“I don’t think he’s coming back,” utters an aide as we watch the most talked-about cabinet minister of the moment move swiftly out of the room.
But she was right – he didn’t come back. Given the furore that has surrounded health secretary Andrew Lansley and his NHS reforms, it’s not surprising he’s not overly anxious to answer questions on how he is going to rescue both the situation and his credibility.
Five minutes before his sudden departure, he had been denying vociferously that the break inserted into the passage of his bill – it will now only probably reach the report stage in mid-June – is a response to the opposition, from several quarters, to its contents. The following week, after our interview, the listening exercise was formally launched.
“What we’ve been hearing, with a single exception, points to a fundamental agreement with the bill,” Lansley says, rejecting any suggestion that there is widespread division over his plans. He continues: “I think people, on balance, broadly support the general practice-led commission and clinical engagement in commissioning.”
When asked whether he accepts that there has been a failure of communication on the message of the reforms, Lansley responds with an emphatic “no”, before proceeding to put forward his opinion that the British Medical Association’s (BMA) opposition to his reforms was premeditated. “The BMA did this before the election. The ‘Keep the NHS public’ was a BMA campaign before the election, and they’ve just carried it on.”
The one exception that he identifies, in his view of the broadly consensual reception his bill has received, is that of the BMA and the trade unions. Lansley says they are against the idea of “any qualified provider”, under which the private sector would be able to bid to provide NHS services. He is dismissive of their view saying, “Basically, it’s a trade union monopoly thing.”
Lansley has more problems than trade union discontent, however. His own party is less than fully supportive. Many of the Conservative MPs we spoke to about the NHS reforms admitted that they had been unclear on exactly what the reforms were and how the details of the bill would work.
One was quick to stand by Lansley in his response to the BMA – if somewhat more blunt: “You just want to tell the trade unions to piss off.” But most are more reticent. There is not an ideological problem for Conservative MPs on changing the NHS but they do recognise the political difficulties it has caused. They are also experiencing two different responses at constituency level. GPs are often keen to take on the extra responsibility, but members of the public are worried. “People are unsure about the movement of power for two reasons. They think their GP is a muppet and don’t want them to have an more power at all, or they love their GP and don’t want their role to change,” says one who represents a marginal urban seat. Even his supporters are cautious. The NHS reforms are in such danger that an MP with professional experience of a primary care trusts (PCTs) can only “hope it will turn out alright”.
The ‘pause’ in the bill’s progress was a serious challenge to Lansley’s vision of an NHS driven by GP-led commissioning. Having spent years painstakingly resurrecting his party’s reputation as its defenders, David Cameron could not allow the opposition to Lansley’s reforms to gain any more momentum and undo all his good work on changing the Conservatives into “the party of the NHS”. The Cameron project must be perceived to as friendly to the NHS.
Nick Clegg, propelled by criticism of the reform from Lib Dems in both Houses of Parliament, has stated his party’s position bluntly: “This is also a question of making substantive changes to the legislation at the end of this two-month process.”
Lansley remains defiant and insists “the principles of the bill are not going to change” even with the pause. He continues:
The coherence and integrity of the bill is not going to be compromised.
"If we make amendments, we’ll make them for a good reason. Past experience tells me that if you do things that are reasonable, evidence-based and justified, even if they involves an amendment, then people accept it. Will any of them actually be u-turns? No, I don’t think they could be characterised as u-turns because they would quite self-evidently be consistent with the principles of the bill.”
He refuses to be drawn on exactly where, and how high up in government, the move for changes to his bill are coming from. Frustrated and annoyed by the suggestion that they emanate from anyone other than him, he says: “We don’t discuss who discusses what points with whom within government. We arrive at a collective decision.”
There has already been a shift in the language surrounding one of the reforms’ key principles – that of “any willing provider”, under which private companies will be eligible to bid to deliver health services as long as they can do so at NHS prices. This has now become known as “any qualified provider”, a change which, Lansley says, reflects the fact that the previous phrase was “misleading” and perhaps didn’t fully communicate the intention behind the provision. “It gave the impression that whoever wants to provide services can, but, in truth, you have to meet NHS quality standards, and obviously there will be an NHS price. Qualification, quality, is actually at the heart of this process.”
As much as this subtle shift in presentation might indicate a willingness to accept change, Lansley is also being extremely careful not to admit that this process of reflection and improvement suggests that the original bill is lacking in anyway, or to commit to any specific changes at this stage. He says: “If people have legitimate concerns, and we can provide reassurance by looking at the structure of the legislation, then we will do so.”
