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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John Major's double warning for Theresa May

The former Tory Prime Minister broke his silence with a very loud rebuke. 

A month after the Prime Minister stood in Chatham House to set out plans for free trading, independent Britain, her predecessor John Major took the floor to puncture what he called "cheap rhetoric".

Standing to attention like a weather forecaster, the former Tory Prime Minister warned of political gales ahead that could break up the union, rattle Brexit negotiations and rot the bonds of trust between politicians and the public even further.

Major said that as he had been on the losing side of the referendum, he had kept silent since June:

“This evening I don't wish to argue that the European Union is perfect, plainly it isn't. Nor do I deny the economy has been more tranquil than expected since the decision to leave was taken. 

“But I do observe that we haven't yet left the European Union. And I watch with growing concern  that the British people have been led to expect a future that seems to be unreal and over-optimistic.”

A seasoned EU negotiator himself, he warned that achieving a trade deal within two years after triggering Article 50 was highly unlikely. Meanwhile, in foreign policy, a UK that abandoned the EU would have to become more dependent on an unpalatable Trumpian United States.

Like Tony Blair, another previous Prime Minister turned Brexit commentator, Major reminded the current occupant of No.10 that 48 per cent of the country voted Remain, and that opinion might “evolve” as the reality of Brexit became clear.

Unlike Blair, he did not call for a second referendum, stressing instead the role of Parliament. But neither did he rule it out.

That was the first warning. 

But it may be Major's second warning that turns out to be the most prescient. Major praised Theresa May's social policy, which he likened to his dream of a “classless society”. He focused his ire instead on those Brexiteers whose promises “are inflated beyond any reasonable expectation of delivery”. 

The Prime Minister understood this, he claimed, but at some point in the Brexit negotiations she will have to confront those who wish for total disengagement from Europe.

“Although today they be allies of the Prime Minister, the risk is tomorrow they may not,” he warned.

For these Brexiteers, the outcome of the Article 50 negotiations did not matter, he suggested, because they were already ideologically committed to an uncompromising version of free trade:

“Some of the most committed Brexit supporters wish to have a clean break and trade only under World Trade Organisation rules. This would include tariffs on goods with nothing to help services. This would not be a panacea for the UK  - it would be the worst possible outcome. 

“But to those who wish to see us go back to a deregulated low cost enterprise economy, it is an attractive option, and wholly consistent with their philosophy.”

There was, he argued, a choice to be made about the foundations of the economic model: “We cannot move to a radical enterprise economy without moving away from a welfare state. 

“Such a direction of policy, once understood by the public, would never command support.”

Major's view of Brexit seems to be a slow-motion car crash, but one where zealous free marketeers like Daniel Hannan are screaming “faster, faster”, on speaker phone. At the end of the day, it is the mainstream Tory party that will bear the brunt of the collision. 

Asked at the end of his speech whether he, like Margaret Thatcher during his premiership, was being a backseat driver, he cracked a smile. 

“I would have been very happy for Margaret to make one speech every eight months,” he said. As for today? No doubt Theresa May will be pleased to hear he is planning another speech on Scotland soon. 

Julia Rampen is the editor of The Staggers, The New Statesman's online rolling politics blog. She was previously deputy editor at Mirror Money Online and has worked as a financial journalist for several trade magazines.