What can Lib Dems learn from the NHS debacle?

The NHS is proving a political nightmare for the Lib Dems.  This reflects a failure to develop a clear vision for the service before the election.

The NHS is now a toxic issue for the Lib Dems.  This is not because the voters are turning against the party on the issue, as they did for student loans.  In the overheated rhetoric surrounding the issue there have been many claims that the public will abandon the party over this latest betrayal.  But the public judges parties on what actually happens to the NHS, not on the speculations of excited activists and commentators.  And so far as front line services are concerned, nothing much has changed, and probably not a huge amount will as a result of the reforms… a major difference with the student fees issue.

No, the damage is being wrought within the party’s activists and members, as this summary of blogs after the Gateshead Conference shows.  Many feel an acute sense of betrayal by the leadership, and a number have left the party; more may follow.  This weakness is being cleverly exploited by Labour; but they didn’t start it.  Lib Dem activists themselves have not required outside assistance.

The party is all over the place.  The outcome of the Gateshead conference last weekend (which I was unable to attend) merely added to the confusion.  The emergency motion to abandon the Bill was not called, the representatives voting for a compromise motion supported by Shirley Williams – but a key paragraph was taken out of this motion by a narrow vote, leaving it saying not much at all.  This has given rebels in parliament cover to break the whip, but not placed serious pressure on the leadership and those not inclined to rebel, who do not see it as a worthwhile expenditure of political capital in the coalition, compared to tax policy, say.

This confusion has deep roots.  What on earth do the Lib Dems want with the NHS?  There is no clarity whatsoever.  I can count four distinct factions.  Currently most the most vocal strand are social democrats (like Shirley Williams, a living saint to many members) – who want a strong, nationally controlled monopoly service, which is able to provide a uniform standard right through the country (England in this case – Scotland, Wales and Northern Ireland have been allowed to get away).  They are relaxed about centralisation, and indeed all the amendments made to the bill over the last year at their behest point to a highly centralised provision.  Next come the economic liberals, with whom the party leadership tend to sympathise.  While this group has not developed any clear vision, they like the idea of what economist John Kay calls “disciplined pluralism” – in other words preserving a choice of providers wherever possible, so long as they are properly accountable.  These people are very relaxed about whether the NHS uses direct employees, third sector organisations, or, indeed, private companies to deliver its service.  A third group consists of NHS insiders – who basically resist any change in practice if not in theory, and who mainly argue for allocating more taxpayer funding through existing structures, whatever they happen to be at the time.  This group was led by Dr Graham Winyard of Winchester (and a former NHS high-up), who has now left the party.  And lastly (because this group is now largely drowned out), we have community politicians.  These want to see much more devolution to local politicians, and a bigger role for local authorities in particular; this group is relaxed about the  “postcode lottery”, so long as it is balanced by postcode accountability.  This group is close to the heart of traditional post-War Liberalism, and closest to my personal views (in spite of my Social Democrat provenance).

The original Bill was essentially a product of the economic liberals and community politicians (amongst whom we should count Paul Burstow, the Lib Dem health minister) within the party, working with Tory Health Secretary Andrew Lansley, whose attitude is quite close to Lib Dem economic liberals.  The resistance was started up by NHS insiders like Graham Winyard, and quickly swept in social democrats.  This alliance overwhelmed the party leadership at last March’s Sheffield conference.  There followed the “pause” in the reforms, and a raft of amendments that took the reforms in a highly social democratic direction, leaving economic liberals and community politicians disenchanted but hoping something could be retrieved from the wreckage.  But then the NHS insiders dug their heels in, as one professional body after another advised killing the whole reform.  This fractured the whole process and left the party with a set of reforms that nobody is very keen on, and to which many are vehemently opposed.

The wider membership, and most activists, are pragmatists, who can’t be pigeon-holed into any of the four groups that have shaped the debate.  Their confusion and general scepticism is understandable .  But this reflects a vacuum at the party’s idealogical heart.  We can agree on liberal social values, internationalism and inclusiveness – but the party seems to have no settled views on how to run the state.

The party should not get too worked up about this of itself.  It shares this confusion with the other main political parties (just try to make sense of the Labour position), and I’m sure the minor parties too if they could ever be forced into making a stand.  All successful political parties are coalitions of one kind or another.  But the party failed to hammer out its own internal compromise before the election, in the way that Vince Cable managed to for tax policy.  Formation of policy at conference was too much a matter of seeking consensus.  There were some quite radical elements of official, conference approved policy (like abolishing Strategic Health Authorities), but little awareness amongst members of the implications of official policy.  The original Bill was probably quite a well crafted compromise between our official policy and Andrew Lansley’s ideas (Paul Burstow certainly thought so).  But as soon as the heat was applied, official Lib Dem policy counted for nothing – it had not been engrained on members’ and activists’ consciences.

