Lansley's bill has killed debate about the future of the NHS

There is a whole lot of politics and very little policy in the war over the government's health refo

Does any of the three main parties actually have a policy for the NHS? It may sound like a peculiar question given that huge stores of energy are currently being spent debating the future of the health service in parliament, but having a big argument in Westminster is not the same as having a coherent agenda.

The Health and Social Care Bill returns to the House of Lords this week and Liberal Democrat peers have some amendments covering the controversial section of the reforms dealing with increased competition between different providers. Crudely, speaking the vital question is how widely market forces will be allowed to operate when, under the new structures created by Andrew Lansley's reforms, GPs are given control over budgets and instructed to purchase the best value care for patients.

Lib Dems in the Lords want to rewrite parts of the Bill that would give the Competition Commission regulatory authority over healthcare. That, it is feared, would amount to a legal mandate for breaking up NHS "monopolies" and, if enough private providers complained about being shut out of contracts, forcing GPs to curtail their use of state services. In terms of the underlying principles of the Lansley project, this argument is pivotal; it is the big one. It is clear from the way the original bill was designed that the Health Secretary wants a radical acceleration of competition to be the main driver of change in the service. The logical extension of the reforms - as initially conceived - is for the NHS label to be, effectively, a kite mark, signalling that care has been paid for by the state and is being carried out by a licensed provider. It should, in theory, be irrelevant whether the people actually doing the caring are public or private sector employees.

It is also clear that the government is too scared to tell the public that this is what Lansley had in mind when he drafted the bill. It sounds and looks a little bit too much like privatisation, which is not a word the Tories want attached to their ambitions for the NHS. That makes it very hard for the government to fight the forthcoming battle in the Lords.

Number 10 is saying it is relaxed about amendments that might "clarify" this crucial section of the bill, but would be unhappy with substantial changes. Does that mean the Prime Minister insists on a level of competition from private providers that forcefully dismantles state monopolies? Or would he be satisfied with a watered down competition clause that amounts, in essence, to an extension of the "internal market" that existed under Labour? Another way of phrasing the question: does Cameron actually want to implement Lansley's vision or is he only pressing ahead with the bill to avoid the humiliation of abandoning a high-profile project in which he has already invested a lot of political capital?

The Lib Dem amendments have been sanctioned by Nick Clegg, largely, it seems, because he is aware of deep dissatisfaction in his party and fearful of being presented, come the next election, as an accomplice in Tory sabotage of a cherished national institution. But does he think a dramatic increase in competition from the private sector - policed by an anti-monopolies regulator - would be a driver of greater efficiency and quality of care in the health service? If the answer is "yes", why is he allowing his peers to sabotage the bill? If the answer is "no", why is he voting for any of this legislation?

As for Ed Miliband, his position is clear enough for an opposition leader. He has written in the Times today calling (again) for the bill to be scrapped. The issue of competition is addressed in passing:

Nor is the cause of integration helped by the Bill's aim to turn the whole NHS into a commercial market explicitly modelled on the privatisation of the utilities in the 1980s. Introducing a free-market model throughout the healthcare system -- quite different from the limited competition currently in place -- will have a chilling effect on the behaviour of those trying to co-ordinate and co-operate.

Another way of putting this might be that market forces are tolerable when Labour allows them to operate in a carefully controlled environment, but destructive and corrosive when unleashed by Tories and Lib Dems. Fair enough, I suppose, but it is a very queasy way of making peace with the Blairite legacy of public service reform. Nowhere else has Miliband dealt explicitly with the question of whether or not he thinks competition is a healthy or a pernicious mechanism for getting value for money in the public sector.

Which brings us back to that initial question. What is the three main parties' health policy? As far as I can make out it is as follows:

Conservatives: secure any version of Lansley's reforms, regardless of what the outcome will actually be for the NHS.

Labour: make sure every problem in the NHS is seen as a consequence of Lansley's reforms; avoid being drawn on alternative plans.

Liberal Democrats: look conspicuously worried about Lansley's reforms; in the event that they are enacted, hide.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

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Something is missing from the Brexit debate

Inside Westminster, few seem to have noticed or care about the biggest question mark in the Brexit talks. 

What do we know about the government’s Brexit strategy that we didn’t before? Not much, to be honest.

Theresa May has now said explicitly what her red lines on European law and free movement of labour said implicitly: that Britain is leaving the single market. She hasn’t ruled out continuing payments from Britain to Brussels, but she has said that they won’t be “vast”. (Much of the detail of Britain’s final arrangement is going to depend on what exactly “vast” means.)  We know that security co-operation will, as expected, continue after Brexit.

What is new? It’s Theresa May’s threat to the EU27 that Britain will walk away from a bad deal and exit without one that dominates the British newspapers.

“It's May Way or the Highway” quips City AM“No deal is better than a bad deal” is the Telegraph’s splash, “Give us a deal… or we walk” is the Mirror’s. The Guardian opts for “May’s Brexit threat to Europe”,  and “May to EU: give us fair deal or you’ll be crushed” is the Times’ splash.

The Mail decides to turn the jingoism up to 11 with “Steel of the new Iron Lady” and a cartoon of Theresa May on the white cliffs of Dover stamping on an EU flag. No, really.  The FT goes for the more sedate approach: “May eases Brexit fears but warns UK will walk away from 'bad deal’” is their splash.

There’s a lot to unpack here. The government is coming under fire for David Davis’ remark that even if Parliament rejects the Brexit deal, we will leave anyway. But as far as the Article 50 process is concerned, that is how it works. You either take the deal that emerges from the Article 50 process or have a disorderly exit. There is no process within exiting the European Union for a do-over.  

The government’s threat to Brussels makes sense from a negotiating perspective. It helps the United Kingdom get a better deal if the EU is convinced that the government is willing to suffer damage if the deal isn’t to its liking. But the risk is that the damage is seen as so asymmetric – and while the direct risk for the EU27 is bad, the knock-on effects for the UK are worse – that the threat looks like a bad bluff. Although European leaders have welcomed the greater clarity, Michel Barnier, the lead negotiator, has reiterated that their order of priority is to settle the terms of divorce first, agree a transition and move to a wider deal after that, rather than the trade deal with a phased transition that May favours.

That the frontpage of the Irish edition of the Daily Mail says “May is wrong, any deal is better than no deal” should give you an idea of how far the “do what I want or I shoot myself” approach is going to take the UK with the EU27. Even a centre-right newspaper in Britain's closest ally isn't buying that Britain will really walk away from a bad deal. 

Speaking of the Irish papers, there’s a big element to yesterday’s speech that has eluded the British ones: May’s de facto abandonment of the customs union and what that means for the border between the North and the South. “May’s speech indicates Border customs controls likely to return” is the Irish Times’ splash, “Brexit open border plan “an illusion”” is the Irish Independent’s, while “Fears for jobs as ‘hard Brexit’ looms” is the Irish Examiner’s.

There is widespread agreement in Westminster, on both sides of the Irish border and in the European Union that no-one wants a return to the borders of the past. The appetite to find a solution is high on all sides. But as one diplomat reflected to me recently, just because everyone wants to find a solution, doesn’t mean there is one to be found. 

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