1 2 Published by: The King’s Fund Institute for Government 11–13 Cavendish Square 2 Carlton Gardens London W1G 0AN London SW1Y 5AA Tel: 020 7307 2400 Tel: 020 7747 0400 Fax: 020 7307 2801 Fax: 020 7766 0700 www.kingsfund.org.uk www.instituteforgovernment.org.uk © The King’s Fund and the Institute for Government 2012 First published 2012 by the Institute for Government The King’s Fund charity registration number: 1126980 Institute for Government charity registration number: 1123926 All rights reserved, including the right of reproduction in whole or in part in any form ISBN: 978 1 85717 643 8 A catalogue record for this publication is available from the British Library Hard copies are available from: The King’s Fund 11–13 Cavendish Square London W1G 0AN Tel: 020 7307 2568 Fax: 020 7307 2801 Email: [email protected] www.kingsfund.org.uk/publications Printed in the UK by Hobbs the Printers PDF can be downloaded (free) from The King’s Fund website and from the Institute for Government website The King’s Fund seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas. The Institute for Government is an independent charity helping to improve government effectiveness. We work with all the main political parties in Westminster and with senior civil servants in Whitehall, providing evidence based advice that draws on best practice from around the world. Synopsis ‘Never Again?’ tells the story of how and why the Health and Social Care Act 2012 – by far the most controversial piece of NHS legislation in more than two decades – became law. It relates the story of a political thriller – from the legislation’s origins 20 years ago, through the development of the 2010 white paper “Liberating the NHS” and the resultant bill; a bill so controversial that it appeared at times as though the Government might lose it. It does so from the view point of opponents and critics, but also from the point of view of the man with whom this legislation is uniquely identified – the current health secretary. On the way, it explains just what it was that Andrew Lansley was trying to do and why the bill was so vast and controversial. It details the events that shaped it – most notably the Coalition’s now partly forgotten “programme for government”. That document – cooked up purely by the politicians in Downing Street over 12 days immediately after the election in May 2010 – radically reshaped the health secretary’s plans. Sorting out the “disaster” in the “programme for government” turned what would have been merely a large shift of power and accountability within the NHS into a huge structural upheaval: one that allowed the reforms to be written up as the biggest reorganisation in the 63-year history of the NHS; and one that could become this Government’s “poll tax”. ‘Never Again?’, in particular, is a story of coalition government and coalition policy making. The act is uniquely identified with Andrew Lansley, but without the Liberal Democrats it would have been a very different bill. At the same time, without the Liberal Democrats, there would have been much less fertile ground within government for opponents to sow the seeds of their dissent. Without them, it would have undergone fewer amendments. And yet, in another twist to the coalition tale, without Liberal Democrat votes the legislation would not have passed. ‘Never Again?’ recounts: • how Andrew Lansley was banned from talking about the detail of his plans ahead of the election • what happened at the meeting that called “the pause” on the legislation • how Sir David Nicholson came to be appointed chief executive designate of the NHS Commissioning Board • how Andy Burnham revived the opposition to the bill • and how the Coalition finessed its legislation through the House of Lords. 5 ‘Never Again?’ also seeks to draw some early lessons from what is widely regarded as a “car crash” of both politics and policy making. But at the same time it explains why the health secretary believes that never again – or at least for the foreseeable future – will the NHS need to undergo another big structural change and raises the possibility that Andrew Lansley could yet emerge as something of a hero of public sector reform. About the author Nicholas Timmins is a senior fellow at the Institute for Government and the King’s Fund. Between 1996 and 2011 he was public policy editor of the Financial Times. He is also a visiting professor in social policy at the London School of Economics, and at King’s College, London in public management. He is a senior associate of the Nuffield Trust. Frontispiece design by Jon Twin at The Bowyer Press [email protected]. 6 Foreword Never Again? The first two years of coalition government in the UK have been dominated by the economy, deficit reduction – and the reform of the NHS. The first two were well trailed before the election. But few expected an argument about “top-down reorganisation” of the NHS to dominate the political debate. The Health and Social Care Act merits attention as a case study of policy making and coalition government. It is also an important milestone in the history of NHS reform – not least since one of the reasons for Andrew Lansley’s full frontal approach was to put the NHS changes onto a more permanent basis – where they could only be undone by legislation, not secretary of state fiat. That is why Institute for Government and the King’s Fund asked Nicholas Timmins to produce a “first draft of history”. Here Nick tells the story to date – judgements, as Nick says, will need to wait for the outcome of the reforms. The Institute for Government’s work on policy making suggests that good policy has to get the right blend of technocracy and politics. Even at this juncture, it is clear that the NHS reforms have required the Government to expend a huge amount of political capital to get the bill through and lose public confidence on an issue that was crucial to David Cameron’s detoxification of the Conservative party. Whether or not the act succeeds in its objectives, there was a failure to get the politics right. The case study looks at how that came about. It brings out important lessons on policy making in opposition, preparation for government, on the dangers of rushing out policy announcements during the first hectic period of transition into office and the particular challenges of coalition government, which are all themes that the Institute has studied. It also sheds important light on the inner workings of the Government in a key policy area – on the role of Number 10, the Treasury and the Centre. The separate Institute for Government commentary goes into those wider lessons in greater depth. The King’s Fund warned early on that the reforms were going “too far, too fast”. Nick’s account of the process of reforms confirms that the Government was in a rush, motivated by a concern to avoid New Labour’s self-confessed mistake of failing to be bold in its first term. In the event, speed was at the expense of engagement, leading to a rising crescendo of opposition that led the prime minister to introduce a pause in the passage of the bill through parliament in order to listen and respond to the concerns of stakeholders. How far the subsequent amendments to the bill amount to substantial changes or cosmetic revisions remains a matter of debate. What is clear is that the pace of reform continues unabated, creating major challenges as the NHS seeks to achieve efficiency savings on a level unprecedented in its history. The impact of the reforms will depend as much on how they are implemented as on the provisions of the Health and Social Care Act. In the detailed debate on the wording of the legislation, the importance of implementation was neglected and yet history shows the many opportunities for the intentions of radical reformers to be altered and distorted as 7 they are carried into action. The NHS has proved to be remarkably resilient in the face of efforts by successive governments to make major changes in how it is run and there is no reason to expect things to be different this time round. Lessons about policy making need to be married with lessons about implementation, and The King’s Fund will be playing its part in analysing the impact during the remainder of this parliament. Peter Riddell Chris Ham 8 “The history that happens underneath our noses ought to be the clearest, and yet it is the most deliquescent.” Julian Barnes “If one day subsequent generations find you cannot make commissioning work, then we have been barking up the wrong tree for the last 20 years.” Kenneth Clarke, former Conservative health secretary, speaking at 60th anniversary of the NHS in 2008 “Labour secretaries of state have got away with introducing private sector providers into the NHS on a scale which would have led the Labour Party onto the streets in demonstration if a Conservative government had ever tried it. In the late 1980s I would have said it is politically impossible to do what we are now doing. I strongly approve.” Ibid1 “You cannot encapsulate in one or two sentences the main thrust of this.” Simon Burns, minister of state for health, March 20122 1 Rejuvenate or retire? View of the NHS at 60, Nuffield Trust, 2008 2 The Report, BBC Radio 4, 22 March 2012 9 Prologue In the best tradition of the digested novel, the story of the Health and Social Care Act 2012 – which proved to be something of a political thriller – is well known.