The motion passed at the Lib Dem spring conference, charging MPs to urge Lansley to think again on the reforms raised the potential for a coalition split. Lib Dem MPs such as Andrew George are openly critical and Norman Lamb, the former Lib Dem health spokesman who was overlooked by Lansley for a position in the health department, has warned he could quit his advisory position to Nick Clegg over it. It was in part to stifle the possibility of a coalition-splitting rebellion in the Commons that Lansley and Cameron were accompanied by Nick Clegg at their launch of the NHS ‘listening exercise’ at a hospital in Surrey.
While Cameron and Lansley’s statements were startlingly similar in content – both pledged earnestly “to pause, to listen, to reflect and to improve” the bill – Clegg emphasised the greater role for local authorities that the bill provides. This was the biggest contribution that the Lib Dems made to the bill upon entering the coalition, and the weight that the deputy prime minister gave to it in his statement clearly signalled an appeal to his own party to back a piece of legislation that could ensure the continued stability of the coalition.
To say that Lansley is invested personally in the future of NHS is an understatement. Appointed to the shadow health brief in 2004 by Michael Howard, Lansley has been preparing for this moment for upwards of six years. As early as 2008, David Cameron announced on the Today programme that were he to be elected prime minister at the next election, Lansley would become his health secretary.
There can be no doubt about Lansley’s command of his brief, and his commitment to delivering reform. Even his Labour opponent admits no one in the House of Commons knows more about the NHS than Andrew Lansley.
These reforms are Lansley’s personal project. To understand how they were arrived at, and what their fate might be over the coming weeks and months, there is only one place to look – at the man behind them.
Lansley had been known as one of the great survivors of the Conservative Party, proving himself adaptable enough to re-emerge as a moderniser in the early 2000s. The health secretary’s nickname among shadow cabinet colleagues was “the permanent secretary”, a reference to his time in the civil service and the traits he is thought to have retained from his days on the other side of the desk. It reflects his colleagues’ faith in his abilities to master detail and retain information, but is also an early indicator of a perception that has grown in recent months, that he lacks the communication skills to deliver successfully such a pivotal package of reform.
“I’m perfectly willing to own up to a fault – maybe I do spend too much of my time with the NHS and too little trying to sell the politics,” Lansley said in a television interview shortly after the announcement that the bill was to be delayed. It’s the closest he’s come to an admission that his communication strategy is partly responsible for the way they have been received.
One key failing has been allowing the idea that these reforms have been sprung upon on an unsuspecting NHS and public. Policy Exchange director Neil O’Brien says: “As shadow health secretary Lansley consistently called for GPs to be given the power to hold patients’ budgets and commission care on their behalf. The Conservative election manifesto clearly sets out the party’s approach to reforming the NHS. However, there have been concerns, notably from large sections of the media, that the Conservatives did not have a defined set of ideas on the NHS, which goes a long way in explaining why there is a perception that these reforms have been plucked from thin air.”
According to a former colleague of Lansley this communication problem stems from the man himself, rather than from any conscious decision on his part. Interestingly, when he was director of the Conservative Research Department during the successful 1992 election campaign, a young Cameron, Steve Hilton and Ed Llewellyn were on his staff. Lansley was their boss. Now, they’re the Downing Street trio who are attempting to reshape the way the NHS reforms have been sold to the public.
“Andrew is the backroom boy who served as adviser for so long, and who has now come out into the limelight,” says a former CCHQ staffer who worked with the health secretary. “I don’t know if he has the skills to be the front man. David Cameron appears on the chat shows, not Andrew Lansley.”
This isn’t to say that he is not at home with his portfolio: “When you see him on visits to hospitals, he’s fantastic with people one-on-one, talking about the health service. But when he’s trying to communicate more broadly, it just doesn’t work for him.”
It has been suggested that this problem stems partly from Lansley’s reluctance to draw on his personal experiences of the NHS to give his reforms some context. He’s had a connection with the NHS his whole life – his father worked in an NHS pathology lab for 30 years, and Lansley’s first wife was a GP who successfully helped him get a second diagnosis for a stroke he suffered at the age of 35. As his former colleague puts it:
“I don’t know why he doesn’t use his family more often. He was married to a GP and now he’s married again, he’s got older and younger children, but he’s just not willing to talk about them at all, and show he’s got a personal connection to the issue. People get scared of change to something like the NHS.”
Not only is the NHS a generally emotive subject, but also the speed at which the reforms arrived has been presented as vital to their success. Lansley’s white paper was published fewer than 60 days after the coalition government was formed. In fact, the pace at which the proposals for change have progressed is a major source of concern.
Policy Exchange’s recent report on GP commissioning backed Lansley’s claim that there is widespread support from GPs across the country for the coalition’s health reforms. But it said the speeds of reforms is causing concern. Director Neil O’Brien says: “The bill states that all PCTs would be abolished by 2013 and responsibility for commissioning treatment to patients would be transferred directly to GPs. The findings of our report showed that while some of the pilot GP consortia schemes were ready to take on commissioning responsibilities in two years’ time, many were not.”
