Steve Richards: Run the NHS better or scrap it – but give up reforming it

'Patient choice' is largely a myth, unless we pay for half-empty hospital wards

(Darren Diss)

The Health Secretary, Andrew Lansley, is far too easy a scapegoat for the costly chaos of the NHS reforms. "Bloody Lansley... He's got the politics of the NHS reforms wrong... He's a useless communicator." These are among the more polite comments within government. Now one insider is reported as expressing a desire to have the Health Secretary shot and replaced with Alan Milburn, a fantasy sequence that makes Lansley seem rooted in reality.

The problem for those in government agonising over the wreckage is that Lansley's proposals chime with the instinctive views of key figures,from David Cameron downwards. The original NHS White Paper epitomised the ideas I heard the Tory Shadow Cabinet discuss in opposition at countless seminars.They insisted that, in their new world, they would turn down interviews on the Today programme on the grounds that they were no longer directly responsible for the delivery of services. The White Paper also included proposals for markets and choice that are well within Cameron's ideological repertoire.

That is why Lansley's White Paper got the thumbs-up in the autumn of 2010 without anyone in No 10 sensing problems ahead. Indeed, they hoped they would make political mischief as a bonus, assuming that most Blairites would back the changes on the grounds that they built on what Tony Blair had started. Again, this was not an irrational calculation. In some respects, they do follow what Blair attempted, somewhat chaotically, during his period in power. In the House of Lords, John Birt, Blair's one-time "blue-skies thinker", spoke enthusiastically in favour of Lansley's reforms. Ed Miliband's office has been trying to persuade Blair to come out against them. He has not done so yet, although he has expressed his doubts.

Cameron and Nick Clegg had plenty of time to decide if they had doubts. In December 2010, Lansley was twice questioned at length by the Tories' Oliver Letwin and the Lib Dems' Danny Alexander. Cameron spoke to Lansley, too. All three were enthused by his authoritative responses and did not stop him from pushing forward on any front. He got the go-ahead because they agreed with him.

Then those, like Shirley Williams, who had bothered to read every word of the White Paper and the following NHS Bill, started to stir. The subsequent "pause" in the legislation was a traumatic episode in No 10, with Cameron wobbling and the likes of Steve Hilton arguing, justifiably, that their entire vision for public services would be undermined if the Bill were dropped. Cameron only wobbled because the political fall-out had taken him by surprise, not because he disagreed with the vision.

This is not an arrogant government. It is led by figures used to losing elections and who have never enjoyed a sustained commanding lead in the polls, effective cures for instinctive arrogance. But I do detect a complacent assumption about their reforms that if only voters understood what was happening, they would all be thrilled. To some extent, this shaped their calculations during the so-called pause. Cameron's former senior adviser, James O'Shaughnessy, suggested to me that the Bill's original objectives survived and the pause was partly tactical.

The pause has not worked. There is still much trouble ahead and those who believe in the changes can only blame Lansley. To question whether the essence of the reforms is wrong would throw all their convictions up in the air. And yet a pattern is starting to appear in the several attempts to introduce a market into a centrally funded service which is free at the point of use.

Alan Milburn tried as Health Secretary and did not last long in the post. His successor, John Reid, stayed for even less time, although he moved on to another big cabinet post. Patricia Hewitt, though sympathetic to reform, discovered chaos at the department when she succeeded Reid. The Coalition criticises, with good cause, some of the detail of those reforms, including one attempt to bring in the private sector that cost a lot of money without companies performing a single task.

In each case, the Labour Health Secretaries had a lot going for them. Milburn and Reid were attractive personalities, great communicators and had the unequivocal support of the Prime Minister, along with nearly all of the media. They blamed Gordon Brown for their failure to deliver in the same way that reformers now blame Lansley. Brown was another easy scapegoat. Perhaps it is not about individuals, but the nature of the changes.

The problem with the entire debate is that Blair/Cameron characterise the argument as between reform and "anti-reform". What they both mean is that they cannot accept any other way of improving the NHS except through their muddled thinking. Yet surely after the latest shambles the time has come, not simply to blame an individual for mishandling the politics (Lansley), or for acting out of spite (Brown), but to pose the question of whether this is the only route to improvement.

The inescapable flaws are deep. If the Government raises the huge sums for the NHS, it cannot, and should not, devolve all power to others to decide how it is spent. Competition is extremely hard to regulate so that there is a genuine market with universal standards, and that patients get the service without paying directly. At the very least, it involves more bureaucrats to regulate and hold the fractured system to account. "Patient choice" is largely a myth, unless we are willing to pay for a surplus of hospitals with half-empty wards and more GPs than are needed at any given time. Those instinctively opposed to the NHS should give up reforming it in this way and instead propose a price mechanism, including vouchers for poorer patients, to create a genuine market.

The rest of us must accept that, while good value and sometimes excellent, the NHS can be wasteful and treat patients with contempt. Some employees are overpaid. Others deserve more. Some PCTs were inefficient and some hospitals are poorly managed. It should not be beyond the wit of a Health Secretary and his army of civil servants to sort this out under existing structures and leave the ideologists on the right to come up with a new approach. But do not blame Lansley personally or the "politics" of the reforms. The reforms are the problem.

s.richards@independent.co.uk; twitter.com/steverichards14