- Nick Seddon, deputy director, Reform, London SW1P 3LT, UK
“And let me speak to th’yet unknowing world / How these things came about,” says Horatio at the end of Hamlet, seeking to make sense of the “accidental judgements” and “casual slaughters” through the act of storytelling. It is to this dramatic tradition that Never Again? appeals, with its mock-Jacobean frontispiece describing it as a “moderne drama In Five Incompleted Acts.” In fact this is a conceit, for it’s a work describing public policy making rather than fiction, but the narrative is unusually captivating. It tells the tale of how the Health and Social Care Bill—the most controversial piece of NHS legislation in over two decades—became law, and tries to ensure that lessons are learnt for the future.
The protagonist, the man with whom this legislation is uniquely identified, is the health secretary, Andrew Lansley. Just weeks after promising “no more top-down reorganisations,” he launched in July 2010 arguably the biggest restructuring the NHS had seen in its 63 year history. Many felt he did so without telling anyone what he was up to. Actually, as Timmins reminds us, Lansley’s early speeches show that he had been testing out and refining most of the policies for many years—and a genealogy can be traced back through the “market-like” NHS reforms introduced by both New Labour and the preceding Conservative administration. The surprise lay in the fact that while the white paper plans were evolutionary in concept they were revolutionary in how they were to be implemented.
Not only would family doctors take over the commissioning of NHS care, for instance, but the entire superstructure of the NHS (special health authorities and primary care trusts) would be abolished. The received wisdom is that this was all Lansley’s doing, but Timmins marshals extensive research and interview material to compose a different picture. This will make for uncomfortable reading for Liberal Democrats, who have at times tried to distance themselves from the plans. It was the hurried horse-trading over the coalition’s “programme for government”—cooked up in Downing Street in May 2010, largely by Oliver Letwin, the Tories’ policy guru, and Danny Alexander, Nick Clegg’s key adviser—that reshaped Lansley’s blueprint and paved the way for GP commissioning to become not voluntary but compulsory.
Much of the rest is a matter of public record—the introduction of the bill into Parliament, its tortuous passage, the “listening exercise,” open divisions in government, the Royal Assent of the bill, with 2000 amendments making it look like something designed by Heath Robinson—though Timmins’ analysis is particularly dextrous and nuanced. 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, the bill would have undergone fewer amendments. And yet, in another twist to the coalition tale, without their votes the legislation would not have passed and Lansley would have no bill at all.
Politics is all about communication, and the coalition never had a story to tell. If “narrative” is an unfashionable word in politics, good politics requires a clear definition of the problem and an explanation of how the policy will fix it. For years, the Tories, especially, have struggled to resolve the contradictory urges to change the service but, in the spirit of detoxification, to say they weren’t going to change it. That the 550 page bill was terribly complicated made matters worse. “You cannot encapsulate in one or two sentences the main thrust of this,” said the health minister Simon Burns. In this vacuum, simple messages cut through, such as the mock eBay site set up by Unison to “sell off” the NHS.
Earlier this year, the BMJ stated in a joint editorial with HSJ and Nursing Times that “we must make sure that nothing like this ever happens again” (BMJ 2012;344:e709); but there is another version of “never again” —the health secretary’s. Over the past 20 years there has been on average a reorganisation—or re-disorganisation—every two years. Although Lansley claimed that he “could have done most of this without the legislation,” it is clear that he viewed legislation as a way to complete and make “permanent” two decades of reforms. But that requires the act to be a success, which in turn depends on how success is measured: if success, like beauty, is in the eyes of the beholder, it seems unlikely that this will be the top-down reorganisation to end them all.
Never Again? combines extensive research, forensic analysis, a gripping plot, and elegant writing. Take a close look at the 10 lessons for politicians and policy makers in the conclusion: in a centrally funded system you can’t take politicians out of the running of the NHS; have a story to tell about reform; develop workable plans and don’t go quiet on those plans before an election or misrepresent them; build constituencies of support, and so on. The past is prologue, the reforms have just begun, and if the forecasts are right there’ll be little money for the NHS for the next decade, which means that more challenges and changes are inevitable. This first history of the coalition’s NHS reforms is essential reading.
Cite this as: BMJ 2012;345:e4844
Never Again? The Story of the Health and Social Care Act 2012
The King’s Fund and the Institute for Government, pp 148
Download for free at www.kingsfund.org.uk/publications/never_again.html
Competing interests: None declared.