So what happened to the reform levers developed between 2001-2010?

…or how did the Conservative Party fall out of love with NHS reform?

Until 2010 New Labour was engaged in a very consistent argument about its reform levers in the NHS. Some of this was about the technical nature of the reforms – but much of it was at an ideological level. Arguments for changing an institution as important the NHS must contain a moral direction (ideology) not just a technical one. This is because much of the argument for the status quo – and against reform – contain their own morality. And when a technical argument meets a moral one the technical argument loses. It’s also absurd for politicians not to engage in politics. Politics is what good politicians do best, and Alan Milburn, John Reid, and Tony Blair were very good at developing and deploying political arguments.

(A brief aside.

Consider for a moment the phrase – ‘having an argument’. This has two key requirements. One is that it is essential, when about to deploy an argument, to possess one before you start. You might be surprised to learn how frequently people try and have an argument when they don’t in fact possess one – that is unless if you’ve been in some pubs late in the day when people often don’t have anything to say, but still want an argument.

The second is that when you deploy an argument you should do so successfully. Argument is essentially a dialogue. You say something – someone refutes it (usually quite cleverly). At this point you need to follow up with an additional argument – which they will also refute. Your cue to strengthen your argument. THAT is what having an argument means.

If you imagine that your opening argument will be sufficient for you to win then you probably don’t know how to have one. Arguments are for the long haul. Tony Blair would always say impatiently, “Yes but what is your FOURTH question?)

From 2001-2010 we had nearly ten years of continuous rows. On and on.And, given the importance of the NHS, so they should.

Much of the debate was with sections of the NHS but some of it was with those on the left who characterised our whole approach to NHS reform as being neo-liberal. The argument – which does have some power – was that we were incorporating into the major public services of the NHS experiences and incentives that are classically part of the lexicon of capitalist experiences and incentives. For example, those who argued that ‘patient choice’ was neo-liberal felt that choice was something lauded strongly by capitalism and essentially a part of the consumer capitalist society. Our counter-argument was that choice was essentially a part of a modern society and telling people where they had to go essentially feudal – sort of making the same point as the opposition. Choice was a key part of modern society, modern society was capitalism, therefore choice was capitalism.

BUT the finishing point of this argument was surely how could telling people which hospital they could go to be progressive? And the only argument they could come back with was that we – the people who made your choices for you – knew more about the whole picture than you did. And – for the few who had read the right books – “Do you really think that feudalism is better than capitalism – because Marx did not”

Ergo, our argument – being based on modern society was based upon experiences within a capitalist society.

My main query in this post is if that were the case (and, as I have said, much of it was) then why did a Conservative Government roll back most of these reforms over the next 13 years? Why did the Conservatives stop payment by results, stop patient choice. Why was the use of a smaller private sector and why did Foundation Trust numbers not expand?

There are two answers – Lansley’s ‘Proposals’ and Tory incapability of winning the argument for NHS reform.

In 2010 Andrew Lansley famously turned up at the Department of Health to become its Secretary of State with a White Paper outlining his reforms virtually already written. By July it was complete, and the Bill was in the Queen’s speech that autumn. Equally famously David Cameron had said that he wanted the Prime Minister to be Chair of the Board and not to double guess his Cabinet members. There was no health policy SPAD in number 10. The Bill ploughed on until in April 2012 Andrew Lansley was asked to Number 10 to announce, with the Prime Minister, a “pause” in the passage of the Bill. David Cameron then appointed a health adviser (I remember a breakfast with him just before he went in to accept). But by then the chaos of the Lansley reforms (“Such a big reform you could see it from outer space – as David Nicholson said) was beginning to be appreciated. The government amended its own legislation so that it could not achieve what it had set out to do (A big ’hurrah’ for many).

The outcome gave dog’s breakfasts a very bad name.

And the Tories were scarred for a decade by their NHS reforms.

Which brings us to the second point. Lansley’s arguments were not strong enough (see above, you say something – I say something – you say something etc.). He always seemed hurt when people disagreed with him. But as I said earlier, arguments are a long haul. The Tories withdrew into being the status quo party on the NHS. (Relatively less financial support – and less reform).

So, as you may have noticed within the last few months, Rishi Sunak has (re)introduced patient choice. (Erm… It was there before 2010). If it needed introduction, where had it been for the previous decade??

Steve Barclay has (re)introduced payment by results to try and get Trusts who do more work to be paid for it. Again, a good idea, but if you have to introduce it where was it between 2010-2023?

That lost decade is one when reforms could have helped the NHS as much as more money.

And the bookend (successful) party manifestos of those 20 years? In 2001 the Labour Manifesto focussed on public service and had 78 mentions of the word reform.

The successful 2019 Conservative Manifesto had just 10.

It will be interesting to see the appetite for change in the two main parties’ next manifestos.

(Editor’s note – Pauls’ thoughts on the Lansley Reforms can also be found in the archive). The piece he wrote after Jeremy Hunt took over the role of Secretary of State is particularly relevant)