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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I'm playing sports again – but things just aren't cricket

I start the new season with red wine stains on my cap, a dodgy shoulder and a burnt nostril.

I’ve put my name up for the first match of the season, playing for that team of redoubtable cricketers, the Rain Men, named after their founder Marcus Berkmann’s book about a team of middle-aged and, er, “mixed-ability” players. The book was first published twenty years ago. Feel free to do some rudimentary maths.

I myself haven’t played for three years. I know this because when I go to get some new contact lenses – I don’t like the idea of running around in glasses, or having a cricket ball lodge them into my eyeballs – I am told I have not bought any since 2013. Yes, that would figure. I couldn’t play for much of 2013, and all of 2014, because two weekends a month I was busy with my children, and the other two I was busy with my lover. A game takes up a whole Sunday – one is committed, including travel and the post-match drink, for about ten hours, and that is too long to spend apart from your loved one, unless of course you are married or otherwise permanently settled and you see them all the time anyway.

In 2015 that restriction was lifted for me, but for some reason I spent that year being too sad to think about playing cricket and also far too unfit. I would occasionally walk long distances and do a few dozen desultory lifts of the dumb-bells in order to achieve even the beginnings of some kind of muscular definition, but in the end the lassitude took over and I thought that maybe the team, however ageing, could do without someone who gets a bit winded when walking down stairs.

Then a brief moment of optimism a couple of weeks ago, combined with a ray of what may possibly have been sunshine, inspired me to rejoin the fold. The team’s meticulously kept records, known among the members as “Sad Stats”, inform me that I have played only eight games for them; when one has played ten, one is eligible for a Rain Men cap, a properly made thing whose design and hooped colours are, in their air of having come from another age, seemingly designed specifically to enrage fast bowlers.

The cap I have says “Antigua, WI”. It’s a battered thing I bought on the island a few years ago, now stained, not sure how, with red wine, but which I will say is my own, fearlessly shed blood, should anyone ever ask. The idea is that, if I wear this cap, some idiot will think I have actually played for Antigua and am thus a force to be reckoned with. However, after a few deliveries, I suspect the opposition has decided that the “WI” stands for Women’s Institute rather than West Indies.

So I start my fitness training a week or so before the match. This involves a walk into town for dinner, followed by a single lift of the dumb-bells before I realise that The Thing That Is Wrong With My Right Shoulder is as bad as it was when it started, about a month ago. What is wrong with it? I can’t move my arm above shoulder height, but I can’t think of any strain I could have put on it. Can you get cancer of the shoulder?

Well, this rules out bowling, except bowling is already ruled out on the grounds that I can no longer bowl, even with a fully rotational shoulder joint. Which in our case we have not got, to quote Henry Reed’s “Naming of Parts”.

In the end, I confine my preparations to a few practice shots with the bat on the back terrace while listening to The Archers. Strangely, the bat seems to have put on a lot of weight since I last held it. I tried practising in front of the mirror in the living room, but as I can only see my head in it, this is not much use except for practising my face. On the terrace, I attempt a pull shot with a fag in my mouth, which clenches so as to make me burn my right nostril really rather badly. A week later, when I actually play, it is still sore to the touch.

As for the game . . . well, it’s an odd one. We manage to eke out a draw, and as for my own contribution, the less said about that, the better. But at least I don’t drop any catches and, even though it causes my shoulder agony, I stop a few balls in the field. The ground itself, however, is right in the shadow of the Didcot A power station, in whose ruins are still at least three bodies of the men who were caught there when it collapsed in February. Throughout the game, lorries tip their burdens of mangled metal on enormous scrapheaps. It puts things in perspective. But look in the other direction, and rapidly backwards and forwards the early bees are assaulting and fumbling the flowers. 

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 19 May 2016 issue of the New Statesman, The Great Huckster