The new Secretary of State must develop a narrative to argue for the Coalition Government’s NHS reform. What might this look like? (1)
Many commentators have argued that the task of the new Secretary of State is a near impossible one (Jeremy Hunt’s in-tray will wipe that smile off his face) as Polly Toynbee put it in the Guardian on Thursday). They have argued that the fact he has been given his new job because he is a good communicator means he is bound to fail because the story he has to tell will inevitably be one of failure.
I don’t think that is necessarily true. I do think that it’s a very difficult story to develop and to tell, but being new he has a number of strong points.
The first being the one for which his predecessor was sacked.
For the past 29 months the Government has not had a narrative about its reforms. We still don’t know what was so wrong with the NHS that it needed such big reform and we still don’t know what the reforms are meant to achieve or how the NHS will be better. That has allowed the opponents of the reforms to say anything, anything at all, and get away with it. Because the Government has had no argument, the price to be paid for anyone making any claim anything at all – about the reforms has been nothing.
People have been able to say, without any fear of getting into an argument with the Government, that the aim of the reforms is to create a US style health system. They can do so without any fear of being made to look ridiculous because the Government has failed to produce a robust argument against this view.
NHS reforms have been, in hunting terms, a real ˜sitting duck” – in the general direction of which anyone can fire with impunity. You could have claimed there was a secret plan to sell the NHS to men from Mars and know that there would be no political cost and no rejoinder from the Government.
The new Secretary of State has a ministerial team full of people who can make an argument who will find that if they start doing so, their opponents will find it a real change from the last two years. They will have people arguing with them in ways that they haven’t previously.
The second reason why developing and deploying an argument will be easier than expected, is that now, in 2012, the reforms are nothing like they were when they were first proposed in 2010. Andrew Lansley found this really difficult because he wanted his reforms from 2010 to still be there as the whole rationale for the coalition. He wanted his reforms to have somehow survived the two years of political change that his original ideas went through.
Over this summer we could see that he couldn’t come to terms with the reality that his reforms had been transformed by his own failure to find a narrative for his original ideas. Throughout the summer he continued to claim that the main outcome of his reform was to give local GPs power over commissioning services for their patients – when in fact the final Health and Social Care Act centralised power as much as decentralising it.
Given that the new team are not so attached to the original reforms as the prior Secretary of State they have the somewhat easier task of developing a narrative about the reality of the reforms and not just one part of them. It is vital when developing and deploying a narrative to do so by touching all of the different aspects of the reforms and not just one of them.
Thirdly the new team can take a very different attitude to the political part that their reforms play in what has been a long sweep of NHS reform. Andrew Lansley, for reasons of personality and politics, did not accept this historical perspective and could never develop a narrative which placed his reforms in the context of 30 years of necessary NHS reform.
For reasons of personality and politics he had to say that real NHS reform began with him in May 2010 and that it was therefore a new story that he was beginning.
I have commented on several occasions on how differently Michael Gove has demonstrated that what he is doing continues much of the work that went on before.
This will be difficult for Jeremy Hunt too. He also has a need to personally and politically claim things for himself and his political party. He tried and failed to do this with the Olympics. But once he calmed down and recognised that the hard yards in creating a successful Olympics had been won by the risk-taking and hard work of a previous Government, he was able talk about a successful Olympics developed by all.
A personality and a personal politics that needs to claim NHS reform for this Government alone would inevitably lead to this Government alone having to defend something quite weird.
So there are three things that could make this new start easier for the Secretary of State in developing a deploying a narrative.
First, it will be a new experience for critics of the Government’s NHS reform to be met with an argument. For some months they will find this very difficult and unnerving (and will probably claim it is unfair).
Second, given we now know what the NHS reforms are, it is possible to develop a narrative around their reality rather than Andrew Lansley’s fantasy of what he believed they should have been.
Third, they can claim that these reforms are part of a much longer sweep of history of NHS reform rather than a recent Tory plot.
How to start doing this anew?
Let’s start with a difficult truth about the reality of where the reforms have landed.
