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The decision to press pause was right but, unless a stronger argument is found, it will be time to press stop and start afresh
Six weeks after pressing the pause button on health reform, David Cameron yesterday hinted where he was heading with a Beatlian ring. To sweeten Andrew Lansley's medicine, the prime minister seemed to be saying, all you need is love. At a London hospital, he poured praise on medics, and said the whole nation was besotted with a "precious" three letter ideal, before reaffirming his own NHS devotion.
The health secretary's passionless presentation frustrates No 10, and this seemed a good moment for the love drug. After all, Mark Britnell, one of the wise men Mr Cameron had unwisely summoned to Downing Street, has been revealed to have been telling corporates they will have "big opportunities" in the new-look NHS, and has also been arguing for forcing patients to pay. Ruling out such new charges, which were never in the pre-pause legislation, was one of several straw men the prime minister felled. As he wafted purple prose about the health service brand over every specific dilemma that must be faced before the play button can be pressed again, it almost sounded as if Mr Cameron had reverted to his past career in public relations. But expert listeners spotted a few informative patterns in the haze.
Even if "choice for patients, not competition for its own sake" sounds like empty rhetoric, the phrase suggests the duties of the regulator will be qualified in law, to make plain that it is not obliged to punt treatment away from public hospitals, a potentially important concession. Fears of privatisation, however, will not be assuaged until the reckless idea of outsourcing commissioning itself is laid to rest. The prime ministerial promise to integrate health and social care more effectively was also new, although how he hopes to achieve this within the current package of reforms when the Dilnot commission into financing care has not even reported is unclear to say the least. Then there are the purse strings. Mr Cameron now suggests they should not be stuffed into the hands of GPs alone, as Mr Lansley had first proposed, but instead held by some mix of family doctors, nurses and consultants.
The last point, in particular, confirms that this is a new political strategy, as opposed to re-engineering of the reforms on the basis of principled argument. Keeping the doctors close to him, by giving them all a piece of the financial power, will no doubt reduce the volume of the reporting on the evening news. However, asking medics on hospital payrolls to be both purchasers and providers at the same time muddies the water of the new healthcare market. There is a coherent case for reverting to integrated central control, as there is also for imposing a strict purchaser/provider split. But giving hospitals back the power they traditionally had, and sometimes used to block worthwhile change, makes no sense in the new world of autonomous foundation trusts run on semi-commercial lines.
The root confusion is that the half-rewritten health and social care bill is now a solution in search of a problem. There are of course desperately serious challenges in nursing an ageing society, but these are inherently long-term. By talking up overlaying problems such as obesity which are getting worse, while ignoring things like smoking which are improving, the prime minister whipped up a more immediate crisis. But if there is a crisis, it is one of funding, and whatever benefits the right reform may ultimately bring, instability will aggravate this at first. Likewise, if Mr Cameron's shaky statistics about cancer and stroke deaths underlined anything, it is that there is already too much variation in care. Neutering Nice and leaving individual consortia to decide what treatments they fancy footing is hardly going to help.
Pressing pause was right, but unless a stronger argument is developed, it will soon be time to press stop. And then start again on an entirely new bill on a saner timetable.