’s very difficult for producers who are legally bound to be balanced, they will sometimes literally have lawyers in the room.”

“That in a way is why some people who are skirting very close or beyond the bounds of taste and decency get on air.”

But while TV may have made Hopkins, it is online where her extreme views perform best.  As digital publishers have learned, the best way to get the shares, clicks and page views that make them money is to provoke an emotional response. And there are few things as good at provoking an emotional response as extreme and outrageous political views.

And in many ways it doesn’t matter whether that response is negative or positive. Those who complain about what Hopkins says are also the ones who draw attention to it – many will read what she writes in order to know exactly why they should hate her.

Of course using outrageous views as a sales tactic is not confined to the web – The Daily Mail prints columns by Sarah Vine for a reason - but the risks of pushing the boundaries of taste and decency are greater in a linear, analogue world. Cancelling a newspaper subscription or changing radio station is a simpler and often longer-lasting act than pledging to never click on a tempting link on Twitter or Facebook. LBC may have had far more to lose from sticking with Hopkins than Mail Online does, and much less to gain. Someone prepared to say what Hopkins says will not be out of work for long. 

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