My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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“Our NHS will be much like what we have today.” – David Cameron 16/05/2011

Filed Under (Conservative party, Health and Social Care Bill) by Paul on 31-05-2011

Last week Whitehall was awash with rumours about the policy deals that had been completed with their resulting amendments to the redrafted Health and Social Care Bill. Parliament too was full of rumours about the political changes that had been completed in order to get the Bill through (or alternatively kill it off).

Others are better placed to blog about this gossip, what I want to do this week is to try and work out two political and two policy issues.

Today, using the quote at the head of this post as a starting point, I want to try and work out why the Prime Minister’s health reform programme that began with a Maoist cry for revolution only 10 months ago has now been reduced to the limited ambition expressed a few days ago that craves that at the end of the process “Our NHS will be much like what we have today.”

Tomorrow I want to try and help the Government think through what its narrative for NHS reform might look like going forward after its pause for a bit of a think.

On Thursday to show how the policy that flows from the Government’s narrative has to demonstrate how it will provide much better value for money for the NHS in a few years’ time.

And on Friday to argue how the necessary policy of integration can be driven much harder within the likely reform package that will emerge.

My opening quote is from David Cameron’s answer to a question on May 16th when he made his latest declaration of love for the NHS in a speech. It will be a bit shocking to many people in the NHS who have suffered the confusion of the past year. It will raise the question in many people’s mind that if this is the only ambition the Prime Minister has for NHS reform, why has he spent the last 10 months launching such a rapid and thoroughgoing set of changes?

One consistent theme of the last year has been the Prime Minister saying that Tony Blair did not reform the NHS quickly or thoroughly enough, and that he, David Cameron, will move speedier and further.

But now the total ambition of all of this change is that “Our NHS will be much like what we have today.” Having had a quick scan through Tony Blair’s speeches I can’t find one that had such a poverty of ambition for NHS reform.

Many people who have been busy applying for their own or other’s jobs in the NHS will want to know why he can’t make up his mind about this. Surely he knows whether he wants to change the NHS a lot or that he doesn’t want to change it very much? Which is it to be?

I think the problem goes much deeper than the Prime Minister being unable to make up his mind. As I tried to work out in a series of posts a year ago, just after they came to power, this is a structural problem for the post-Thatcher Conservative Party.

(And in very different ways there is exactly the same sort of problem for the Liberal Democrat and the Labour Party on the reform of public services)

The useful thing about keeping an archive in this blog is that you can re-examine different parts of the history of a problem.

Let’s go back to August 2009. With less than a year to go before the general election a Conservative Euro MP went across to join in the Republican attack upon the NHS. At the time the Republicans were claiming that the NHS had death committees where bureaucrats decided that they could not afford care for old ladies and would pull the switch on them and leave them to die. The Conservative Euro MP joined this jolly bunch and said that the NHS was an anachronism.

David Cameron acted swiftly and withdrew the whip from the offender, but at the same time there were other surveys of Conservative candidates that demonstrated their lack of affinity for the NHS. At the time I wrote that every dinner party I went to would at some point during the evening feature a couple of stories about NHS care. (This is partly a consequence of my age and of the ageing relatives of the people I know).  Most evenings’ stories would contain some fantastically good points and some very bad points, but the phrase that David Cameron uses – ‘our NHS’ – feels apposite for these discussions. There were worries, anxieties, pride and affection.

I am not saying that that isn’t true for Conservative MPs, but it is not so completely a part of their culture. So although they know it’s very important to their constituents,  their feel for it is not the same. Knowing an institution as a part of your culture means that you have a better understanding of the enormity of the task of reform.

In May 2010 I explored the two very powerful and contradictory themes in modern post Thatcherite conservatism. The modern Conservative party very strongly believes in the efficacy of markets. Again they are not alone in this but as a political force, as a group of MPs, many of them will have experienced the importance of markets in their personal lives by making money out of them. As well-off consumers the market treats them well.

Their lives provide a lot of evidence that they believe that the application of market mechanisms leads to improvement in people lives. They gauge that belief against one that mainly believes that the public sector is bureaucratic and inefficient and treats the people that use it badly.

Moral critics of this Conservative position are wrong if they believe that the Conservative Party itself – or through its allies – wants to make money out of these markets. It’s not the money but what they expect to be the better economic and social outcomes that matter most to them.

(That is not so say that they are daft enough to believe that all markets in all places at all times do that. They have much too much experience of different forms of regulation to think that. But generally they will believe that markets will create better public services)

So by the late 1980s and 90s, as Margaret Thatcher’s liberated markets ripped through the nation, many modern Conservatives could see very great improvements.

The problem was that the improvements came at a cost. Corner shops, bank branches, high street stores and then post offices and job centres all closed because they weren’t economic any more. In a market they were not sustainable. Many market towns and villages represented by these same Conservatives had their hearts ripped out by the market forces that the Conservatives had unleashed.

But these same Conservatives, as the name suggests, really want to conserve sets of social relationships and institutions. They love the continuity that exists in many parts of the country. This is a genuine powerful part of what makes modern Conservatism work. They love the continuity of institutions over time.

So they do believe passionately in the radical transformative outcomes of markets and believe that much more of our society will be a better place if the writ of markets ran much faster through much more of society.

And they do passionately believe in the importance of “Conserving” social relationships and institutions which form the bedrock of how one generation passes on history and continuity to the next.

