Steve Richards: Has Cameron forgotten about Thatcher and the poll tax?

For revolutionaries to alter the course of a revolution reluctantly is almost as dangerous as sticking to their original plans

More than any other issue, the proposed revolution in the NHS tests the strength and unity of the Coalition. This is not because senior ministers disagree over the changes, but the precise opposite. At the top of the Coalition they are united in agreement. They are true believers in the crusade, and yet almost, but not quite, contemplate stepping back.

For revolutionaries to alter the course of a revolution reluctantly is almost as dangerous as sticking with their original plans. So for now they choose to "listen" while almost holding firm. This is a third way of limited mileage. Soon they must decide whether to press ahead with small changes and risk an unpredictable level of tension within the Coalition or make fundamental revisions of the type being demanded by senior Liberal Democrats – an almost impossible dilemma.

I almost feel sorry for the Health Secretary, Andrew Lansley, who is partially isolated from his more flaky crusaders and was forced to announce yesterday that he was "modernising" and "listening" simultaneously. In opposition, David Cameron announced, unusually, that Lansley would be Health Secretary in a Tory government. A senior ally of Lansley's points out to me that Cameron was aware, when he made the assurance, of the reforms that his future Health Secretary had in mind. Presumably Cameron supported them or his act of pre-election patronage would have been a little perverse.

In fairness to both Cameron and Lansley, voters and the media also had the chance to become aware of what they had in mind. The Tories published a document on their NHS reforms in January 2010 and their manifesto contained the essence. Cameron is culpable because he proclaimed at the same time a message about having no plans for upheaval. But the outline of the revolution was clear.

Cameron's contradictory technique is becoming familiar. Quite often in recent months he has declared emphatically that the Government has no intention of doing X, Y or Z when ministers have announced something close to X, Y and Z. I doubt whether Cameron will be able to get away with suggesting that he is not across the detail for much longer, as he has done in relation to the NHS. In a way it is more unforgiveable not to know what is going on than it is to support what is going on.

For these two reasons – support for the ideological principles behind the reforms, and the confusion about what the Conservatives said in advance – there are parallels with the poll tax, the calamitous policy that was a factor in the fall of Margaret Thatcher and was never scrutinised in the election that preceded its implementation.

The problem the Conservative government faced in the late 1980s over the poll tax was that Thatcher supported the policy passionately. She understood the political damage. She saw the theoretical need for revision, but she could not bring herself – at first – to change fundamentally a policy that was destroying her leadership. Chris Patten, the Environment Secretary in the late 1980s, told me mournfully at the time: "Each week I tell Margaret Hilda the projected Bills in different parts of the country. She does not believe them."

Similarly the most influential ministers now do not believe there is much wrong with the NHS reforms. Both Oliver Letwin and Danny Alexander (Nick Clegg's closest ministerial ally) were called upon to question Lansley closely at the end of last year; they emerged almost elated by the Health Secretary's grasp of detail and ideological verve. Now they know there must be changes, but do not really want to make them.

The message of the Coalition is increasingly confused. There will be big changes. There will not be big changes. There will be a pause, but there was always going to be a pause because of the parliamentary timetable. The only consistent message from them all is that they have mishandled the politics of the reforms.

That is undoubtedly the case, but it is also a complacent interpretation of the criticisms that have erupted around them. In terms of the politics, there was a better way. The Coalition should have noted the demands on the NHS, the limited resources and then guided a debate towards its radical solution. This is what Gordon Brown, Ed Balls and Ed Miliband did when they moved carefully towards proposing a tax rise to pay for increased investment in the NHS. By the time Brown announced the tax rise, it was what most voters were demanding.

Those who believe the two Eds are a couple of vote-losing lefties up against the sophisticated wiliness of Cameron/Osborne should compare the handling of that tax rise with the state of the current NHS reforms, and at least reflect on their assumptions.

But the politics is not the main problem with the reforms. The substance is the problem. The reforms seek to transform healthcare into something much more like a regulated industry of competing providers and one over which the Health Secretary will no longer have control. The Bill will set up an independent commissioning board that will hand out the £100bn budget and in theory manage the performance of GPs. There will also be an economic regulator that will oversee the market for the provision of NHS care from a mix of publicly, privately or voluntary-owned providers.

The money raised will come from the taxpayer and yet central government is giving up control over how it is spent or monitored. Quite possibly the GP consortiums will employ more bureaucrats. Thousands of lawyers and accountants are ready to leap as impossibly complex contracts are drawn up with the private sector, some of which will not be as robust as they should be and will be sheltered from accountability on grounds of commercial confidentiality. The reforms are weak in relation to accountability, transparency and value for money.

The dilemma for the revolutionaries who are now reluctant compromisers is that the proposals are elaborately interwoven. In the end, Thatcher agreed to several big changes to the poll tax, which rendered the original plan meaningless. Yet because she was so attached to it, the tax remained in place – the worst of all worlds. Beginning by "listening" and yet remaining largely committed to the original proposals, the Coalition embarks on a similar course.

s.richards@independent.co.uk