Editorial Wednesday 23 May 2012: The NHS pillar of Conservative electoral strategy

The Conservative Home website offers a useful insight into parts of the Tory policymaking world.

It is interesting to remember that as recently as February, CH editor Tim Montgomerie was among the voices calling for the Health And Social Care Bill to be dropped, with the headline "The unnecessary and unpopular NHS Bill could cost the Conservatives the next election".

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Today, Paul Goodman publishes a five-point list of Conservative values, said to be Prime Minister David Cameron's strategy for winning in 2015.

Number Three of these is "Winning support on the NHS.  Never forget the stress that Mr Cameron put in opposition, second only to restoring the party's reputation for economic competence, on trying to establish that the NHS would be 'safe in his hands'."

This is interesting stuff. It has long been obvious that the NHS is going to be a battleground at the 2015 general election.

'Battleground' isn't a warming metaphor, but it is an accurate one. Battlegrounds don't tend to be wonderful places to be, either during the battle or in its aftermath. They are initially noisy and dangerous, and then devastated and polluted ... and still dangerous.

The NHS is continuing to deliver remarkably good performance on the very national targets which Mr Cameron planned to stop ("With their endless targets and reorganisations, Labour have tried to run the NHS like a machine ... those targets you hate, they're gone").

This is an excellent achievement, and anyone who genuinely supports the NHS should celebrate it and the staff who are achieving it.

We should be properly cautious about the effect of The Nicholson Challenge - £4 billion a year in efficiency and productivity gains lies ahead in each of the remaining financial years. A cumulative effect will at some point show itself.

More to the point, former PCT and SHA staff are still left desperately short of clarity about their future in commissioning support services. If there is not much of one, PCT clusters and CCGs are looking at big redundancy costs.

There is a new system being built. The NHS Commissioning Board's Chairman Mal apparently told the recent NICE conference that the process was like "changing a wheel on a bicycle while cycling downhill". It's an admirable metaphor.

What is interesting in the aftermath of the Health Bill furore is that there appears to be an growing consensus that clinically-led commissioning is in fact the way to go.

There remains massive polarisation about whether the Bill - the Act - was required, and significant concern about the Any Qualified Provider policy and Monitor's in-built conflict of interest between being an FT overseer and an economic regulator. Policy for addressing commissioner-side failure in the new system struggles to rise to the level of incoherence, as we have repeatedly said.

Average voters
Elections are win and lost among average voters on average incomes, not policy geeks.

The average voter knows that there has been a big row over Conservative-led changes in the NHS, and may think the Lib Dems had something to do with altering them. She or he knows that Labour were against the reforms, but probably hasn't got a clue what Labour planned to do instead. (This means things for each party's storytelling.)

The average voter also filters this noise over NHS politics through the signal of their experience of the NHS - personal, family, friends and anecdotal.

The average voter is probably going to be feeling worse-off as some lose their child benefit, see fuel prices remain high, experience stagnant or perhaps falling property prices and see banks remain unwilling to lend.

And the NHS matters to the average voter (who, on an average salary, cannot afford private medical insurance).

Even if they are averagely young and averagely healthy, the NHS remains a source of national pride. The latest YouGov poll for Prospect magazine is not yet online, but reveals that 57% of respondents listed the NHS as the second best thing about Britain today. (The poll was commissioned to mark Queen Elizabeth II's 60 years on the throne, and ranks 'Monarchy / Queen' third on 51%. The countryside was first, with 65%.)

The more things change ...
The NHS will try to do its best to make these changes work, because the vast majority of its staff are in it for the patient care. But these are not easy changes, and The Nicholson Challenge is not an easy challenge.

Oh, and there is provider reconfiguration ahead. Also known as shutting parts of local hospitals. This was known but ducked back when there was easy money; it is un-duckable now there isn't. It will make for interesting, and very local, politics.

Clinical commissioning is going to deliver some great some things in some areas. In some areas, it will keep things about the same. In some areas, it will fail spectacularly due to incompetence, greed or bad luck.

Nobody knows how the NHS in England will split by commissioner competence. We will, though. Soon. The hotly contested nature of the introduction of the reforms will mean that the pro- and anti- camps are both likely to overstate their cases significantly.

Battleground propaganda. Can't wait.