Thursday, 14 April 2011

Andrew Lansley, the NHS, the Lib Dems and the Coalition Agreement.

Andrew Lansley’s NHS reforms have become something of a noose hanging around the Coalition’s neck. The Lib Dems had made their displeasure with the NHS reforms known for quite some time, with the grassroots notably voting against them at the party’s spring conference. The party leadership took this as a signal to start fighting against them full pelt, with crescendo being reached with Norman Lamb, Clegg’s chief policy adviser and former Lib Dem health bod said to be fighting Lansley ‘to the death’ in the wake of his statement that he would resign with impressive success. It is not yet quite clear what the endpoint of the NHS reforms will be but I think it is a safe bet that Lansley’s current proposals are dead in the water, and will be overhauled considerably.

Perhaps an important, question, however, is ‘why this?’. Why not tuition fees, for example, or some other issue close to the Lib Dem’s heart? For the answer to this we must return to our old friend, the Coalition Agreement. Here is what the coalition agreement says regarding tuition fees (Pages 31-32):

We will await Lord Browne’s final report into higher education funding and will judge its proposals ... If the response of the Government to Lord Browne’s report is one that Liberal Democrats cannot accept, then arrangements will be made to enable Liberal Democrat MPs to abstain in any vote.”

There’s also some stuff about increasing social mobility, debt, part time students but the long and the short of it is “We’ll wait to see what Lord Browne says, we’ll adjust it slightly so we can make the Lib Dems happy, but tuition fees are going up. Any Lib Dem who doesn’t like it can abstain.” The truth is that everybody knew before the election that Lord Browne was going to recommend the tuition fee cap come off, the only question was to what extent the government, after the election, would water it down, but here’s what the section on the NHS (pages 22-24) says:

We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.”

Even Lansley admits that this is a massive reorganisation of the NHS, though ‘top-down’ may have some semantic arguments (considering the localising intent of the reforms one could argue it’s a ‘bottom up’ reorganisation, though this just sounds silly in my opinion). The language in this section of the coalition agreement is, frankly, bizarre considering that the agreement also promises to cut spending on administration by 1/3rd. One fails to see how you cut administration costs by that much WITHOUT reorganisation.

We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.”

This is the central point of the reform, so yes, they’re doing that, and whatever the final version of the reforms the Lib Dems will have agree to something along this line.

“We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT).”

This is nowhere to be seen in Lansley’s reforms. In fact the PCTs are being abolished as part of Lansley’s reforms.

And so on. Basically the point is that the Lib Dems read the coalition agreement segment on tuition fees and say ‘Well we agree to it in the coalition agreement, so I guess we have to go along with it.’ They look at Lansley’s healthcare reforms and they see Conservative Party policy that they agreed to but in a much more radical package and lacking certain things close to their hearts like elected representatives on PCTs. The thing Andrew Lansley seems to have forgotten is the nature of coalition and of the Coalition Agreement. The Coalition Agreement is a contract between two parties, two colleagues. It is not a 100% guide to government. For one thing it is only forty pages long, and sometimes things change and policies must be abandoned (something that is not restricted just to coalition agreements but also to party manifestoes when they reach government). When a part of the Coalition Agreement is abandoned or changed by mutual consent of the two parties, this is fine, but when arguments brew between parties the Coalition Agreement rules. The two parties have already agreed to this, and so they cannot worm out. I am a bit of a student of European politics, so I’ll tell you now that when a coalition collapses in, say, the Netherlands, the first question that is asked is ‘Which party wronged who?’ the answer is pretty much always the party that broke an old promise to its coalition partner.

For example, after the last Dutch government collapsed over a disagreement over Afghanistan, an election was called, the formerly dominant Christian Democrats came fourth, whereas the Labour Party, who they were seen as having betrayed, came within a seat of winning, indeed Labour had been languishing in the polls before they were seen as being wronged, heading towards their worst result ever, the Christian Democrat betrayal (if that was what it was) resulted in a doubling of Labour Party support in the polls almost overnight.

