Andrew Lansley, the Health Secretary, is having a miserable time. Vandals have painted "Hands off our NHS, Tory scum" on the wall of his constituency office in south Cambridgeshire. A rap video on YouTube - in which Lansley is denounced as a "grey-haired, manky codger" and called a "tosser" by members of the public - has gone viral, with hundreds of thousands of hits.

Humiliated, Lansley has had to appear in the Commons to announce a "pause" to his NHS reforms and a period of listening. Consider the formidable army of critics arrayed against the Health Secretary and his Health and Social Care Bill: the British Medical Association, the British Medical Journal, the Royal College of GPs, the King's Fund, the NHS Confederation, the health select committee, the Nuffield Trust, the Social Market Foundation, Unison, Policy Exchange, the Lib Dem grass roots, David Owen and Norman Tebbit. It is difficult to dismiss them all as "vested interests".

As Lansley is mocked and ridiculed, David Cameron floats above the fray, intervening from on high to "rein in" his "dogmatic" Health Secretary, who makes an easy fall guy. Rumours abound that he is for the chop, come the first reshuffle after May's local elections. "It's so unfair," says a cabinet colleague. "Andrew is one of the nicest men in politics." In politics, however, niceness is irrelevant. (And Lansley is not as nice as he seems: he once boasted that the Tories campaigned on immigration because it "played particularly well in the tabloids and has more potential to hurt [Labour]".)

Where the buck stops

There are two main issues at stake in the question of NHS reform - the Prime Minister's judgement and his honesty. At his first conference as Tory leader in 2006, Cameron declaimed that his political priority could be defined in three letters: NHS. Cameron, whose late son, Ivan, had been treated in NHS hospitals, went out of his way in opposition to neutralise one of the party's Achilles heels.

In government, he gave his full support to the Health Secretary from the moment the controversial reforms to the NHS - involving the abolition of primary care trusts, the transfer of budgets and commissioning powers to GPs and a much bigger role for the private sector and competition law - were unveiled, nine months ago. He cannot now evade responsibility. On 23 March, Cameron defended the Health and Social Care Bill in the Commons: "The point of reforming the NHS is to safeguard it for the future." In a speech on 17 January, he denounced the "status quo" in the NHS, declaring: "We can't afford not to modernise."

The recent NHS debacle is a symptom of a wider malaise: the Cameron-led government's preference for pace and haste over debate and deliberation. Cabinet ministers - including the Prime Minister - have told friendly journalists that they have read and imbibed the lesson
of Tony Blair's memoir, A Journey. It is, in the words of the Education Secretary, Michael Gove: "Don't hang around."

As naive and inexperienced cabinet ministers rush off in different directions to embark on "radical", "bold" and "controversial" reforms to health, education, welfare and local government, the Prime Minister is often nowhere to be seen. Tory commentators, such as ConservativeHome's Tim Montgomerie, have noted Cameron's lack of attention to detail. Gordon Brown may have been a workaholic and control freak but a disengaged and distracted approach is not the solution, either.

Some have remarked that the Prime Minister sees himself as chairman rather than chief executive of UK plc. So who is the chief executive? There have long been grumblings from Tory backbenchers that the Prime Minister is in need of a "Leo McGarry figure" - a pointed reference to the fictional chief of staff in the US television drama The West Wing - someone who bangs heads together on behalf of his boss, the president, and looks out for trouble.

Given its complex and contentious nature, the 299-clause Health and Social Care Bill was an accident waiting to happen. Late last year, the Prime Minister despatched his Cabinet Office minister Oliver Letwin to review the reforms. A hands-on, rather than hands-off, leader would have immersed himself in the arguments - and much earlier, too.

Instead, on 16 March, at PMQs, Cameron was left floundering as Ed Miliband held a copy of the bill aloft and quoted various clauses at him. "Why does the Prime Minister not answer the question?" asked the Labour leader. "Does he even know whether the health service will now be subject to EU competition law?"

Broken promises

The row over NHS reform is an example of not just political misjudgement on Cameron's part but dishonesty, too. First, Cameron, as leader of the opposition, promised that there would be "no more pointless reorganisations" of the health service and the coalition agreement pledged to "stop the top-down reorganisations of the NHS". How does the Prime Minister square this pledge with his bill, described by Chris Ham, chief executive of the King's Fund think tank, as "the biggest organisational upheaval in the health service, probably, since its inception"?

Second, Cameron promised to "ring-fence" the NHS budget and increase spending on health care in real terms over the lifetime of this parliament. But the King's Fund's chief health economist, John Appleby, says that, given the recent revision to inflation figures by the Office for Budget Responsibility: "It looks like, for the moment, at least, the pledge won't be met." Appleby calculates that the real cut in spending on the NHS will amount to £900m by 2015.

Third, Cameron promised to promote the NHS as a comprehensive and national service and protect it from privatisation. But his proposals will transform the NHS into a fund that purchases services from a range of providers - from not-for-profit "social enterprises" and foundation trusts to for-profit private companies. Writing in the British Medical Journal, the academics Allyson Pollock and David Price conclude: "The bill, as drafted, amounts to the abolition of the English NHS as a universal, comprehensive, publicly accountable, tax-funded service, free at the point of delivery."
On the health service, as in the case of spending cuts, benefit changes and "free" schools, Cameron the "compassionate Conservative" is going far beyond the reforms of Margaret That­cher. Say whatever you like about the Iron Lady, but the NHS was safe in her hands.