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 can’t follow Marie Kondo's advice – even an empty Wotsits packet “sparks joy” in me

I thought I’d give her loopy, OCD theories a go, but when I held up an empty Wotsits bag I was suffused with so many happy memories of the time we’d spent together that I couldn’t bear to throw it away.

I have been brooding lately on the Japanese tidying freak Marie Kondo. (I forgot her name so I typed “Japanese tidying freak” into Google, and it was a great help.) The “Japanese” bit is excusable in this context, and explains a bit, as I gather Japan is more on the case with the whole “being tidy” thing than Britain, but still.

Apart from telling us that we need to take an enormous amount of care, to the point where we perform origami when we fold our underpants, which is pretty much where she lost me, she advises us to throw away anything that does not, when you hold it, “spark joy”. Perhaps I have too much joy in my life. I thought I’d give her loopy, OCD theories a go, but when I held up an empty Wotsits bag I was suffused with so many happy memories of the time we’d spent together that I couldn’t bear to throw it away.

After a while I gave up on this because I was getting a bit too happy with all the memories, so then I thought to myself, about her: “This is someone who isn’t getting laid enough,” and then I decided that was a crude and ungallant thought, and besides, who am I to wag the finger? At least if she invites someone to her bedroom no one is going to run screaming from it, as they would if I invited anyone to my boudoir. (Etym: from the French “bouder”, to sulk. How very apt in my case.) Marie Kondo – should bizarre circumstance ever conspire to bring her to the threshold – would run screaming from the Hovel before she’d even alighted the stairs from the front door.

I contemplate my bedroom. As I write, the cleaning lady is in it. To say that I have to spend half an hour cleaning out empty Wotsits packets, and indeed wotnot, before I let her in there should give you some idea of how shameful it has got. And even then I have to pay her to do so.

A girlfriend who used to be referred to often in these pages, though I think the term should be a rather less flippant one than “girlfriend”, managed to get round my natural messiness problem by inventing a game called “keep or chuck”.

She even made up a theme song for it, to the tune from the old Spiderman TV show. She would show me some object, which was not really rubbish, but usually a book (it may not surprise you to learn that it is the piles of books that cause most of the clutter here), and say, “Keep or chuck?” in the manner of a high-speed game show host. At one point I vacillated and so she then pointed at herself and said, “Keep or chuck?” I got the message.

These days the chances of a woman getting into the bedroom are remote. For one thing, you can’t just walk down the street and whistle for one much as one would hail a cab, although my daughter is often baffled by my ability to attract females, and suspects I have some kind of “mind ray”. Well, if I ever did it’s on the blink now, and not only that – right now, I’m not even particularly bothered that it’s on the blink. Because, for another thing, I would frankly not care to inflict myself upon anyone else at the moment.

It was all a bit of a giggle eight years ago, when I was wheeled out of the family home and left to my own devices. Of course, when I say “a bit of a giggle”, I mean “terrifying and miserable”, but I had rather fewer miles on the clock than I do now, and a man can, I think, get away with a little bit more scampish behaviour, and entertain a few more illusions about the future and his own plausibility as a character, when he is squarely in his mid-forties than when he is approaching, at speed, his middle fifties.

Death has rather a lot to do with it, I suppose. I had not actually seen, or touched, a dead body until I saw, and touched, my own father’s a few weeks ago. That’s what turns an abstract into a concrete reality. You finally put that to one side and gird up your loins – and then bloody David Bowie snuffs it, and you find yourself watching the videos for “Blackstar” and “Lazarus” over and over again, and reach the inescapable conclusion that death is not only incredibly unpleasant, it is also remorseless and very much nearer than you think.

And would you, dear reader, want to be involved with anyone who kept thinking along those lines? I mean, even if he learned how to fold his undercrackers into an upright cylinder, like a napkin at a fancy restaurant, before putting them in his drawer? When he doesn’t even have a drawer?

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 05 February 2015 issue of the New Statesman, Putin's war