The point is that you don’t break promises unless both parties agree to it. Parties that break promises to each other tend to get screwed if one then withdraws from government over it. This is a rather odd form of politics, from a British point of view, because it is promises between parties, not, necessarily, to voters. However, the former colleagues use these betrayals to pass aspersions on a party’s trustworthiness in general and their capability to govern honestly, while promoting their own integrity.

We keep hearing that Andrew Lansley has been working on his NHS reforms for eight years. Perhaps that is the trouble. These proposals do not betray a Lib Dem influence; they look, to me, largely like Conservative Party policy without Lib Dem input. Lansley strikes me as having an incredible mind for policy. He was David Cameron’s boss at the Conservative Research Department, but he also strikes me as someone who is rather in love with his own proposals, and as someone who has trouble explaining why his proposals are good. The most enlightening piece I have read on the reforms has been this in Prospect Magazine from December last year (Shadow Health Minister John Healey’s rebuttal is also worth looking at), but Prospect is a magazine for policy nerds, the type of people who read white papers for fun. Lansley’s reforms miss on the Lib Dem factor but he is also seemingly incapable of translating them from policy nerd into English. As I say, he strikes me as someone who is in love with his own proposals too. It would have been advisable for Norman Lamb to work together with him on the policy, crafting something more clearly based on the Coalition Agreement. We would have probably avoided the fireworks we have ended up, and seen something the Lib Dems could more easily deal with, but Lansley apparently refused to have Lamb appointed to his department after the election. Perhaps compromise is what Lansley feared, but refusing to compromise has led to this whole debacle. Let this be a lesson to coalition governments, present and future: you cannot ride rough shod over your partners without their agreement, you cannot backtrack on prior promises unilaterally and you have to communicate with each other.

Whatever the worthiness of his reforms Andrew Lansley has succeeded in gifting the Lib Dems a big demonstration of clear yellow water between coalition partners where they can paint themselves as the defenders of the NHS just prior to local elections. He has also weakened his own position in government which will come back to bite him as the reforms are redrafted with Lib Dem input and undermined the Conservative Party’s credibility on the NHS, a key plank of the Cameron project. If David Cameron has any sense he will make sure this never happens again.

And for politicos out there: keep the coalition agreement close, it remains the most accurate blueprint for the next four years.

1 comment:

  1. Nice analysis.

    I like that you've noticed the pledge to "cut spending on administration by 1/3rd", few seems to realise that this is the source of the debacle.

    Before the election Lansley never said he would abolish PCTs. Indeed, in all of the policy documents he has said he would retain them, indeed, those documents often refers to PCTs and SHAs and says that they will be retained "to prevent organisational upheaval". I suspect his idea was (and possibly still is) to replicate the Practice Based Commissioning that happens in Cumbria across the country. This model relies on a slimmed down PCT providing support for the GPs. The problem is that third.

    Many parts of the Bill can be found in Conservative health policy documents: HealthWatch, value based pricing, neutering NICE, GP commissioning. But abolishing SHAs and PCTs is nowhere, neither is there a pledge to cut admin by a third. It was a rash pledge made apparently sometime near the end of 2009.

    The problem is that Lansley has no control over Foundation Trusts (half of hospitals at the time of the election and more now) and no control over GPs. So where was he going to get that cut from? I am sure someone in the Dept of Health said to him as soon as he got there "Well, minister, the only management you have control over is this department and its outshoots, the SHAs and PCTs. If you are going to save one third of admin, the only place is in these three: DH, SHAs, PCTs" Lansley is moving much of the Dept to the National Commissioning Board, and he's made some sackings, but he still needs them to do his work. That leaves the SHAs and PCTs.

    Basically Clarke is right. Lansley is being hung out to dry, but it is on a policy that he never created in the first place.