Editorial Thursday 12 July 2012: Book review - 'Never Again?' by Nicholas Timmins

'Never Again?’ by Nicholas Timmins

Institute For Government / Kings Fund 2012

This tightly written, fast-paced biography of the 2012 Health And Social Care Act by Nick Timmins (also author of the seminal ‘The Five Giants’ and until recently public policy editor of the Financial Times) is very good indeed.

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Click here for details of BMA: “Resign, Lansley! But fix our pension deal first” - Is SOS Lansley a misunderstood genius channelling Schopenhauer?, the new issue of subscription-based Health Policy Intelligence.

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So far, so unsurprising: Nick is among the unmissable writers and thinkers on public policy. He has a long frame of reference, great contacts and an ability to relate to context dispassionately and without jargon. His writing is elegant, understated and witty - exemplified by the wise, wry title ‘Never Again?’

The book opens with the context-setting Kenneth Clarke ‘Working For Patients’ reforms that introduced the purchaser-provider split to the NHS in the early 1990s.

It also offers a detailed and sympathetic account of the two key players: the odd couple of the Act’s main author Health Secretary Andrew Lansley (who gave an interview) and they key implementer NHS chief executive and NHS Commissioning Board CE-designate Sir David Nicholson (who does not seem to have done so).

‘Never Again?’ observes that much of the 2012 Act builds on aspects of New Labour reforms. Although the purchaser-provider split was killed off in 1997, fulfilling a manifesto pledge, it was gradually reintroduced in the wake of 2000’s ‘The NHS Plan’ and the cash taps being turned on. (A key if oft-forgotten reason for New Labour’s slow early public policy progress was the Blair-Brown decision to leave the previous Conservative administration in economic charge for their first two years in office, by sticking to Ken Clarke’s spending plans.)

The considerable shadow of Tony Blair hangs over the philosophy of the reforms, too. Famously, Mr Blair’s autobiography revealed his regrets at having failed to go ‘further, faster’ on reform. No policywatcher would level that accusation at liberating Mr Lansley.

The book also confirms from several sources the accuracy of comments by Michael Portillo on BBC TV’s ‘This Week’ that it had been Conservative strategy to keep the scope and scale of the NHS reforms deliberately under the radar pre-election. Indeed it quotes Mr Cameron’s pre-election promise to “immediately stop the proposed closures of vital local services”.

The role of George Osborne in this strategy may not alter the currently negative outlook on the chancellor’s political stock: the book reports that “when Lansley protested that ‘he was not being allowed to set out his stall and that might lead to trouble’, he was over-ruled”.

Fascinatingly, it reports that leaders of NHS Alliance and the National Association of Primary Care – the two groups most supportive of Mr Lansley’s original conception of GP commissioning – as saying that while involved in discussions, they were unaware or unclear about key details of Mr Lansley’s plans.

Timmins locates one root of the Bill’s troubles in the ‘programme for government’ created after the Coalition Agreement. Senior Lib Dems believed the NHS was to be an area of stability. Government head of communications Matt Tee reports that the NHS didn’t feature on a Cabinet Office list of contentious issues. And there was no specialist health adviser: “Oliver Letwin, the Tories’ overall policy chief, did understand Lansley’s plan, but at a somewhat high level”.

Tee called the result “a fudge between the Tories and Lib Dems, which sort of made both feel okay. But it wasn’t really designed by either of them”. A DH official adds that Lansley “did see it in draft and he was fighting back and saying this is completely nuts. He fought back and didn’t win. There wasn’t basically a discussion”.

Any public policy reform must be built on three main pillars: economics, politics and communications. The tough economic background to these reforms hails from the global recession that followed the sub-prime property market collapse and associated demise of Lehman Brothers. With large financial and service sectors, the UK was always going to be hard-hit.

‘Never Again?’ outlines unsparingly how ineptly the politics of the reforms were handled. Observers of policy and politics infrequently agree, but formed a broad consensus that the communication of the case for these reforms struggled to rise above the appalling. The book quotes legendary health minister Simon Burns “You cannot encapsulate in one or two sentences the main thrust of this”: a quote so good it appears three times.

Much of the blame for both falls on Mr Lansley, who said to Gavin Esler on BBC Newsnight “I’m not in this for the politics; I’m in this for the NHS”, and to nurses at RCN Congress “I’m sorry if what I’m trying to do hasn’t communicated itself”.

The book rightly notes the Health Secretary’s “genuine attachment to the NHS”, and contextualises his relationship with David Cameron and George Osborne from their time working for him at Conservative Central Office. Despite this, Mr Lansley was briefed against by Number 10, and his reforms attacked by both the Conservative Home website and his political hero Lord Tebbit.

Yet Mr Lansley got much of what he wanted in his original Bill, with relatively minor and often rhetorical dilutions – GP commissioning became clinical commissioning; Monitor’s promoting competition became preventing anti-competitive behaviour. David Cameron reassured his own backbenchers that the pre-pause problems were issues of “presentation, not substance”. Nick Clegg reportedly told Lansley ther pause was needed “because you have put the ideological cart before the political horse”.

Why did so little change in the pause? In part, the books concludes, because of Mr Lansley’s extreme single-mindedness and certainty that his plans are absolutely right (in their interview, he asked Timmins “what’s not to understand?”).

Events also fell Mr Lansley’s way, crucially with the lack of any cutting edge among Lib Dem opponents of the Bill. And he rightly identifies the extreme unction administered in the Bill’s post-pause progress through the Lords by the beautifully-mannered Earl Howe.

Timmins rightly points out that “without the Liberal Democrats, (it) would have looked very different. It would almost certainly have involved less immediate structural upheaval … and almost paradoxically, without the Liberal Democrats, there would have been much less fertile ground within government on which opponents could grow the seeds of their dissent”.

I would love to hear his views on whether and how the legacy of the Act will divide the coalitions within each Coalition party: One Nation Tories and the dry tendency; likewise Orange Book social democrats and classical liberals.

Will the Act work? Rightly, Timmins concludes that only time will tell – and warns that the inevitable financial issues facing the NHS with no real-terms funding growth will be politically conflated with any negative impact of the Act, real or perceived. He draws out ten lessons from the passage of the Act, and offers his view that NHS reform will not be the Coalition’s ‘poll tax’ issue.

The book concludes with the thought that, should these reforms succeed and deliver NHS structural stability, Mr Lansley may become “an unlikely and somewhat awkward hero of public service reform”. Should they fail, the purchaser-provider split will have failed to deliver for the fifth or sixth time in 20 years.

The stakes are high. The jury is out.

The book is essential reading.