Liberal Democrats in coalition: health Overview: health policy under the coalition Peter Sloman hen the coalition government was Paper which proposed to abolish Strategic Health Nick Clegg, David formed in May 2010, few observ- Authorities and Primary Care Trusts, transfer Cameron and Andrew Wers expected it to engage in radical NHS commissioning to GPs, and promote com- Lansley (Secretary of reform of the National Health Service. Health petition between providers. The resulting Health State for Health, 2012– featured less prominently in the 2010 general elec- and Social Care Act 2012 became one of the coa- 12) in February 2012 tion than in any other recent campaign, partly lition’s most controversial – and consequential – because New Labour’s investment programme measures. What role did the Liberal Democrats had improved public satisfaction with the NHS play in the Lansley reforms, and how far were and partly because the Conservatives worked Paul Burstow and Norman Lamb able to use their hard to neutralise the issue. The issue was hardly position at the Department of Health to achieve touched on in the coalition negotiations, and the liberal objectives? NHS section of the coalition agreement focused In the years before the coalition, it was not on the commitment to increase health spending in always easy to discern a distinctive Liberal Demo- real terms and ‘stop the top-down reorganisations crat vision for the health service. Under Charles of the NHS that have got in the way of patient Kennedy’s leadership, the party had stressed the care’. Within weeks, however, the new Health need for more investment in the NHS, greater Secretary Andrew Lansley had published a White autonomy for health professionals, and a bigger Journal of Liberal History 92 Autumn 2016 23 Liberal Democrats in coalition: health role for local councils: the Liberal Democrats thus coalition agreement, which had been hastily cob- Clegg initially opposed the Blair government’s plans for foun- bled together by Oliver Letwin and Danny Alex- dation hospitals and promised to introduce free ander from the two parties’ manifestos. During hailed the result- personal care for the elderly.1 However, David the first three months of 2011, however, a group Laws’ provocative chapter in The Orange Book – of Liberal Democrat activists led by the Charles ing Health and suggesting that the NHS should be turned into West, Evan Harris, and Shirley Williams began a continental-style social insurance system – to campaign against the bill on the grounds that it Social Care Bill opened up a debate on the merits of competition would fragment the NHS and allow cherry-pick- as an expression and choice which had not been resolved by 2010.2 ing by private providers. When the party’s spring After becoming leader, Nick Clegg waxed lyrical conference in Sheffield in March 2011 amended a of the coalition’s about the advantages of personal health budgets motion on the NHS to criticise Lansley’s ‘dam- and identified mental health services as a priority aging and unjustified market-based approach’, commitment for investment, but his vision of ‘a People’s Health Clegg backtracked and persuaded Cameron to Service … built on personal empowerment, local launch an independent review of the legislation.9 to localism and control, and fairness’ did not feature prominently During this two-month ‘pause’ Clegg and his col- in the party’s campaigning in the run-up to the leagues secured a number of changes to the bill, decentralisation. general election.3 The health section of the Lib- including an expanded role for Health and Well- eral Democrat manifesto – based on the report of being Boards and a redefinition of the duties of a working group chaired by Baroness Neuberger the health regulator, Monitor; and Liberal Demo- – proposed to halve the size of the Department crat peers obtained further amendments when the of Health, abolish Strategic Health Authorities bill went through the Lords. None of this, how- (SHAs), and replace Primary Care Trusts (PCTs) ever, seems to have allayed public concerns about with elected Local Health Boards in order to the disruption which the Lansley reforms caused, improve accountability and free up resources for or the prospect of creeping ‘privatisation’ of the frontline services.4 As supporters of the Lansley health service. Indeed, Charles West and other reforms pointed out, it also proposed that Local Liberal Democrat activists continued to campaign Health Boards should be free to commission ser- against the Act, though Shirley Williams was vices from ‘a range of different types of provider’; persuaded that the amendments had safeguarded but this was qualified by a promise to end ‘any the founding principles of the NHS. This led to a current bias in favour of private providers’, and sat major row at the 2012 spring conference.10 uneasily with the broader emphasis on integrating Burstow’s specific portfolio of social care was health