I know Andrew Lansley always wanted his reforms to be about the decentralisation of power – away from him as Secretary of State – but in reality now, in the autumn of 2012, they are also about a very considerable centralisation of power.
It was difficult for his predecessor to claim that the centralising part of the reforms were his because he so clearly had them forced upon him, but Jeremy Hunt has no such problem. His job is to explain the reforms as they are and not as he might want them to be.
At first sight this looks like a difficult task. To create a story which explains that the end result of the reforms has BOTH a centralising and decentralising set of outcomes.
When I say, in my day-to-day job of explaining all this to the NHS, that this is the outcome of the Government reforms people generally react by giggling at how daft that is. Why can’t the Government make up its mind about whether it wants to centralise or decentralise power? Isn’t it just stupid to try and achieve such opposing things?
Then we have a discussion about the NHS. About how it is paid for out of national taxation and how the public expect, since it is being paid for nationally, that there should be a national offer and not just a local offer. Most people quickly agree that there should be a strengthening of the national offer.
Over the last 10 years this has been a natural argument for the left in all of the arguments about NHS reform. They felt that this is the core meaning of the NHS.
A service free at the point of need with equal national access for all and paid for out of national taxation.
This is a great national principle – one in which I believe.
But the problem for the NHS has been that it has never delivered on the practice of the principle.
In nearly every aspect of the NHS there are very considerable variations between its different parts. For all of its 60 years the NHS has not delivered national equality of access, let alone output or outcome.
Those conservatives that want to keep close control of the NHS have still been able to argue that they are protecting it to provide an equal service for all. But this Government has not come back at them to point out that while this may be a great principle it is not applied in practice.
It is true the NHS needs to be radically reformed to strengthen it and one of the end results of the Government reforms has been to increase centralisation.
So one part of the narrative could be,
“We think the principle of national equality of NHS provision is a really great principle. In fact we believe in it so much that we thought we might continue the reforms of our predecessors to put it much more into practice. At the moment, when you look at the outcomes around cancer, or the take up of a drug, or hip replacement surgery etc. etc., there are shocking variations in practice. It is clear that the current NHS does not carry out this principle of equal access for all members of the public. That is why our reforms have built on the previous Government’s strengthening of NICE and their inclusion of the national right to NICE approved drugs in the National Health Service constitution, but we will be expecting all NHS local health care to be commissioned within the guidelines set out by our new National Commissioning Board.”
The other outcome of the Government reforms is to increase decentralisation by giving power to local GPs. The end result of this is much more circumscribed than its original intention, but there will be more GPs involved in commissioning local commissioning than before.
Again, in discussion, people get this. Most recognise that in an organisation that has one million interactions every 36 hours it is not possible to have each one of those consultations run from the centre – and in fact no one wants these interactions to be run from the centre. The public recognise that they want their nurse and their doctor to be able to treat them as a person and not as a part of a nationally controlled service. The public don’t just want a local NHS; they want an individual, personalised NHS. They demand, and they are right to demand because it is true, to be treated as being a very different person from their neighbour.
So they want the NHS to be much more personal – with a lot less feeling that nurses and doctors are being told what to do from above.
Again, in discussion with people in the NHS it is recognised that this is what the public wants – even if they don’t actually get it.
When discussing this with NHS people occasionally someone might say, “But doesn’t that mean the public want opposing things? If they both want a national service and a personal service – isn’t that just impossible?”.
Of course the answer is that since the public pay for the NHS and since they want both of these things (and they do very strongly) then that is what the NHS should give them.
And THAT is the reason for reforming the NHS.
It is perfectly reasonable for the public to expect a national service which provides a personal experience. It’s what happens in other services and industries and it’s what NHS reform needs to achieve.
That is why the NHS cannot be controlled from the centre but also why aspects of the Government’s narrative on localisation can fit into reform as well as aspects of its narrative on centralisation.
Over the next few weeks we will see whether the new Secretary of State and his team is more capable of this than his predecessor.
I will continue to try to demonstrate how robust arguments for reform can be developed.