He points out that a large number of these pilot consortia were set up in 2006, highlighting that it will take more than two years for GPs to be prepared to take on extra responsibilities such as advising cancer patients on the best form of treatment. He adds: “If the coalition does not slow down the pace of the transition, there is a danger that the new consortia end up doing exactly the same job as the PCTs in everything but name.”
The health select committee, chaired by former Conservative health secretary Stephen Dorrell, has not expressed outright opposition to the reforms. However, in a recent report into the impact of GP-led commissioning, the speed was one of the major reservations highlighted.
Dorrell told us that the rapidity at which the reforms have emerged has only compounded people’s fears: “Familiar fears on the NHS are re-establishing themselves – with different names on the outside. There’s a divorce between politics and policy. You must evolve a position over time.”
More stealth is required to reform the NHS successfully than has so far been exhibited, the former health secretary believes. The high-profile way in which the reforms have been conducted has only given opposition the chance to develop.
“The NHS is more sensitive than many other policy areas,” Dorrell says. “My personal view is that if you change something on the NHS, don’t draw attention to it unless you’ve done it already. If you create lots of attention on reform, you’re giving people the chance to oppose it, rather than getting on and doing it.”
When we put this concern about the pace of change to Lansley himself, he’s quick to brush it off: “Well, I was talking to someone the other day, a very senior local authority figure, who said he did have a problem with the speed of it, that we weren’t proceeding fast enough. He thinks local authorities are ready to take a greater responsibility in public health sooner than we are planning that they should in 2013 – but be that as it may.”
In fact, although we have now entered a legislative hiatus in the progress of the reforms, out in the field the implementation of the new GP consortia and public health strategy has already begun. This is a major point of pride, and a source of comfort, for Lansley, who clearly hopes to be able to refute future criticism by pointing to the success of already-existing examples of the new structure.
As he says: “Around 90 per cent of local authorities volunteered to be early implementers of the health and wellbeing pods. At the moment, there are 177 pathfinder GP consortia.” This has exceeded even his expectations, he explains. “From my point of view, we are ahead of where we thought we would be at this moment, because more GP consortia have come forward to pilot the commissioning.”
However, the BMA has a very different account of this pattern of early uptake of the reforms. It characterises it as GPs being realistic and attempting to do the best by their patients under the new regime, rather than overtly expressing support for Lansley’s plans. As one GP and BMA council member said: “GPs are very practical people; they will try to make it work for the sake of their patients. So it’s about GPs thinking that the changes are going to come, and looking at how they can make the best of them.”
Some of the most vocal opposition to the reforms has come from within Lansley’s own party. Dr Sarah Wollaston, Tory MP for Totnes, former GP and member of the health select committee, hasn’t minced her words in expressing her concerns. Several months ago, she was equating Lansley’s management restructuring with “someone lobbing a grenade into primary care trusts”, and her language has, if anything, become stronger since.
However, cross-government communication has really worked in neutralising Wollaston, and with great efficiency. As a former GP, she has become a prominent member of the select committee and a popular media pundit. But a last-minute visit to her constituency by junior DEFRA minister Richard Benyon unfortunately kept her from the launch of the committee’s latest report into GP consortia.
Once the bill is debated again, the local and devolved elections and the AV referendum will have taken place. The Lib Dems will have suffered heavy losses at local level and there will be further discussion about their role in the coalition, fearing what might happen at future elections. Despite speculation about the security of his own position in the cabinet, Lansley wants to continue the fight on his bill.
The listening exercise will have to overcome a massive parliamentary obstacle too once it is re-introduced. As former Conservative health secretary Stephen Dorrell says, it isn’t the Commons about which the government is worried: “The Health and Social Care Bill will probably get through the House of Commons in its current state, but it wouldn’t get through the Lords.”
As Andrew Lansley tacitly admits, the communication and politics of his reforms haven’t been handled particularly well:
It’s an evolution. What part of it isn’t?
The tragedy for Lansley personally is that he has failed to cast the reforms in this light.
He says: “What people are frightened by is change and what people see is the security of the hierarchy of management. We are all very clear that if you are going to transfer greater responsibility for commissioning and delivering to front line organisations with more autonomy, then you’ve got to disempower the hierarchy and tiers of management. If you are going to give more authority to local authorities, which we are, you can’t keep all the authority within the tiers of management that exist.”
Change had to happen, then. Many of coalition MPs are in full agreement that change is not an inherently bad thing for the NHS. Lansley claims: “The reforms are not revolutionary. You can see the direct line from past experiences and changes to what is now being put forward.” Perhaps the health secretary’s great problem is that he simply failed to explain his great project for the NHS.