and social care.5 more comfortable terrain for the Liberal Demo- When the coalition was formed, Nick Clegg crats within the coalition. Following a heated initially proposed Norman Lamb as Minister of controversy over Labour’s plans for a compul- State for Health, but Lamb’s appointment appears sory levy on estates to pay for social care in the to have been vetoed by Lansley.6 Clegg’s second run-up to the 2010 election, the Liberal Democrat choice was Paul Burstow, who had been party’s manifesto suggested ‘an independent commis- health spokesman during the 2001 parliament. sion … to develop proposals for long-term care In many ways, Burstow was a natural choice for of the elderly’, and Nick Clegg gained plaudits in the post, since his background as a former dep- the first leaders’ debate by calling for the parties uty leader of Sutton Council prepared him well to reach a consensus on the issue.11 In this field the for the care services brief. On the other hand, Liberal Democrat approach offered the path of Burstow’s focus on strengthening local govern- least resistance, and Burstow quickly appointed ment made him more receptive to Lansley’s vision a small commission chaired by the economist for the NHS than Lamb might have been. In his Andrew Dilnot to consider how far people should definitive study of the Lansley reforms,Never be required to pay for their own care. Dilnot’s Again?, Nicholas Timmins has pointed out that July 2011 report recommended that individu- Burstow’s involvement made the White Paper and als’ liability to contribute to care costs should be the Health and Social Care Bill more rather than capped at approximately £35,000 – a sum which less radical. In particular, Burstow was willing to could plausibly be covered by private insurance transfer commissioning to GPs because this made policies – and that the asset threshold for means- it possible to abolish PCTs and SHAs and to give tested assistance should be raised to £100,000.12 responsibility for public health to local govern- The Treasury seems to have balked at the cost of ment. Lansley also agreed to establish council- the proposals, which Dilnot estimated at £1.7 bil- led Health and Wellbeing Boards to coordinate lion, and though it eventually accepted the reform health and social care provision in each area.7 in principle it insisted on setting the cap at the Burstow seems have been broadly satisfied by higher level of £72,000.13 This cap was included in this deal, and Clegg initially hailed the result- the 2014 Care Act and was due to come into effect ing Health and Social Care Bill as an expres- in April 2016, but the new Conservative govern- sion of the coalition’s commitment to localism ment has postponed it until at least 2020.14 and decentralisation.8 It certainly offered a more Alongside funding reforms, the Care Act coherent synthesis of Conservative and Liberal established a new statutory framework for the Democrat ideas than the health section of the social care sector, which Richard Humphries 24 Journal of Liberal History 92 Autumn 2016 Liberal Democrats in coalition: health of the King’s Fund has called ‘the most compre- social care, but early research suggested that their hensive and ambitious overhaul of social care impact was ‘variable, and generally limited’.19 legislation since 1948’.15 This drew heavily on a Similarly, efforts to improve social care and men- three-year Law Commission review which had tal health services were badly undermined by been set up by the Brown government, but it also spending cuts in local government.20 included measures to safeguard elderly people Although Paul Burstow and Norman Lamb against abuse in response to the Francis Inquiry can have much to be proud of, then, the lesson of into failings at Stafford Hospital and to extend the coalition seems to be that voters are ultimately Care Quality Commission’s inspection regime to focused on the bigger picture. Participants in pre- the financial management of care homes follow- election focus groups organised by Lord Ashcroft, ing the collapse of Southern Cross. Paul Burstow for instance, thought the Liberal Democrats were chaired the joint parliamentary committee which marginally more ‘caring’ than the Conservatives scrutinised the draft bill after he returned to the but ‘were unable to identify a distinctive Liberal backbenches in September 2012, and it was piloted Democrat approach to the NHS’.21 Perhaps dis- into law in 2014 by his successor Norman Lamb. tinctiveness is too much to ask for, since health has Lamb’s appointment, together with David never been as central to Liberal Democrat cam- Laws’ return to government as schools minister, paigning as, say, education or the environment. suggested that Clegg wanted to make more politi- Nevertheless, regaining trust among doctors and Although Paul cal capital from health and education in the sec- other public-sector professionals will be vital if ond half of the parliament.