Andrew Haldenby is Co-Founder of Aiming for Health Success, a new research and advisory body, and a former Head of the Political Section in the Conservative Research Department.
As the Party website says, the Conservatives have been running the NHS for 44 of its 71 years. After all that time, we might expect it to know the service, understand it, have a feel for it.
And it should. The Health Service is the biggest public service by far, with a budget three times that of schools and ten times that of the police. Its decisions determine the treatment of over 90 per cent of the population. In terms of politics, it is typically top of the list of voters’ concerns in opinion polls.
But Conservatives remain uncomfortable. The confidence that the Party displays on the economy, on defence, on criminal justice and (in recent years) on schools disappears when it comes to health and care.
I treasure a point made by Dominic Cummings in his key article after the Brexit referendum. He quoted Peter Bone MP: “I’ve spent years trying to ignore the NHS in elections Dominic and I’m not going to change now.”
I don’t mention this to pick on Peter. Rather, it speaks to something recognisable – a wish to move on from the NHS, or at best neutralise it as an issue, while focusing on other things.
I remember discussing the NHS with one of the most senior members of Theresa May’s Government. Having not looked at it before, he was horrified by its size and complexity. He asked me why the Government shouldn’t just appoint a “big man”, to run the NHS and let ministers get on with other matters.
Another example came in 2010, when David Cameron’s team realised they didn’t understand their own health policy. In his memoirs, the then-Prime Minister tells the story of Andrew Lansley’s presentation to Cabinet: “It was like an artist unveiling a piece he’d spent years on, and everyone wondering what on earth it was.”
Cameron was critical of Lansley (“he was too submerged in the detail”) but the real point for me is that the Prime Minister and his advisers had been happy to avoid the detail completely. His team had some broad political objectives (“the modern, compassionate Conservative Party would be the party of the NHS”) but they lacked a grounded understanding.
Without this, the Party finds itself stuck in two contradictory positions.
The first is that “we love the NHS” and want to prove it, usually with more money. Cameron said that his priorities could be summed up in three letters: “N.H.S.” The 2019 manifesto was a long list of commitments to higher spending, more buildings and more staff, without any ideas as to how they would be well used. The Brexit campaign bus promised a very big NHS spending increase should the referendum be won.
The second is distrust and a sense that a bureaucratic, monopolistic service is acting in its own interest rather than that of patients.
This is the line that the Telegraph and the Mail newspapers have taken since last year. Their campaign in favour of face-to-face GP appointments was based on the accusation that the NHS is unresponsive to the needs of actual people (forgetting to mention that a Conservative Secretary of State, Matthew Hancock, had asked GPs to conduct more telephone consultations in order to keep the service open during Covid-19).
Some place the NHS on the wrong side of the culture wars. When he left GB News, Andrew Neil said that the perception of the station was “we hate migrants, we hate the NHS, we hate lockdown and we hate Meghan Markle”.
Life Support, the new book by Michael Ashcroft and Isabel Oakeshott, falls into the latter category. The argument of the book is that the NHS is like the emperor’s new clothes – when we all look closer, we can see that it is not as good as everyone pretends. As they say, “the book seeks to strip away the spin and uncover the true state of the NHS: good, the bad and the ugly”.
The authors report on the NHS as if it is a patient, under five headings: “Vital statistics” (the headline numbers), “Circulation” (hospitals and IT); “Head” (management), “Body” (workforce), “Soul” (culture) and “Bowels” (the marginalised parts of the Service, such as mental health).
Thirty individual chapters focus on poor performance in particular areas, from aspects of provision (waiting times) to workforce (GPs, nurses, consultants) to transparency. The authors are particularly tough on what they describe as a “cult of secrecy” that “surrounds errors and failings”.
There is a consistent message: far from being the greatest health service in the world, the Service’s ability to provide a decent standard of care “has never been more in doubt”.
There are strong arguments on making the NHS more productive and on the potential of new technology. But these points don’t come together into an agenda for action. The main recommendation is for a Royal Commission, which would not necessarily have cross-party support, and which would report many years from now.
What is to be done? Clearly I hope this book is the first of many Conservative views that fill in the gaps in the Party’s understanding. I also hope Lord Ashcroft produces a second edition, adding positive recommendations on the way forward.
I also wonder if Oliver Dowden has a job here. Somehow the Party must build the Conservative network in the NHS, build understanding of the Service in the wider Party, and develop consistent policies that seek to make the NHS pound go further.
Should he get some donors – including Lord Ashcroft? – to support an in-house unit to do just that, at least for the next decade? It wouldn’t cost much.
Conservatives should aim to be at ease with the NHS, as well as being its longest-serving custodians.