The politics of the health reshuffle


Yesterday I looked at the major challenges facing Jeremy Hunt in his new role.  These are, inevitably, policy challenges. But what of the politics underpinning the reshuffle and how will they affect the politics of health?

A shock?

The appointment of Jeremy Hunt as Health Secretary – the most widely trailed move some months ago – still managed to shock politics-watchers.  Back in the early part of the year it would have been seen as bizarre that the change would have been seen as a ‘shock’ (given the preponderance of people falling over themselves to declare Andrew Lansley a dead man walking).  But things change quickly in politics. 

A combination of improvements in Lansley’s communications operation, following the recruitment of Paul Stephenson from a political perspective and Sam Lister from the civil service, did change the dynamic.  This was combined with missteps in many other areas of government, notably the Budget. Lansleyshambles quickly became omnishambles. 

On top of this, at a time when Lansley’s political fortunes began to pick up, so Jeremy Hunt’s previously uninterrupted ascent hit its first bout of serious turbulence, with revelations about his links to the Murdoch empire.

But, the ‘shock’ happened.  What can we expect on health in a post-reshuffle world?

There are three points that I can make of the reshuffle thus far.

A redistribution of power?

The first, and most boring, is that the appointment shifts power towards Number 10. That is unsurprising; reshuffles, by their nature, always do.  And so begins the short process once again of ministers ‘going native’ (or getting to know their policy area), at which point a further reshuffle is usually required.   It is unsurprising, but it does mean that Number 10 will try to assert a Blair-esque grip on health policy for the first time under the Coalition, in a way which it did not have when Andrew Lansley was running his semi-autonomous Department.  Number 10 is well and truly back in play.

The second, and more interesting point, is that it shifts power towards Number 11.  We know from Leveson that Jeremy Hunt and Osborne are chummy enough to exchange regular texts.  And that means… well, that the Treasury is back in play.   Having been outmanoeuvred on NHS reform, we can now expect the Treasury to seek to reassert what it sees as the natural order of things.  And the relationship at the top of the two departments will help and not hinder this.

The third point is that the ministerial team at the Department looks fairly incendiary. Anna Soubry is a rising star, not a shrinking violet, and will want to make her mark.  Norman Lamb is well-versed on health policy matters, is not going to restrict himself to social care and is a known sceptic of Andrew Lansley’s health reforms.  The team will clash – repeatedly – and Jeremy Hunt’s job will in part be keeping a lid on things.  If the removal of Andrew Lansley is an attempt to keep things quiet, then the junior ministerial appointments will not help this process.  Expect journalists to get some entertainment value from the differing personalities within the team.

What this does indicate, however, is that the Department of Health – after a period in which junior ministers did as they were told by the Secretary of State – now has more ‘activist’ ministers under a more open-minded Secretary of State.  We no longer have a department where control rests solely with the man at the top.  And so, junior ministers are back in play.

That is what I can make of the reshuffle thus far. But what I can’t get my head around is why.

Person or policy?

Prime Ministers reshuffle their ministers for one of two reasons: the person or the policy.  And so it is obvious to me what has happened with Justine Greening, Ken Clarke, Caroline Spelman and the rest.  Apart from Andrew Lansley.  Is it the person, or the policy, or both?  

My instinct is that this decision was made some months ago for both person and policy reasons.  I suspect that Number 10 – at that time – did not care much for the policy, and Number 11 did not care much for the person.  But that was at a time when the noise of the health reforms was at its loudest.  Number 10 may have reappraised its view of Lansley since someone briefed the media that he should be shot, but Number 11 did not.  And so a months-old decision was never revisited.  Hence the ‘shock’ at Lansley’s departure.

But then, if Number 10 does really now want the policy implemented (as the press has been briefed), it really needed to put up with the person.  Precious few people beyond Lansley understand what needs to happen next and most of ‘what needs to happen’ needs to happen by April 2013. Those few people who do are no longer in Government (more of that below).  All this does is encourage opponents to revisit aspects of the policy in the hope of getting a different decision.  So if the Prime Minister was supportive of the policy, then he should have gritted his teeth a while longer and dumped Lansley in a few months’ time.  Moving him makes implementation harder and not easier.

Or perhaps we should conclude that the Prime Minister wants the policy changed.  But if that is true, he is in a right mess.  As Nick Timmins pointed out in his recent book, the purpose of nailing down everything in legislation was to ensure that the policy was person-proofed.  Those who scoffed at Andrew Lansley’s ‘vanity’ piece of legislation will now, presumably, begin to see the point.  Monitor is going to be an economic regulator, required by law to produce a ‘level playing field’ review in a matter of months.  We hear speculation that the independent NHS Commissioning Board is going to act more independently under its new Secretary of State.  Exactly.  And even the mechanics of the new system – such as putting a hospital into administration – are already being used, bomb-proofed against political interference.  

Virtually any tweak to the policy requires primary legislation to unwind it, and it is difficult to see collective agreement on any further health reform being secured ever again under the Coalition.

A right turn?

So if the Prime Minister does want to change health policy, it cannot be Coalition Government but Conservative manifesto territory.  Which opens up another question: where on earth does Conservative health policy go next?  Lansley has been a fierce custodian of the health turf since 2003, with few others getting a look in.  His main policy advisers have been Bill Morgan and Sean Worth.  Fiercely intelligent, and intolerant of fools, the three of them have pretty-much monopolised the health brief for almost a decade.  The unshakeable alliance between the latter two managed to successfully see off what were probably George Osborne’s first and second attempts to choke off the health reforms.  But Sean left some months ago and Bill has left with Lansley.  

If Lansley monopolised Conservative thinking within Central Office and the parliamentary party, then right wing think tanks were hardly a fertile ground for new ideas either.  Put simply, there aren’t a lot of Conservative thinkers on health in the Conservative Party any more.

This creates a risk to those who believe in a taxpayer-funded NHS.  Lansley, Morgan and Worth all shared a passionate belief in the current funding model – something not shared by all of their party.  Indeed it is the natural inclination of the Tory right, to whom we are led to believe the Prime Minister has just yielded, to think the unthinkable in terms of funding when challenged to develop fresh ideas on health.  

Under David Cameron, the Conservative Party worked hard to recapture a foothold in the centreground on health (and despite the controversy created by the reforms, it still does).  David Cameron and Jeremy Hunt are both highly effective communicators and will know that ‘Conservative’, ‘radical’ and ‘health’ are not three words which sit well with the electorate, but absence of the leading centrist policy thinkers creates a vacuum which could easily lead to the Party vacating its hard-won territory, almost by default.

My instinct is that this is not what the Prime Minister wants and nor is it what Jeremy Hunt would wish to oversee.  Instead, the departure of Lansley is a months-old decision, never revisited even though it maybe should have been.  As a result, it comes at an awkward point for the NHS (and for Jeremy Hunt, given the content of his in-tray).  Contrary to all expectations a few months ago, this was not a reshuffle inspired by the need for change at Health, but instead change at Health occurred because the reshuffle was happening now.  Nonetheless, an unintended consequence of the reshuffle has been to create a vacuum in health thinking in the Conservative Party.  How this is filled will have far-reaching consequences.  As I wrote back in 2011, those on the left who called for Lansley’s departure may have cause to think they should have been more careful in what they wished for.