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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When Theresa May speaks, why don’t we listen?

Not many Prime Ministers have to repeat themselves three times. 

Theresa May is the candidate of Brexit and market panic. She ascended to the highest office because, in the fraught weeks after Britain’s vote to leave the European Union, she represented a safe haven for nervous Conservative MPs, the dependable family mutual that remained open while all along the Conservative high street, her rivals were shutting up shop.

Her popularity, as revealed in high poll ratings outside Westminster, too, owes itself to the perception that she is a serious politician in serious times, happily installed atop the ship of state to guide it through the rocky waters of Brexit negotiations.

May’s premiership has been defined by market panics of a different kind, however. The first is in the currency markets, where sterling takes a tumble whenever she pronounces on Britain’s future relationship with the European Union, falling both after her conference speech on 2 October and after her start-of-the-year interview with Sophy Ridge on 8 January. The second is in the opinion pages, where May’s stock oscillates wildly from bullish to bearish.

In the first months of May’s government, she was hailed as an Anglo-Saxon counterpart to Angela Merkel: a solid centre-right Christian democrat who would usher in a decade of conservative hegemony. More recently, she has been compared to Gordon Brown because of her perceived indecisiveness and repeatedly accused of failing to spell out what, exactly, her government’s Brexit objectives are.

In a symbol of the splits on the right between the Brexiteers and Remainers, the Economist, that bible of free-market globalisation and usually a reliable tastemaker as far as Westminster groupthink is concerned, began 2017 by dubbing the Prime Minister “Theresa Maybe”. Though May’s Downing Street is less concerned with the minutiae of what goes on in the public press than David Cameron’s, the contention that she is indecisive was a source of frustration.

There is an element of truth in the claim that May still views the world through a “Home Office lens”. One senior minister complains that Downing Street considers the Ministry of Justice as a “rogue outpost” of May’s old stomping ground, rather than a fully fledged department with its own interests and perspectives.

Yet even the most authoritarian of home secretaries would struggle to secure a conviction against May on the charge of opacity as far as her Brexit approach is concerned. She has hit the same grace notes with the reliability of a professional musician: Brexit means freedom from the jurisdiction of the European Court of Justice and control over Britain’s borders, two objectives that can only be achieved as a result of Britain’s exit not only from the EU but also the single market. This was confirmed on 17 January in the Prime Minister’s Lancaster House speech in London.

David Cameron used to say that he would never have “a people”. Certainly, there is no Cameroon tendency in the country at large to match the generation of council house residents that became homeowners and lifelong Conservatives because of Margaret Thatcher and Right to Buy. However, there is, unquestionably, a Cameroon people or faction to be found at almost every rung of London’s financial services sector or at editorial meetings of the Economist, though it as at the Times and the Sun where the treatment of May is at its most noticably rougher than in the Cameron era. 

Michael Gove, her old rival, is not only employed as a columnist by the Times; he enjoys the confidence and admiration of Rupert Murdoch. That the Times secured the first British interview with Donald Trump was a coup for Murdoch, an old associate of the president-elect, and for Gove, who conducted it. It left May in the unlovely position of making history as the first prime minister to be scooped to a first meeting with a new American president by a sitting MP in modern times. It also attested to a source of frustration among May’s allies that she is, for all her undoubted popularity, still ignored or doubted by much of the right-wing establishment.

That condescension partly explains why her words are often listened to briefly, acted on hastily and swiftly forgotten, hence the pound’s cycle of falling when she makes an intervention on Brexit and rising shortly thereafter. The Lancaster House speech was designed to break this pattern. Downing Street briefed the most potent paragraphs at the weekend so that the markets could absorb what she would say before she said it.

As a result, the pound rallied as May delivered her speech, which contained a commitment to a transitional deal that would come into effect after Britain has left the EU. Some financiers believe this arrangement could become permanent, which once again demonstrates how much they underestimate May’s ability to enforce her will.

Being underestimated by Cameron’s people, in Westminster and the City, has the unintended effect of shoring up Theresa May’s position. A prolonged and sustained bout of panic would increase the pressure for a soft landing, but its absence makes it harder for Labour to oppose her effectively, although it has largely acquiesced to the Tory plan for Brexit, at least as far as membership of the single market is concerned. 

Yet for all the plaudits that the Prime Minister’s Lancaster House speech attracted, for all her undoubted popularity in the country, she is in the anomalous position of being a Conservative Prime Minister who has priorities on the European stage other than the preservation of the City of London and to whom Rupert Murdoch is not a natural ally.

As such, she may find that her deadlier enemies come from the right.

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.