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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Theresa May's Article 50 letter fires the Brexit starting gun

But as well as handing over a letter, Theresa May hands over control of the process. 

So the starting gun will be fired, and the Brexit process will begin. The delivery of the letter from Theresa May to Donald Tusk is a highly symbolic moment. It is also, crucially, the moment when the Prime Minister loses control of the process.

Perhaps the most striking thing about the Brexit process to date has been the remarkable degree of control exercised over it by Downing Street. Brexit means Brexit, declared the Prime Minister, and since that day it has been her who has defined what precisely it does mean. After a quarter century of bitter division over Europe, culminating in a referendum where the Parliamentary party was split down the middle, she has managed to unite the overwhelming majority of the Conservative party for a “hard Brexit” that very few claimed to support a year ago.  As an impotent opposition and ineffective Tory opponents watched on, she has made it clear from the first that Britain will leave the single market and, almost certainly, the customs union. Rumours from Whitehall suggest that, whatever the concerns or doubts of line departments, these have been ignored or over-ruled.

Now, however, the Prime Minister has lost control of the process. Inevitably, given the relative strength of the parties’ negotiating positions, both the agenda and outcome of the talks will be determined largely by our European partners. It is of course true that they have an interest in preserving trade with us, as do we with them; nor do they have any interest, either economic or political, in “punishing” us for the sake of it. That being said, our interests and theirs are far from aligned. They have other priorities. Not allowing cherry picking among EU rules is one. Ensuring Britain pays its fair share is another.

And, while it is in neither side’s interest for the talks to collapse, we have considerably more to lose. May’s claim that “no deal is better than a bad deal” may play well with the Daily Express, but is has not gone down well with UK business. As the economics professor Jonathan Portes sets out here, the consequences of “no deal” would go far beyond the mere imposition of tariffs; the economic impacts would be significant for other EU countries, and very  severe indeed for the UK.  There are increasing signs that ministers are, belatedly, appreciating the risks, and are anxious to avoid such an outcome.

So both sides want a deal – and the UK, at least, needs one. But several hurdles stand in the way. In the first place, there is the vexed question of money. Britain, as our partners are concerned, has outstanding liabilities that must be paid. The British government may accept some of these, but is sure to quibble about the sums. Discussions of money are never easy in the EU, and the task of figuring out what a net contributor to the budget might owe at a time when discussions over the new 5 year funding programme are about to start will be no exception.  Nevertheless, if it were simply left to the civil servants, no doubt an acceptable compromise would be reached. The bigger  issue  is whether Mrs May  is prepared to take on some of her own backbenchers – and, more importantly, sections of the UK press – to sell a deal that will inevitably mean that the UK writes a sizeable cheque.

Second, there is the question of how to ensure the "frictionless" trade of which the Prime Minister has spoken. This makes eminent sense on one level – why make trade more difficult with the partner that buys 44 per cent of our exports? On another, though, it is hard to see how she can deliver.

I for one simply lack the imagination to see how we can be sufficiently out of the customs union to allow us to sign our own trade deals, while sufficiently in it to avoid customs checks and tariffs. For another, it is difficult to foresee conditions under which the EU would allow us to enjoy any of the benefits of the single market – whereby states accept each other’s rules and standards – without the oversight provided by the European Court of Justice.

And finally, since all parties now seem to accept that the prospects of concluding an “ambitious and comprensive” trade deal by March 2019 are vanishingly, there is the question of what happens then. The government has talked about an “implementation phase”; but how do you have an “implementation phase” when you do not know exactly what you are trying to implement?

It could just be me. I may simply not have fathomed the subtle devices that might allow these circles to be squared. But it does seem clear to me that doing so would be far from straightforward.

And then, of course, whatever is negotiated needs to be approved. Forget for a moment the continent, where there has probably never been a worse time to try to get a free trade deal approved by 27 European parliaments. The Prime Minister will almost certainly have parliamentary problems here in the UK.

The Labour party has adopted a position whereby they will vote against any deal that does not provide the “exact same benefits” as we currently have as members of the single market and customs union,” to quote Keir Starmer. If the other member states are to be believed, the full benefits of membership are, and will be, only available to members, so this is will simply not be the case.

Labour, then, will probably end up voting against the bill. What Tories opposed to either Brexit or to leaving the single market might then do is anyone’s guess. It may be that, by autumn of 2018, they feel sufficiently empowered  - either because of a shift in public opinion, or because of indications of falling economic confidence, or, conceivably, because of declining faith in the Prime Minster – to make common cause with the opposition.

Under such circumstances, May might face the real possibility of defeat in Parliament. Which in turn poses the question as to why she would she risk putting a deal that might be rejected to a vote?

It seems to me that she would have very little incentive to do so. If she cannot get the kind of deal that seems, on the surface, impossible to get anyway, surely better, from her point of view to simply walk away? Blaming the Europeans for failure would be all to easy. And holding a snap election on a patriotic ticket and opposed by the current Labour party would guarantee a healthy majority.

Two years is a long time in politics. And much that is unexpected will doubtless transpire during the negotiations to come. Do not, however, discount the possibility that it might all go wrong. 

Anand Menon is director of The UK in a Changing Europe and professor of European politics and foreign affairs at King's College London.