“NHS reforms our worst mistake, Tories admit,” the Times (£) front page declares today. A Cabinet member has told the paper that: “We’ve made three mistakes that I regret, the first being restructuring the NHS. The rest are minor.” “George kicks himself for not having spotted it and stopped it. He had the opportunity then and he didn’t take it,” an “ally” of the Chancellor is quoted as having said. “The Tories admit that public trust of their stewardship of the NHS has been undermined by Mr Lansley’s reforms,” the story continues.
Since this site had a hand in the debate about the reforms under the editorship of my predecessor, Tim Montgomerie – now a Times columnist – it is important to be clear about what went wrong, what we said, and what has happened to the NHS since they were implemented.
Journalism involves shorthand, and the paper’s headline conflates two parts of the longer story for the sake of concision. The first is the reforms. The second is Andrew Lansley’s Health Bill, which was drawn up to implement some of them – that’s to say, the Bill both in its original and later form.
I probed the reforms and the Bill in 2011, and concluded that the proposals were sound but the politics was risky. I also thought that they wouldn’t stave off an NHS winter crisis, and that Osborne would have to throw more money at the system to calm it down. This hasn’t happened, at least partly because he has presciently thrown money at the system before the crisis could occur rather than be forced to do so after one has started. Last year, £250 million was sent out much earlier than usual – in September – and concentrated on the 53 hospital trusts that were judged to be most in need of help.
One of the main reasons why Lansley’s original plans were solid was that the main element of them was simple – the transfer of commissioning from Primary Care Trusts (PCTs), a bureaucracy, to groups of GPs themselves: the Clinical Commissioning Groups (CCGs). This was in effect a return to the fundholding reforms of the Thatcher era and takes us to a crucial point. The Bill wasn’t needed to effect this change. Labour, having first ended fundholding, started it again as “practice-based commissioning”. In some parts of the country, GPs were already taking much more control – in West London and Cumbria, for example.
The Bill did make some changes for which legislation was necessary – to the public health responsibilities of local authorities, for example. Lansley could have produced a shorter, snappier measure to effect them, and waited for more PCTs to abolish themselves and GPs to assume more power. Instead, the Government opted for a big bill. Enter the Liberal Democrats. By 2012 and the party’s spring conference, the two parts of the Coalition were already at odds. At its conference a year earlier, Shirley Williams and Evan Harris had demanded changes to the bill, and duly got some. But a “pause” in the Bill had not quelled the party’s dissenters. It was in trouble.
It was at this point that ConservativeHome, in the form of its editor, argued that the Bill should be pulled: Tim’s main point was that the game was no longer worth the candle. I wrote separately that while the original Lansley plans were straightforward in design, the post-pause Bill, groaning with Liberal Democrat-inspired amendments, would probably produce “an NHS Railtrack of new, overlapping and competing bureaucracies”. The Times (£) reports today that it has been necessary for the service to produce an “acronym-buster”.
The best part of five years on from the original Bill, the question remains: was it worth it? The Times quotes Jeremy Hunt as follows: “Andrew’s structural changes are saving the NHS more than £1 billion a year. Because of that we can employ 7,000 more doctors and 3,500 more nurses.”
It is impossible to know what would have happened if the Bill hadn’t been introduced. My best guess is that the switch from PCTs to CCGs would have taken place more slowly. So on the one hand, the savings Hunt cites would be lower. On the other, the costs of bureaucracy would be lower, too.
What is certain is that the politics of the Bill didn’t work. Lansley is an intelligent man – he knows the NHS from top to bottom – but not a crisp communicator. He found it hard to explain the benefits of the Bill in simple terms that voters understood. The Liberal Democrats spotted a weakness and pounced on it. The moral of the story is bleak. Health costs continue to soar as the population ages. But rational plans to restrain them meet ferocious opposition, all the more if they come from Conservative Ministers. I suspect that it will eventually be a Labour Government that cuts the NHS – and deeply.