Of course when you put it like this the contradiction is obvious. But for most modern Conservatives these two conflicting passions do not appear at the same time. It is also the case that whilst I think both are important to every Conservative MP, some love markets more and some love conserving more. But they all love both.

So last summer was the time for change. The Government luxuriated in thinking of itself as Maoist and not being able to walk past an institution without wanting to radically change it. They planned the unleashing of change in institution after institution.

By July 2010 it was the turn of the NHS. The foreword of the White Paper had clear ambition. And the drive for very radical change was clear.

“We aim to create the largest social enterprise sector in the world

Monitor will become an economic regulator, to promote effective and efficient providers of health and care, to promote competition, regulate prices and safeguard the continuity of services.

This is a challenging and far-reaching set of reforms, which will drive cultural changes in the NHS.”

Then, over the autumn, there was that odd three months of silence lasting from September to December. On September 14th I commented on the lack of a narrative about why they were doing all this They were silent for most of the autumn, but insofar as there was any answer it was the importance of radicalism in their approach.

In December, just before the Bill was published, there had been a minor hiccup. The Government became anxious about whether this would work and instead of asking people outside the Government about that, they asked their own ideologists whether the reforms were coherent. The people they asked were in charge of radical change and therefore found the reforms were radical and coherent and should go ahead.

From that date onward the PM came out arguing for the reforms and has done so ever since.

From January until April, recognising that the Government had not established a rationale for doing any of these things, those opposed to change started to attack the reforms forcibly. Their attack on the Government focussed on the importance of stability for the NHS and the danger of involving private sector organisations in delivering NHS care.

It’s not that support ebbed away over this period. The vast majority of the country didn’t know what all of these changes were about, and the majority of the Government’s own MPs didn’t really know why all this was happening. (Even in May one opinion poll had 75% of electors not understanding what the reforms were about). Everyone knows that the Government must have its reasons for doing these things, and if it won’t share them with us, then we will look at what other explanations there are from the opponents to reform.

Most opponents had organised around the word ‘risky’ to describe the reforms, frequently with an adjective like ‘extremely’ put in front of it.

At the end of March the Prime Minister, having moved on from when he first entered no 10 when he wanted to be chair of the Government not Chief Executive, decided that he needed to have both a policy unit and a much bigger political communications unit.

At this time – for the first time – the Prime Minister appointed a health adviser. But at the time a much more important new appointee was the political strategist Andrew Cooper.

The Spectator in late May (and with much more insight into a Conservative No 10 than I) takes up the story from March,

“The most alarming example of Cameron’s dangerous complacency is in NHS reform. The Prime Minister personally launched the plans earlier this year, and the legislation easily passed its first and second reading in the House of Commons. But having come so far, he has now ordered a ‘pause’ to the coalition’s reforms and is promising ‘substantial’ changes to them.

What makes Cameron’s decision to back away from the reforms all the more alarming is that he only recently seemed so up for the fight. When in March, the British Medical Association criticised the reforms, he dismissed this as the predictable whining of just another trade union. His aides reassured people that unlike the forest sell-off and several other minor questions, the PM was not for turning on this issue. But less than a month later, the Prime Minister was, in his most emollient tone, launching a ‘listening exercise’ with the aim of appeasing the BMA and other interest groups. The Prime Minister had blinked.

But Cameron’s change of heart on health is not an isolated incident. It is part of a general pattern of Cameron giving up on public service reform. In the eyes of the reformers, there are two villains behind Cameron’s change of pace, Andrew Cooper and the Liberal Democrats.

Cooper is the pollster who has been hired as the Prime Minister’s director of political strategy. His polls are now king in Downing Street and he is the man with the Prime Minister’s ear. Cooper’s numbers are setting the agenda….. (Oddly enough, before Cooper’s arrival the Cameron operation didn’t do much market research at all.)….. ‘A political catastrophe’ was Cooper’s three-word verdict on the NHS reforms” (28/05/2011)

So for the first time, in March 2011, the Government started to look at the political outcomes of its radicalism in the NHS, and decided that it needed to have a bit of a think about what it’s doing.

This pause is launched with an infamous pamphlet which talked gushingly about how ‘we love the NHS’. This is followed up by further professions of undying love for the NHS.

And the Prime Minister starts to use the word “preciousness” about the NHS.

The use of the word preciousness is an example of how this Conservative Party has rediscovered its belief in conserving institutions. We need to preserve the NHS for future generations so that “Our NHS will be much like what we have today.”

In the words of last July’s  White Paper he wants a reform that is “a challenging and far-reaching set of reforms, which will drive cultural changes in the NHS.” yet in the words of his speech 9 months later comes a radical change – “ Our NHS will be much like what we have today.”

I am sure the Prime Minister believes in both of these ideas. His problem going forward after his bit of a think is that if he tries to maintain that he is doing both, his story will fall apart. He has to construct a narrative that explains how the reforms he is putting forward will solve the problem that he claims is big enough to need them.

A story which says he wants an end result of reform to be that Our NHS will be much like what we have today. will not be accomplished by a set of challenging and far-reaching set of reforms, which will drive cultural changes in the NHS.”

Modern Conservatism will have to decide whether it is for radically changing the NHS or conserving it.

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One Response to ““Our NHS will be much like what we have today.” – David Cameron 16/05/2011”


  1. […] famously on 16th May 2011 – as he was in the middle of his pause – he said that after the reform “Our NHS will be very much like it is […]

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