This site will weep no tears for the Lansley reforms. Parts of them were good, parts of them were bad, and all of them were worse once they had been showboated by the Liberal Democrats. Tim Montgomerie ran an outspoken campaign against them when editor of this site – and he was right.
But the Government is not proposing simply to junk the byzantine Lansley structure. It is planning also to U-turn, if reports are correct, on the direction taken by a generation of healthcare reforms, applied by Conservative and Labour governments alike (though more fitfully by the latter).
The Lansley approach fell into two main parts. The first was to take power away from Ministers and put it into the hands of administrators, and so distancing them from decisions made about the NHS. His original vision saw the Secretary of State essentially as a Minister for Public Health. The second was to promote competition within the service.
The Government is right to want to revise the first element. The political effect of further quangoising power in the NHS wasn’t to pluck Ministers from the hurly-burly of controversy; rather, it was to plunge them deeper in it, because it rendered them powerless when bureaucrats made unpopular decisions.
Those administrators consequently became exemplars of the Stanley Baldwin principle – power without responsibility (a term he originally applied to the press). It became apparent by the time Jeremy Hunt replaced Lansley that Simon Stevens, the Chief Executive of the NHS in England, was the real Health Secretary, at least in most of the country and for most of the service.
Nonetheless, Ministers should think very carefully about how far they want to go. The reports suggest that they want to take power to put more fluoride in water, say, or switch funds to campign against obesity. That’s all fine as far as it goes: those are political decisions and so require political responsibility.
So do hospital closures – in principle. Ministers are apparently preparing to take direct control of these, too. Are Ministers sure that they want to face the consquences in practice? Anyone who knows anything about such closures knows that the first rule of them is that the local MP always, we repeat always, campaigns against them.
So what will Matt Hancock (or his successor) do when an MP from a red wall seat comes at knocking his door – pleading that his constituency not be turned Labour again at a stroke? Come to think of it, what will he do when any of his colleagues do the same? And if Ministers are to make the decisions, shouldn’t backbenchers then vote on them?
The brute fact is that if resources are limited, hospitals must sometimes close – if patients are not to be harmed by services being spread so meagrely that they become inadequate if not actually dangerous. Has Downing Street really thought the implications through? If not, it should start doing so now.
If Ministers taking back control would be a good thing, up to a point, curbing competition would be more dubious. We call as our first witness Alan Milburn, the most impactful of Labour’s recent health secretaries. On his watch, Labour “sought partnership with private health care to create new capacity and to provide a challenge to complacency in the NHS,” as the Nuffield Trust puts it.
“Milburn and his successors developed and refined the Conservative reforms, with a new and sometimes disruptive dynamism and a desire for massive change across a broad front,” it says. Who thought up and pushed through those reforms? Step forward our second witness: Ken Clarke.
He writes in his memoirs that he was originally “impressed by an article in the Economist by Professor Alain Enthoven who was a health economist at Stanford University, little known in the UK. He advocated setting up a system of purchaser and provider contracting within the healthcare system”.
“The key principles were competition and choice, with the aim of better outcomes for patients being the fundamental issue in deciding where resources were directed.” The internal market and GP fundholding were the products of this approach. Clarke begat Milburn and Milburn begat Lansley, as one of those biblical genealogies would put it.
Now competition is not the only principle that should power healthcare policy. If you go into hospital, you will be in the charge of one group of doctors and nurses. Once you leave it, you will be back in the hands of your doctor. In between and afterwards float health visitors, community nurses, medical centres, care homes, and a mass of specialist services. So co-operation matters too.
Finding the perfect mix between the two is the philsopher’s stone of healthcare policy. Pour in too much of one or the other, and all you get is a smoking residue. Or, as Jeremy Hunt put it yesterday, relaxing the spur of competition could result in the re-emergence of “cosy local monopolies”.
Hunt sought to steer his way round Stevens (“the intellectual force behind many of Labour’s reforms”, says Nuffield). He was a hand-on Secretary of State insofar as he could be, wanting to know how many accidental deaths there were in the NHS each day, and borrowing from Michael Gove’s education reforms to create a Ofsted-style structure of inspections, ratings and special measures.
A piece he wrote for ConservativeHome in 2017 about the salvaging of Colchester Hospital sums up his approach. So no wonder he was warning yesterday that a shift to the co-operation principle would require a “proper accountability mechanism”. However, there is more at stake in these proposals than the details of who should do what where, and how.
Aneurin Bevan said that “if a bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall.” That was the approach to which the Conservatives, who supported a national health service but opposed Bevan’s hospital nationalisations, objected to and voted against in the 1940s – preferring the pluralist ideals of Henry Willink, Churchill’s wartime health minister.
If Boris Johnson now wants to decouple himself from Clarke’s legacy on the political dancefloor, so to speak, and hitch up instead with Bevan’s, Parliament will surely let him do so. (Though the Conservative Manifesto said nothing much about public service reform in general and heath service reform in principle.)
But to further distance himself from the Thatcher project would mark a significant moment. It would be a simplification to say that Red Wall Tory MPs are for a bigger state policy approach and the bluer south MPs for a smaller state one. But that is where the situation of their voters tends to drive them.
The last election saw a shift in Conservative electoral representation towards parts of the country where the public sector is bigger, the private sector smaller, and voters are more likely to lean left on economic isses and right on social ones. Johnson is striving for a new equilibrium that will keep this coalition together – and “level up”.
Our concern is not only about whether a big set of NHS reforms would move policy in the wrong direction. We question whether the service needs another set of reforms “so big you can see it from outer space” – to borrow a phrase originally applied to those Lansley changes.
Which is why we call as our final witness none other than David Cameron – certainly older, doubtless wiser. The Lansley reforms, he writes in his memoirs, “took up a lot of energy and missed the biggest targets we should have been aiming for, which was the costs of an ageing population and reforming social care”.