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Steve Richards: This sleeping monster could unleash chaos

When the NHS saga reaches its baffling denouement the Government risks losing a reputation for competence

Is the Health Secretary, Andrew Lansley, starting to panic? I do not raise the question lightly, having been impressed with his dignified calm during what must have been the most traumatic phase of his career. The policies were, and are, a chaotic shambles, but Lansley has been the model of polite restraint, behaving as if it were an everyday occurrence for a minister to be told that it was necessary to review a bill on which he had staked his reputation.

The signs of uncharacteristic panic take the form of an interview in yesterday's Daily Telegraph and a speech in which Lansley set out 60 centrally determined "benchmarks" for improvements in the NHS on which he, personally, would be judged. They include a commitment to prevent unnecessary early deaths, a pledge to enhance the quality of life for sufferers of long-term conditions, and new measures to ensure that patients have a more positive experience when using the NHS. Admittedly, some of the so-called benchmarks are carefully chosen and cannot be precisely measured. Partly a re-packaging of existing proposals, they give Lansley wriggle room if they are not met. In some ways, they are targets without the same precision and pressure to deliver, arguably the worst of all worlds.

And, yet for all its presentational guile, there is no getting away from it. From the centre, Lansley decrees the areas in which he demands improvements and declares himself accountable if they do not come about. Such nervy positioning contradicts entirely the spirit behind the bill in which Lansley seeks to devolve responsibility from the centre to a big new quango, GP consortia, individual hospitals and the private sector. Until the health reforms reached the House of Lords, the Health Secretary was to have no formal, constitutional responsibility for the delivery of the NHS. Ideologically, this is the terrain on which Lansley firmly stands, a new world in which he would turn down a request from the Today programme when something goes wrong in the NHS on the grounds that he is no longer responsible.

But, practically and politically, the ideological momentum behind the bill is challenged at every stage. Now even the leading ideologist mounts a challenge. Suddenly, Lansley feels the need to generate headlines about how he is setting 60 "goals" for hospitals. The contradictory tone reinforces the fatal flaw arising from the original proposals, the convoluted and yet modest reform of the reforms, and Lansley's latest attempt to reassure that he is setting tough targets on which to be judged. The question as to who is accountable to whom and who is responsible for what becomes increasingly difficult to answer, always an ominous sign in any institution. If Lansley says he will be personally accountable for his 60 new targets, what is the role for the new non-elected quango in relation to these newly defined benchmarks? If it is not accountable for those how do we measure its powers and success in implementing them? The Government is responsible for setting budgets and raising the money to pay for them; is it, the quango, or various consortia accountable for the way the money is spent? How do patients and taxpayers decide?

The economic crisis has propelled the NHS reforms to the margins for the time being, but they form a sleeping monster that will wake up soon. To some extent, the bill is being carved up in the non-elected Lords, a parliamentary process that raises as many questions about democratic accountability as the reforms themselves. Indeed it is a dark twist that the non-elected Lords rightly expose the evasion of democratic accountability in the health reforms.

At the other end, on the ground, there is the potential for chaos. As part of the recent pause, Primary Care Trusts were told they could breathe for a bit longer, but most of them had wound down already. In many cases, the GP consortia are not ready to acquire a myriad of administrative and financial responsibilities. Some would prefer not to do so. They turn to the PCTs, and find there is nothing there. In other cases, puny PCTs stagger on, liaising with embryonic new consortia, awaiting further instruction from the quango with overall responsibility for the NHS while now receiving specific orders from Lansley in the columns of the Daily Telegraph. All this takes place at a point when the biggest real terms cuts are being imposed on the NHS in its history.

In politics, a perception of competence is a potent weapon. Senior ministers brief that their approach to the economy proves that they are responsibly competent compared with Labour. This takes some chutzpah given that Ed Balls has been proven right in his early assessment of where their deficit-reduction strategy would lead. Nonetheless, for now, polls suggest voters are inclined to give the Coalition the benefit of the doubt on the economy. When the NHS saga reaches its baffling denouement, the Government risks losing a reputation for competence. On those grounds alone, the impressively calm Andrew Lansley has good cause to panic.