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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If only I could wangle a job in the John Lewis menswear department I’d get to say, “Suits you, sir”

I’m afraid I am going to have to stick to writing.

So now that I have made the news public that I am even deeper in the soup than I was when I started this column, various people – in fact, a far greater number than I had dared hope would – have expressed their support. Most notable, as far as I can tell, was Philip Pullman’s. That was decent of him. But the good wishes of people less in the public eye are just as warming to the heart.

Meanwhile, the question is still nagging away at me: what are you going to do now? This was the question my mother’s sisters would always ask her when a show she was in closed, and my gig might have been running for almost as long as The Mousetrap but hitherto the parallels with entertainment had eluded me.

“That’s show business,” she said to me, and for some reason that, too, is a useful comment. (I once saw a picture of a fairly well-known writer for page and screen dressed up, for a fancy-dress party, as a hot dog. The caption ran: “What? And give up show business?”)

Anyway, the funds dwindle, although I am busy enough to find that time does not weigh too heavily on my hands. The problem is that this work has either already been paid for or else is some way off being paid for, if ever, and there is little fat in the bank account. So I am intrigued when word reaches me, via the Estranged Wife, that another family member, who perhaps would prefer not to be identified, suggests that I retrain as a member of the shopfloor staff in the menswear department of John Lewis.

At first I thought something had gone wrong with my hearing. But the E W continued. The person who had made the suggestion had gone on to say that I was fairly dapper, could talk posh, and had the bearing, when it suited me, of a gentleman.

I have now thought rather a lot about this idea and I must admit that it has enormous appeal. I can just see myself. “Not the checked jacket, sir. It does not become sir. May I suggest the heather-mixture with the faint red stripe?”

In the hallowed portals of Jean Louis (to be said in a French accent), as I have learned to call it, my silver locks would add an air of gravitas, instead of being a sign of superannuation, and an invitation to scorn. I would also get an enormous amount of amusement from saying “Walk this way” and “Suits you, sir”.

Then there are the considerable benefits of working for the John Lewis Partnership itself. There is the famed annual bonus; a pension; a discount after three months’ employment; paid holiday leave; et cetera, et cetera, not to mention the camaraderie of my fellow workers. I have worked too long alone, and spend too much time writing in bed, nude, surrounded by empty packets of Frazzles and Dinky Deckers. (For those who are unfamiliar with the latter, a Dinky Decker is a miniature version of a Double Decker, which comes in a bag, cunningly placed by the tills of Sainsbury’s Locals, which is usually priced at a very competitive £1.)

I do some research. I learn from an independent website that a retail sales assistant can expect to make £7.91 an hour on average. This is somewhat less than what is considered the living wage in London, but maybe this is accounted for in the John Lewis flagship store in Oxford Street. It is, though, a full 6p an hour more than the living wage in the rest of the land. Let the good times roll!

At which point a sudden panic assails me: what if employment at that store is only granted to those of long and proven service? God, they might send me out to Brent Cross or somewhere. I don’t think I could stand that. I remember when Brent Cross Shopping Centre opened and thought to myself, even as a child, that this was my idea of hell. (It still is, though my concept of hell has broadened to include Westfield in Shepherd’s Bush.)

But, alas, I fear this tempting change of career is not to be. For one thing, I am probably too old to train now. By the time I will have been taught to everyone’s satisfaction how to operate a till or measure an inside leg, I will be only a few months, if that, from retirement age, and I doubt that even so liberal an employer as John Lewis would be willing to invest in someone so close to the finish line.

Also, I have a nasty feeling that it’s not all heather-mixture suits with (or without) the faint red stripe these days. The public demands other, less tasteful apparel.

So I’m afraid I am going to have to stick to writing.

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 22 June 2017 issue of the New Statesman, The zombie PM

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