Has politics or policy won on the NHS?

Good policy and good politics don’t always go hand in hand – do politicians act primarily on what they believe to be right, or what is right for their political position?

After the kicking the Lib Dems took in May’s elections Nick Clegg declared the NHS was his priority – he seemed to have decided this was the issue on which to define himself as different to his coalition partners, to prove the Liberal Democrats were still a political force with a different point of view. The Conservatives too needed to show they had listened to the concerns of the medical profession and patients. So did they choose politics over policy? 

For the Conservative leadership a listening exercise that really changes policy can cut both ways – it might look like you are listening and embracing that ‘new politics’ you talked about, or it might look like weakness and the flawed thinking that got you into the mess in the first place catching up with you.

They still don’t have a very good answer to the question of whether David Cameron really knew what Andrew Lansley’s plans for the NHS were before the election. If he did, and didn’t make it explicit in the election campaign was he hiding the truth? When the coalition agreement talked about Primary Care Trusts were they concealing the plan to scrap them, or did they not know?

Whatever the truth about that, once the NHS plan was revealed the Government clearly failed to do the political work required to support the policy. Conservatives admit they were surprised at the strength of opposition. The profession and the public had not been convinced GPs would know best how to spend the budget, or that private sector competition would drive either standards up or prices down.

The newspapers and political commentators were turning on the Government over it. So politically they had to call the pause. Initially they no doubt hoped this was mainly about convincing the sceptics rather than changing the plan, taking the argument to the public and doing the legwork they had failed to do before. But the Liberal Democrats seem to have had other ideas after their disastrous results in the local and Scottish elections.

Liberal Democrats want us to believe the NHS has now been saved by them from unbridled market forces, that a compromise has been found that meets the worries of hospital doctors as well as GP’s while still placing power in the hands of the professionals. This is the proof, they believe, of their real power in the coalition.

The Conservatives, despite some frustration, believe the direction of travel on reform has been firmly established. The regulator, Monitor, will concentrate on integration of new providers rather than competition (Lib Dem tick), but there will almost certainly be more private sector contracts in future to provide NHS services (Conservative tick). GPs will now not be forced to take control of commissioning by 2013 (Lib Dem tick) but it will probably happen in most places eventually, they believe (Conservative tick). And even though hospital doctors and the public will now be involved in the GP consortia (Lib Dem tick) it will be the primary care providers who hold the upper hand if they want to (Conservative tick).

So what kind of NHS will this create for us?  Well it could be a long way from what either side in the Coalition really want. The greatest irony could be that over the next couple of years a reform supposed to devolve power to doctors at local level could instead result in one of the biggest shifts of power to the centre ever seen – the new NHS Commissioning Board looks set to have immense power, overseeing all local commissioning and taking responsibility where consortia are not in place.

It appears that an area could find decisions about local services being taken hundreds of miles away by the NHS Commissioning Board. And there is still no shortage of people (especially Conservatives) who believe the real challenge on funding health has not been addressed and we will have to look at a social insurance model one day. So the eventual NHS and Social Care Bill at the end of this process is unlikely to settle policy for long.

The true political ramifications could also be hidden. The NHS was a key part of detoxifying the Conservative brand for David Cameron – and his team will believe that he has shown how much he really cares about it in how he’s handled the reform.

However, much of the pain in the health service at the moment comes not from Andrew Lansley’s reorganisation but from the £20billion of “efficiency savings” ordered by the last Labour Government. The Lansley plans – whatever you might think about them – would have potentially removed vast amounts of administration costs which get the NHS near that savings target. If it now fails to make those savings the NHS could need more money to avoid politically toxic cuts and winter beds crises. The Treasury could have to find money to plug an NHS black hole – money George Osborne probably hoped to have for some pre-election tax cuts.

Follow Krishnan on Twitter – @krishgm