Nick Clegg has responded decisively to his party's democratic will, and is training his sights on the heart of Andrew Lansley's plans
Nick Clegg is making a real difference. These are not common words to read these days, and yet they are becoming hard to dispute with the stalled English health reforms. It is true that the deputy prime minister would be better placed to claim credit if he had not initially nodded Andrew Lansley's bill through, and true, too, that not all the sweeping concessions he now demands fit with the scepticism about the NHS he has sometimes shown in the past. Nonetheless, Mr Clegg has responded decisively to his party's democratic will, and is training his sights on the heart of the Lansley plans.
First, he drew a red line around the crucial clause that tasks the regulator with "promoting competition", and he has now done the same with the legislative invitation for "any qualified provider" to take on the NHS. The deputy PM must now apply a third veto to the unacceptable plan to allow private firms to discharge the core public function of spending health service money. He will then have removed the three greatest drivers of privatisation from among the 80-odd clauses that create an NHS market. Assuming, of course, that he can strong-arm the Conservatives into agreeing. He can afford no compromise. Savaged in Scotland, ravaged in the referendum and trashed in town halls, Mr Clegg retains a grip over his parliamentary party that surprises many outsiders. To keep it, however, he simply has to win this fight.
One reason to be optimistic is that the tide of opinion seems to have decisively turned. Marketising medicine had been steadily becoming entrenched as the orthodoxy, ever since Tony Blair made it his millennial mission. The bust-up over the bill, however, has made the whole approach controversial again. Suddenly Labour's John Healey, who spent a lonely autumn developing all the criticisms of the Lansley blueprint that medics and Lib Dems now voice with such passion, concedes that his own party wrongly pursued "competition for its own sake" through overpriced and underutilised private treatment centres.
It is not merely opinions but the facts that have changed. The pros and cons of competition depend on context. Where there are surplus resources, public providers can potentially respond by raising their game. Where there are none, they will instead slam their doors and blow holes in the delicate network that sustains expertise, training and comprehensive cover.
Europe's social insurance systems traditionally harnessed a measure of choice alongside higher expenditure, and were often more responsive to patients than the NHS. Mr Blair sought to take England in a European direction, by providing extra resources and encouraging private players to compete for them. Sketched out in more prosperous times, Mr Lansley's grand plan originally aimed to give the system a fresh push in the same direction. But then the cash dried up. Suddenly, he was asking market forces to do two things at once – respond more keenly to consumers and curb costs. It is hard to think of anywhere in the world where both things have been achieved simultaneously.
Maintaining quality through the squeeze will involve closing facilities that are not absolutely necessary. Full-throated markets were always a reckless way to identify what to shut, and the political will is faltering. But with waiting times creeping up, a disabling muddle will follow unless an alternative means of stretching the money is found. During the great Canadian cuts of the 1990s, a precedent the coalition often cites, many tough choices on hospitals were made after authority was centralised within the regions. For the moment, all three British parties remain committed to vesting power in islands of autonomy, such as foundation trusts. Unless commercial pressures force their hand, these will not shut themselves. Market forces are already looking like a fad from the good times. Decentralisation, too, may also soon have to yield to a touch of command.