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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There are two sides to the Muslim segregation story

White families must also be prepared to have Muslim neighbours. 

Dame Louise Casey finally published her review on social integration in Britain. Although it mentions all communities, there is a clear focus on Muslim communities. However, the issues she raises - religious conservatism, segregation in some areas and Muslim women experiencing inequalities -  are not new. In this case, they have been placed in one report and discussed in the context of hindering integration. If we are truly committed to addressing these issues, though, we have a duty of care to discuss the findings with nuance, not take them out of context, as some tabloids have already done.

The review, for example, highlights that in some areas Muslims make up 85 per cent of the local population. This should not be interpreted to mean that Muslims are choosing to isolate themselves and not integrate. For a start, the review makes it clear that there are also certain areas in Britain that are predominantly Sikh, Hindu or Jewish.

Secondly, when migrants arrive in the UK, it is not unreasonable for them to gravitate towards people from similar cultural and faith backgrounds.  Later, they may choose to remain in these same areas due to convenience, such as being able to buy their own food, accessing their place of worship or being near elderly relatives.

However, very little, if any, attention is given to the role played by white families in creating segregated communities. These families moved out of such areas after the arrival of ethnic minorities. This isn't necessarily due to racism, but because such families are able to afford to move up the housing ladder. And when they do move, perhaps they feel more comfortable living with people of a similar background to themselves. Again, this is understandable, but it highlights that segregation is a two-way street. Such a phenomenon cannot be prevented or reversed unless white families are also willing to have Muslim neighbours. Is the government also prepared to have these difficult conversations?

Casey also mentions inequalities that are holding some Muslim women back, inequalities driven by misogyny, cultural abuses, not being able to speak English and the high numbers of Muslim women who are economically inactive. It’s true that the English language is a strong enabler of integration. It can help women engage better with their children, have access to services and the jobs market, and be better informed about their rights.

Nevertheless, we should remember that first-generation Pakistani and Bangladeshi women, who could not speak English, have proved perfectly able to bring up children now employed in a vast range of professions including politics, medicine, and the law. The cultural abuses mentioned in the review such as forced marriage, honour-based violence and female genital mutilation, are already being tackled by government. It would be more valuable to see the government challenge the hate crimes and discrimination regularly faced by Muslim women when trying to access public services and the jobs market. 

The review recommends an "Oath of Integration with British Values and Society" for immigrants on arrival. This raises the perennial question of what "British Values" are. The Casey review uses the list from the government’s counter-extremism strategy. In reality, the vast majority of individuals, regardless of faith or ethnic background, would agree to sign up to them.  The key challenge for any integration strategy is to persuade all groups to practice these values every day, rather than just getting immigrants to read them out once. 

Shaista Gohir is the chair of Muslim Women's Network UK, and Sophie Garner is the general secretary and a barrister.