Leading article: The mystery of NHS reform

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The kindest way to put it is that we are baffled.
The Independent on Sunday was long prepared to extend to David Cameron the benefit of the doubt. In opposition, he made many of the brave and necessary changes to the Conservative Party for it to become electable again – although we were sceptical about, for example, his conversion to the Green cause. One of the most important changes was to neutralise his party's reputation for hostility to the National Health Service.

Now, less than a year into government, Mr Cameron's claim to lead the party of the NHS is in doubt. As we report today, the Prime Minister and his deputy are preparing, in conditions of unusual secrecy, to announce this week a delay to the Health and Social Care Bill, which has just completed its committee stage in the House of Commons.

The confusion over the Government's plans for the NHS is, to put it at its most moderate, surprising. This is a matter not just of ideology but of competence.

The Prime Minister seems to have assumed, despite the evidence over many years, that Andrew Lansley, the Secretary of State for Health, knew what he was doing. When Mr Lansley succeeded in uniting doctors, nurses, public opinion and most Liberal Democrats against his reforms, No 10 seems to have assumed that he needed to communicate the changes better.

It is certainly the case that the communication of the policy has been lamentable. Mr Lansley's main message has been that GP- commissioning was promised in the Tory and Liberal Democrat manifestos, and in their coalition agreement. That claim lacks a basis in fact, to put it politely. The Tory manifesto spoke of giving GPs the power to commission care, rather than requiring them to do so, and the coalition document was similarly permissive. The Lib Dem manifesto was silent on the issue. The coalition agreement also promises that primary care trusts (PCTs) "will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs". The Bill dispenses with the trusts altogether.

As David Owen argues today, Mr Lansley has no mandate for his reform. That is why Nick Clegg felt emboldened to seek changes to the policy; what the changes are precisely we will find out soon. (The main business in private seems to have been a struggle over the extent to which Mr Clegg will take credit for saving the day.) In many ways, however, it is already too late. Our willingness to give the Government the benefit of the doubt has been forfeited. We do not know how the reorganisation of the NHS was supposed to work, and suspect that Mr Lansley does not either.

Mr Cameron seems to have drawn two unfortunate lessons from the experience of Tony Blair, the predecessor he so admires. One is that he accepted Mr Blair's self-critical assessment of his first term, that it was a wasted chance to launch public service reform from the start. The other is that he did not want to replicate Mr Blair's reputation for over-centralisation. So he delegated to Cabinet colleagues, with instructions to go for reform full-tilt. Thus in many areas, and health is the most important, he has ended up with the worst of both worlds: of making haste and letting ministers get on with it.

Can it be put right? It is not as if the Prime Minister's handling of policy in other areas inspires confidence. Plainly, most of the many government flip-flops to date were on minor matters, from free school milk to the forests sell-off. But it is possible to detect a worryingly U-shaped pattern.

Increasingly, it looks as if Mr Cameron's ease on the public stage has been mistaken for a sureness of touch; that his plausible front has been misread as an instinctive feel for public opinion.

Much too late, it seems, Mr Cameron and Mr Clegg realised that they had a disaster on their hands. As Anthony Seldon reports today, the Prime Minister has just revamped the Downing Street operation to remedy its failure to spot incoming trouble. Craig Oliver and Andrew Cooper, the new communications and strategy chiefs, seem to have decided that their first task must be to defuse a time bomb set to go off in the run-up to the next election.

Who knows if they will succeed? But the fact that this last-minute rescue mission has had to be mounted at all is genuinely baffling. It poses alarming questions about competence at the heart of government.

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