Health: Never Again? - The Institute for Government

150 Pages·2012·4.17 MB·English

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Synopsis
‘Never Again?’ tells the story of how and why the Health and Social Care Act 2012 – by far
the most controversial piece of NHS legislation in more than two decades – became law.
It relates the story of a political thriller – from the legislation’s origins 20 years ago, through
the development of the 2010 white paper “Liberating the NHS” and the resultant bill; a bill
so controversial that it appeared at times as though the Government might lose it.
It does so from the view point of opponents and critics, but also from the point of view of
the man with whom this legislation is uniquely identified – the current health secretary.
On the way, it explains just what it was that Andrew Lansley was trying to do and why the
bill was so vast and controversial.
It details the events that shaped it – most notably the Coalition’s now partly forgotten
“programme for government”. That document – cooked up purely by the politicians in
Downing Street over 12 days immediately after the election in May 2010 – radically
reshaped the health secretary’s plans.
Sorting out the “disaster” in the “programme for government” turned what would
have been merely a large shift of power and accountability within the NHS into a
huge structural upheaval: one that allowed the reforms to be written up as the biggest
reorganisation in the 63-year history of the NHS; and one that could become this
Government’s “poll tax”.
‘Never Again?’, in particular, is a story of coalition government and coalition policy making.
The act is uniquely identified with Andrew Lansley, but without the Liberal Democrats it
would have been a very different bill. At the same time, without the Liberal Democrats,
there would have been much less fertile ground within government for opponents to sow
the seeds of their dissent. Without them, it would have undergone fewer amendments. And
yet, in another twist to the coalition tale, without Liberal Democrat votes the legislation
would not have passed.
‘Never Again?’ recounts:
• how Andrew Lansley was banned from talking about the detail of his plans ahead
of the election
• what happened at the meeting that called “the pause” on the legislation
• how Sir David Nicholson came to be appointed chief executive designate of the
NHS Commissioning Board
• how Andy Burnham revived the opposition to the bill
• and how the Coalition finessed its legislation through the House of Lords.
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‘Never Again?’ also seeks to draw some early lessons from what is widely regarded as a
“car crash” of both politics and policy making. But at the same time it explains why the
health secretary believes that never again – or at least for the foreseeable future – will the
NHS need to undergo another big structural change and raises the possibility that Andrew
Lansley could yet emerge as something of a hero of public sector reform.
About the author
Nicholas Timmins is a senior fellow at the Institute for Government and the King’s Fund.
Between 1996 and 2011 he was public policy editor of the Financial Times. He is also a
visiting professor in social policy at the London School of Economics, and at King’s College,
London in public management. He is a senior associate of the Nuffield Trust.
Frontispiece design by Jon Twin at The Bowyer Press
[email protected].
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Foreword
Never Again?
The first two years of coalition government in the UK have been dominated by the
economy, deficit reduction – and the reform of the NHS. The first two were well trailed
before the election. But few expected an argument about “top-down reorganisation” of the
NHS to dominate the political debate.
The Health and Social Care Act merits attention as a case study of policy making and
coalition government. It is also an important milestone in the history of NHS reform –
not least since one of the reasons for Andrew Lansley’s full frontal approach was to put
the NHS changes onto a more permanent basis – where they could only be undone by
legislation, not secretary of state fiat. That is why Institute for Government and the King’s
Fund asked Nicholas Timmins to produce a “first draft of history”.
Here Nick tells the story to date – judgements, as Nick says, will need to wait for the
outcome of the reforms. The Institute for Government’s work on policy making suggests
that good policy has to get the right blend of technocracy and politics. Even at this
juncture, it is clear that the NHS reforms have required the Government to expend a huge
amount of political capital to get the bill through and lose public confidence on an issue
that was crucial to David Cameron’s detoxification of the Conservative party. Whether or
not the act succeeds in its objectives, there was a failure to get the politics right.
The case study looks at how that came about. It brings out important lessons on policy
making in opposition, preparation for government, on the dangers of rushing out policy
announcements during the first hectic period of transition into office and the particular
challenges of coalition government, which are all themes that the Institute has studied.
It also sheds important light on the inner workings of the Government in a key policy
area – on the role of Number 10, the Treasury and the Centre. The separate Institute for
Government commentary goes into those wider lessons in greater depth.
The King’s Fund warned early on that the reforms were going “too far, too fast”. Nick’s
account of the process of reforms confirms that the Government was in a rush, motivated
by a concern to avoid New Labour’s self-confessed mistake of failing to be bold in its first
term. In the event, speed was at the expense of engagement, leading to a rising crescendo
of opposition that led the prime minister to introduce a pause in the passage of the bill
through parliament in order to listen and respond to the concerns of stakeholders. How
far the subsequent amendments to the bill amount to substantial changes or cosmetic
revisions remains a matter of debate. What is clear is that the pace of reform continues
unabated, creating major challenges as the NHS seeks to achieve efficiency savings on a
level unprecedented in its history.
The impact of the reforms will depend as much on how they are implemented as on the
provisions of the Health and Social Care Act. In the detailed debate on the wording of the
legislation, the importance of implementation was neglected and yet history shows the
many opportunities for the intentions of radical reformers to be altered and distorted as
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they are carried into action. The NHS has proved to be remarkably resilient in the face of
efforts by successive governments to make major changes in how it is run and there is no
reason to expect things to be different this time round. Lessons about policy making need
to be married with lessons about implementation, and The King’s Fund will be playing its
part in analysing the impact during the remainder of this parliament.