So where next?  The first point is that Liberal Democrats must realise that they either hang together with the Tories, or else the two parties will be hung separately on the NHS.  The Tories will curb their privatising zeal; the Lib Dems need to stop being so destructive.  There is no future in the parties scoring points off each other on this issue -they both need to show that all the apocalyptic talk is hot air.  I expect this means that we’ll have to find some extra funding before 2015.

And Liberal Democrats need to forge their own vision for the NHS, hopefully in time for 2015.  In doing so each of the various interest groups will have to compromise.  The best way of doing this is to have some controversial debates and votes at conference – like we did with tax policy.  Much better to have the arguments before the policy is agreed than after we try to implement it.

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3 thoughts on “What can Lib Dems learn from the NHS debacle?”

  1. Thank you for this, I come to understand the Liberal position, but even after following this debate in the news, I am still very foggy. Could you point me in the right direction?

    What is the purpose of the new bill? One side seems to be saying that it is to make the NHS more efficient, the other to dismantle it. Is it considered a bad idea tactically or ideologically? What are the government hopes for the bill, and are their any chance of their hopes being realised?

    I believe these issues are complex and have been made more so by the many modifications it has suffered. It seems that many are gravely concerned over changing the NHS, but only the government is concerned with leaving it as it is. The news reports endless talking heads expressing worry and concern, and then wheels out Mr Cameron to express hope and resolve. But the issues have remained foggy. Is it true that the NHS doesn’t need fixing? If it does, and this bill won’t do the job, do the objecters have an alternative strategy?

    Too many questions, if you don’t have the time to answer them, can you point me to some articles?

    1. This is long and complicated issue, with most commentators having hidden agendas. I can’t think of any articles that give a good overview. But let me give you my personal take.

      First the background. Labour vastly expanded state expenditure on the NHS, while at the same time implementing substantial reforms in fits and starts. This involved firstly making hospitals more autonomous, being paid by the volume of work they undertook and expected to make their own way financially. Secondly they tried to impose a commissioning infrastructure on all services to set the shape of service provision, including diversifying the sources of provision (including the introduction of more private sector providers). This commissioning process was led by two levels of bureaucracy – regional Strategic Health Authorities, and district Primary Care Trusts (PCTs). This second stage of reform was in full process of being implemented when Labour lost power in 2010. Untouched by the reform process was a highly centralised accountability to the secretary of State.

      Why reform? There is felt to be a demographic crisis that is about engulf the service. The baby boom bulge is moving into an age where they will demand more services. Meanwhile the working population which provides the taxes that fund it looks likely to shrink. There is also a perception that all the extra money spent on the NHS has relatively little to show for it – though in fact public confidence in the service has greatly improved.

      The new government (mainly Andrew Lansley, who is a doctor) had serious issues with Labour’s commissioning reforms. They were seriously bureaucratic (a management consultant’s heaven), and they failed to involve clinicians properly (though not through lack of effort). They thought the whole structure was wrong headed and wanted to reform the process based on groups of GP practices that would be both less bureaucratic and force GPs to become more involved. Certain Tories were also keen to accelerate the introduction of private providers into the system. For Lib Dems the big problem was accountability, and so they designed in a number of checks and reporting lines to dilute the central control of the secretary of state and involve local authorities. The result was the first incarnation of the health bill.

      Workers in the NHS were horrified. This meant turning upside down all their efforts to develop commissioning under the PCTs and having to start all over again. Also latent concerns over the introduction of private sector providers emerged, though these would have applied to the Labour reforms as well. The first criticism was well grounded – and I think the government would surely have been better off adapting the previous PCT system and pushing it for another 5 years. The second criticism has some basis in that health reformers in both the current and previous government wanted to introduce more diversity of provision. It wasn’t so much a criticism of the Bill – but that the Bill was an opportunity to stop this process in its tracks.

      The recent modifications of the Bill have involved centralising more power and accountability to a National Commissioning Board that will (I think) be responsible for more than half the budget, and make the introduction of external providers more difficult, potentially prohibitively so. Various extra bureaucratic controls have been put in. Meanwhile the government under its executive powers has pressed ahead with the process of winding up PCTs and strategic health authorities while establishing prototype groups of GPs. The main case for pressing ahead with the Bill is that this process has been taken so far forward that we might as well finish it – and also that a lot of the local accountability provisions are worth hanging on to. Personally I think there will be a big gain in forcing GPs to be more accountable than the previous system was able to achieve – and the GP side of the NHS is a systemic weakness. But the end result does make one ask whether the whole process was worth starting.

  2. Thanks very much for this! It’s every bit as complicated as I feared, but I’m getting clearer.

    In my experience in IT, new management/IT provisions seem to be remarkably difficult to evaluate before they are actually in place – they prove to have both unexpected advantages and disadvantages. I wish these reforms the best of luck.

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