The Liberal Democrats will demand five major changes to the Government's flagship health reforms as the price of securing their passage through Parliament.
Nick Clegg's party is threatening to join forces with Labour to dilute the NHS and Social Care Bill unless Andrew Lansley, the Health Secretary, agrees to make the changes sought by the Liberal Democrats' spring conference last month.
David Cameron and Mr Clegg will press Mr Lansley to implement at least some of the Liberal Democrat ideas. But the Health Secretary is digging in against major surgery. "He sees is it as a problem of communication," one Cabinet source said yesterday. "That is not how others see it."
At a joint event today, Mr Cameron, Mr Clegg and Mr Lansley will begin their campaign to reassure the public and health professionals over the plan to hand 60 per cent of the NHS budget to GPs, who will commission services themselves, instead of primary care trusts (PCTs). Behind the scenes, the three men face a tense debate on how far to water down the reforms, after Mr Lansley had to promise on Monday to "pause, listen and engage".
Liberal Democrat MPs and peers have agreed to press for changes which would have to ensure that:
* Private health companies do not exploit new rules on competition to "cherry-pick" profitable NHS services;
* Monitor, the new regulator which will set prices and boost competition, also promotes "equity and fairness" in access to health services;
* GP-led consortia meet in public, include other NHS professionals and have tougher rules to prevent conflicts of interests;
* Local councillors get a bigger role, possibly by sitting on expanded consortia boards;
* The pace of change is slowed, possibly by allowing flexibility over the April 2013 date for GPs to take on commissioning.
Yesterday Mr Clegg raised the stakes by going much further than Mr Lansley did on Monday. He told the Commons there would be "substantive changes" to the Bill and said there was nothing "doctrinaire" about the 2013 deadline. In a round of media interviews, Mr Clegg said it would have been "reckless" to press ahead with the reforms regardless of people's concerns. "I would never accept any scheme which could lead to privatisation of the NHS," he said.
Lib Dem MPs say they should not be whipped into supporting the Bill when it returns to the Commons in June as it was not included in the Coalition Agreement last May. They hope Mr Cameron will make enough concessions for them to support the measure. And Tory whips have warned the Prime Minister he will have to give ground to ensure approval by the Lords.
The Health Secretary may have other ideas. He has spent seven-and-a-half years in opposition and in government working up his proposals and is reluctant to tear them up.
How did they get so far without running into the trouble they are now in? Mainly because Mr Cameron trusted Mr Lansley, who became his boss as director of the Conservative Research Department when a fresh-faced Mr Cameron was in his first job.
There have been wobbles since Mr Lansley produced a a White Paper in July, seen by the Liberal Democrats as the biggest breach of the "no nasty surprises" rule they agreed when the Coalition was formed. The Coalition Agreement promised: "We will stop the top-down reorganisations of the NHS that have got in the way of patient care." Mr Lansley is now trying to implement what many experts regard as the biggest top-down reorganisation of the NHS since it was born in 1948.
Last autumn, Mr Cameron asked Oliver Letwin, whose title of Cabinet Office Minister vastly understates the crucial importance of his role as the Prime Minister's policy guru, to road-test the Lansley blueprint. It passed Mr Letwin's test. "Lansley can argue it through with anyone in the Cabinet room but he can't explain it to the public," complained one Downing Street insider. There was another wobble in the new year as more groups representing health professionals lined up against the reforms.
Mr Cameron, believing the problem was poor communication rather than a poor policy, resolved to join the mission to explain it. But his initiative fizzled out, partly because he was swamped by other pressures. "With hindsight, he should have kept that going for more than two weeks," an aide admits. Mr Cameron's dilemma now is how far to push Mr Lansley on concessions. It is too late to pull the plug on the reforms, as the Prime Minister did when he forced the Environment Secretary Caroline Spelman to drop plans to sell off England's public forests. Mr Lansley is warning there will be extra costs if the switch to GP-led commissioning is delayed.
But Mr Cameron knows his tireless work in defusing health as a negative issue – a key plank of his "detoxification" of the Tories – could be undone unless he allays fears over "back door privatisation". As Evan Harris, a former Lib Dem MP and GP who is advising the party in its negotiations, puts it: "The changes we want would be good for the NHS, good for the Lib Dems and good for the Conservatives. We are saving the Conservatives from retoxifying their brand."