One year on from its adoption, Rudolf Klein argues that only one thing is certain about the Health and Social Care Act: it will be a vote loser for all parties in the coalition government. Predictions of disaster will probably not come to pass, nor will the changes be likely to make the NHS more effective and efficient. The Act may be the most dramatic example of a policy fiasco in the history of the coalition government, but it is not the only one.
With little celebration and much hand wringing about the dire prospects ahead, the coalition government’s most contentious measure came into force on April 1st. Conceptually, there may have been little new in the Health and Social Care Act. Its driving themes of choice, competition and devolution to the front line were familiar in the history of the National Health Service (NHS). But organisationally it was radical. At a time when the NHS faced a bleak fiscal future, having to find savings of £20 billion out of a total budget of £100 billion, its institutional chess board was overturned. NHS England, as the NHS Commissioning Board has entitled itself, now runs the service with the Secretary of State distanced (in theory) from day to day operations. Clinical Commissioning Groups, coalitions of general practitioners, are in charge of buying care for their patients. And so on. Much amended during its progress through Parliament, the legislation had failed to win many friends or to satisfy the critics.
In all probability, the predictions of disaster – the warnings that the changes mean the privatisation and disintegration of the NHS – will be confounded. That has happened before: the prophets of doom are a familiar cast. It is even conceivable, though less likely, that the changes will eventually make the NHS more effective and efficient. Only one prediction can be made with total confidence. Come the 2015 General Election, the NHS will be a certain vote loser for all parties in the Coalition Government. This was always likely, given fiscal pressures. But these have been compounded by discontent within the NHS: incentives to dramatise inadequacies have been reinforced. While any benefits from the changes can at best be long term, the political costs are immediate.
So we come to a central puzzle in all this. Why did the Coalition Government embark on what was, predictably from the start, such a politically self-harming course? There were no powerful interests pressing for such a comprehensive package of change, to balance the opposition of the British Medical Association and other professional bodies (conspiracy theories about the private sector waiting to pick the flesh off the bones of the NHS aside). Both partners in the Coalition had strongly dismissed any intention of yet another top down re-organisation of the NHS in the run up to the 2010 election. There was no hint in the coalition agreement of the impending switch in policy. The organisationally disruptive and comprehensive package introduced by Andrew Lansley, the new Health Secretary, caught everyone by surprise.
For once, a Cleopatra’s nose explanation seems apposite. If anyone else but Lansley had become Health secretary, things would have been different. He brought with him the tablets of stone that he had carved as Conservative spokesman on health in opposition. Anyone who had read them should, in fact, not have been surprised by the White Paper published by Lansley within months of taking office. If even those of us who had read them were astonished by the White Paper, it was because we could not believe that the coalition government would be reckless enough to give him free rein. So the search for an explanation has to move beyond Cleopatra’s nose, to ask why the Cabinet sonambulated towards political disaster.
A variety of reasons have been given. In his study of the legislation, Nick Timmins puts much emphasis at the lack of political advisers with relevant expertise of the NHS and awareness of the political risks being run, particularly at No.10. Another explanation may well be that the new, inexperienced Cabinet Ministers were more anxious to book a place in the legislative programme for themselves than to risk retaliation by scrutinising the proposals of colleagues too closely: a phenomenon which will be all too familiar to anyone who has ever sat on an academic committee.
In any case, as I have already suggested, there was little to frighten anyone in the general themes of the proposed legislation. It was familiar stuff. The devil, it turned out, lay in the detail. It was no accident that opposition to the Lansley proposals was slow to mobilise and only gathered full force when the White Paper’s bland prose had been translated into a Parliamentary Bill. Until the cabinet papers become available, we can’t be certain about this, but it seems unlikely that Lansley’s proposals got the kind of detailed, critical scrutiny that Nye Bevan’s draft legislation got in 1945.
But if Ministers lacked political nose, what about the civil servants? One of their roles has always been to warn ministers about the risks involved in proposed courses of action. What happened in this case? The Timmins study, drawing on interviews with those involved, concludes that the civil servants at the Department of Health did warn Lansley about the risks he was running, though the evidence is not wholly conclusive. What we cannot know is the tone of voice used: just how strongly did the civil servants try to hold Lansley back from his plunge into the political whirlpool? What we do know, however, is that the culture of the Department of Health is a can-do one. reputations are made not by writing sophisticated policy papers but by implementing unsophisticated policies, to exaggerate only a little.
This raises a larger point about the policy making process. The case of the NHS may be the most dramatic example of a policy fiasco in the history of the coalition Government but it is not the only one. There are plenty of others, from the proposed auction of national forests to the miscalculation of the cost of student loans. What this suggests is that the civil service, far from frustrating ministerial policy making ambitions, may be too accommodating of them. Decades of criticism, and emphasis on policy delivery rather than policy formulation, may have made civil servants all too ready to show their mettle by loyally carrying out policies that could well have done with more time in the Whitehall oven.
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Rudolf Klein, FBA, is Emeritus Professor of Social policy at Bath University. His books include studies of accountability, consumer representation and performance measurement. The seventh, updated edition of his The New Politics of the NHS will be published later this year.