Peter Riddell Chris Ham
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“The history that happens underneath our noses ought to be the
clearest, and yet it is the most deliquescent.”
Julian Barnes
“If one day subsequent generations find you cannot make
commissioning work, then we have been barking up the wrong tree
for the last 20 years.”
Kenneth Clarke, former Conservative health secretary, speaking at 60th anniversary
of the NHS in 2008
“Labour secretaries of state have got away with introducing private
sector providers into the NHS on a scale which would have led the
Labour Party onto the streets in demonstration if a Conservative
government had ever tried it. In the late 1980s I would have said
it is politically impossible to do what we are now doing. I strongly
approve.”
Ibid1
“You cannot encapsulate in one or two sentences the main thrust of
this.”
Simon Burns, minister of state for health, March 20122
1 Rejuvenate or retire? View of the NHS at 60, Nuffield Trust, 2008
2 The Report, BBC Radio 4, 22 March 2012
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Prologue
In the best tradition of the digested novel, the story of the Health and Social Care Act 2012
– which proved to be something of a political thriller – is well known. It can easily be told.
A man in a hurry who was part of a coalition government (that just weeks earlier had
promised the country “no more top-down reorganisations” of the National Health Service)
launched arguably the biggest restructuring it had seen in its 63-year history. He did so
without having told anyone what he was up to – at least as far as most of the public and
the staff of the NHS were concerned.
So great was the resistance – not least from the grass roots of one part of the coalition –
that the Government was forced into an unprecedented “pause” over its legislation. The
pause, however, failed to silence the critics. There were times when it looked like the bill
would be lost. In fact it got through. It did so, in part, thanks to the obduracy of a man with
a mission, whose big idea this was. It was passed, however, at enormous political cost.
Commentators from both the right and the left predicted that these reforms would prove
this government’s “poll tax” (the radical idea for a new form of local taxation that became
a key factor in the downfall of Margaret Thatcher) and that it could cost the Coalition the
next election.
The lessons are obvious: don’t do anything so radical to one of Britain’s best loved
institutions when the electorate and the staff do not believe that you told them about your
plans. And certainly don’t do it this way.
And all of the above is true, at least up to a point.
But the full story of how the Government got into what is widely seen as a “car crash” in
terms of both policy and politics is inevitably more complex than that. And the lessons to
be learned may not be just the obvious ones.
After all, this set of changes – whose roots go back more than 20 years, not just into the
history of the previous Labour government but that of the Conservative administration
before it – may work, in which case the lessons will be very different.
Either way, the story of how and why they happened is worth telling, not least because
it raises issues of interest to both the Institute for Government and the King’s Fund who
jointly commissioned this work.
Where did the ideas come from? Why were they such a surprise? Particularly when
they contained little or nothing that was new, save perhaps in degree? What does the
experience reveal about the preparations for government? The transition to it? And the
nature of policy making and its presentation?
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In particular what does it tell us about this Coalition government? For while the act came
to be seen as the property of essentially one man – the Conservative health secretary
Andrew Lansley – the package, without the Liberal Democrats, would have looked very
different.
It would almost certainly have involved less immediate structural upheaval. Without
Liberal Democrat votes, it is inconceivable that a minority Conservative government could
have got this bill through. But then again, without them it would have been a different
bill. Furthermore, and almost paradoxically, without the Liberal Democrats, there would
have been much less fertile ground within government on which opponents could grow the
seeds of their dissent.
David Donnison once remarked that social reform is a process, not an event – a kind of
drama.3 What follows, therefore, is a drama in five acts, with the sixth and most important
– implementation – yet to be written.
This introduction comes with two warnings. It opens with two chapters to set the scene
– scenes one and two – before Andrew Lansley gets involved and the story really takes off.
Readers are welcome to try skipping them. But without a little early graft to understand
the history, it is difficult to fully understand what the current health secretary was trying to
achieve.
The second warning is a related one. Given the length of this, there will be a temptation to
jump to Act Five to look at the still somewhat tentative lessons and conclusions. Readers
are, of course, welcome to do that. It might, however, be a little like watching only the last
scene of a Jacobean drama in which there are plenty of bodies lying around the stage – but
you get no real idea of how and why they got there, or why there is still at least some light
at the end of the tunnel.
As time goes by, far better accounts than this will be written of the near two-year
struggle to get Andrew Lansley’s mighty reform of the NHS on to the statute book. More
documents will become available. Many more people will feel free, both on and off the
record, to relate what happened and why.
History will also provide a judgement that right now is impossible: how far the act proves
a success, how far a failure; whether it will really transform the way the NHS functions,
for good or ill; or whether, as indeed is most likely, the most radical edges of this package
get knocked off in the same way that, intentionally or not, the impact of most previous
attempts at reform have been muted by both politicians and by the NHS itself. The service
has a distinct tendency to revert to type.
History will also demonstrate whether – as Andrew Lansley hopes and believes – this will
prove to be the last great structural reform of the NHS, at least for many years.
3 The Politics of Poverty, David Donnison, Martin Robertson 1982
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