Steve Richards: Lansley won't survive the surgery now facing his reform

As long as the NHS is financed centrally and free at the point of use, the Government cannot step back and allow a free-for-all administered by quangos

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We are witnessing an unusual contortion. Most of those presiding over what is known comically as the pause in the NHS reforms supported the original proposals, and to some extent still do. They may have the odd reservation and worry about the "way the Bill was handled", but on the whole they were enthusiasts as recently as the start of this year.

Privately and publicly, Nick Clegg was a genuinely keen advocate. His party's MPs voted for the Bill in the autumn, an early example of a malleability and gullibility that presumably will no longer apply in the changed political context. David Cameron might be a laid-back Prime Minister, but the notion he had no idea what his Health Secretary, Andrew Lansley, was planning is absurd. He knew and was keen. So was his senior adviser, Steve Hilton, who not only knew what was being planned, but with some justification insists that the rest of us could have known as well on the basis of what was said before the election. Oliver Letwin, the intellectual force behind the Coalition's public service revolution, questioned Lansley at length in January on the proposals and emerged as supportive as when he began his polite interrogation. The Lib Dems' Danny Alexander joined Letwin and was wholly reassured too.

Cameron and Hilton are still keen to preserve as many of the proposals as possible. But they know that they can only do so if they can win over those who work in the NHS and, as important, convince voters that they are improving rather than wrecking the institution, a perception as explosive for the Conservatives as the Lib Dems. To some extent, Clegg and his entourage cling to the assumption that the politics of the reforms were maladroit and that quite a lot of the original proposals were broadly right. But Clegg is discovering that those who supported the Lib Dems, or used to do so, take a different view, and he is now acting wisely as a leader who needs to save his party rather than as an ideologically free spirit.

Then there is George Osborne, playing a dual role as an eternally calculating tactician and as representative of the Treasury. No doubt Osborne is a theoretical supporter of the original changes too, but he knows that, in the short term at least, they will cost money to implement, and might lose even more, as the Government deliberately cedes all control over how taxpayers' cash is spent. In the priorities of the Treasury and the reforming zeal of Number 10 there is the slightest echo of the tensions between Blair/Brown. With good cause, chancellors worry about the precise layers of accountability when vast sums leave the Treasury and head off in an uncertain direction.

This is the political cast list, and its ambiguous stance, that will decide the outcome of the review. What is clear from suddenly assertive public statements from Nick Clegg is that the direction of travel will not greatly change. He emphasises a change of speed and speaks of evolutionary reform, highlighting one area where the brake might be applied. Perhaps GPs will not have a vast array of new administrative and financial responsibilities imposed on them if they do not wish to form consortiums immediately. There will also be further safeguards in an attempt to reassure that quality will prevail over profit. The problem facing the suddenly fearful revolutionaries is that although fearful, they are still revolutionaries. They share a deep wariness of the state and an assumption that a thousand flowers will bloom if government steps back. Yet they back the popular state-owned NHS, or at least feel obliged to do so. The confusion already causes decline. The sweepingly indiscriminate removal of government targets has led to a predictable increase in waiting lists. Already, private health insurance companies advertise that if patients want to avoid the newly lengthening waiting lists, this is the time to sign up to them. The ministerial loathing of all targets (some were silly, but not all of them) produced a curious alliance between the Coalition's small-state, free-market ideologues and the previously cosseted providers within the NHS, some of whom resented being held to account. Now the providers can lapse into inefficiency without any questions being asked.

As long as the NHS is financed centrally and free at the point of use, the Government cannot step back and allow a free-for-all, administered by quangos. This is the dynamic that the NHS Bill fails to recognise. Governments raise money and decide the level of the funding. Ultimately they must be responsible for the quality of care. New powers for local authorities do not address the issue of democratic accountability. Councils do not fund the NHS and most councillors are not experts in healthcare delivery. Without any financial obligations they can posture without accountability or expertise. In the end, the democratic link can only be made where the money is provided, the dreaded centre. Yet the Government plans to fund the NHS and then have virtually nothing to do with it.

So what is likely to happen in the short term? If GPs were offered a right to opt out they would function in a vacuum, dependent on almost defunct Primary Care Trusts. Probably, most will decide to go ahead as the Government wishes. Safeguards will be introduced theoretically to prevent big companies from making hay, but the relevant parts of the private sector seem confident still that their moment has come. Probably, Andrew Lansley will be reshuffled into a post safely distant from the NHS. His reforms will almost go ahead as envisaged, but with a sense that GPs and others are choosing to go along with them. And then what will follow? Probably, most Lib Dems will not be satisfied and the chaos in the NHS being predicted will still be a strong possibility. That seems to be the only likely outcome when attempts to amend radical reforms are made. At least when a review of an alternative of the poll tax was conducted, Michael Heseltine, a long-term consistent opponent, was in charge. From the beginning and with conviction, he knew sweeping, genuine change was required, including the abolition of the tax. The outcome of the NHS review will be less clear-cut when original enthusiasts seek reluctant change.

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