On the face of it, Andy Burnham has had a good Bill. He has kept the spotlight on NHS reform and proved adept at creating media opportunities to maximise both sides of the Coalition’s discomfort. He has also smoothed the path for greater opposition from the professionals to the Bill, cleverly making clear his support for clinically led commissioning, thereby enabling some royal colleges and unions to square their support for the concept with their dislike of competition. He has maintained focus on competition, which lies at the heart of much of the unease with the Bill, arguably ignoring other parts of the legislation which needed improvement, but nevertheless to good political effect.
The Shadow Secretary of State has also proved to be an effective campaigner, combining his knowledge of how the Department of Health works (and doesn’t work) with an effective use of the parliamentary process and a flair for online engagement. Through this he has broadened, encouraged and mobilised the coalition of opponents to the reforms. A Labour tribalist, he has also played on Liberal Democrat discomfort, making conciliatory offers to work together while rarely missing an opportunity to rub salt in Liberal Democrat wounds.
Admittedly, he has been helped by the failure of the Secretary of State for Health to make effectively a case for reform which normal voters (or indeed the media) can understand. As discussed on this blog last week, some of this was deliberate, and highly effective in legislative terms, but it did create extra-parliamentary political opportunities for the Opposition. Some inept manoeuvring by Downing Street and the Deputy Prime Minister’s office has also proved helpful. However, you can only oppose what is in front of you, and Andy Burnham has done a good job of that.
Moving on from #droptheBill
Despite all this, he has lost. The Bill is now an Act and Labour has therefore failed in its explicit intention of forcing the Coalition to #dropthebill. This is inescapable. Andy Burnham needs to acknowledge it and move on. #dropthebill is one thing, but Labour cannot rely on #scraptheact to get the cut-through it needs in the run-up to the next election. It will need to move on to a more positive policy position.
The question is, move on to what? In this sense, the tactics which have proved so effective over the last few months may create problems moving forward. Andy Burnham has stated that he would repeal the Health and Social Act in its entirety, yet as we wrote last week it is not clear that this will be desirable or even feasible when Labour is next in power. Labour actually agrees with many of the provisions in the Act and it is important to recognise that many in the NHS will ‘reset’ around the new structures, opting to work within them in preference to yet more upheaval. Ed Miliband appears to acknowledge this – and has reportedly told members of the Labour National Executive Committee this week that the Act would not be repealed in its entirety. Instead he argues that the focus would be on repealing those aspects of the Act that refer to competition (which are, arguably, among the most difficult to reverse). It is also worth noting that, in voting for a rebel Liberal Democrat amendment in a recent Opposition debate, Labour actually expressed its support for the Coalition Agreement as the basis of health policy. As much of this is in the Act, it is clear that there is some untangling for Andy Burnham and Ed Miliband to do before a clear Labour position emerges.
Those who opposed the Bill did so fervently and will be disappointed that they ultimately failed, despite the long odds against them succeeding. Andy Burnham needs to translate their opposition to the reforms into support for a Labour vision for the future of the NHS. In doing so, he faces a challenge: many of the Act’s opponents were no fans of Labour’s health policy and, without a significant shift leftward from the Opposition, will remain sceptical. The anti-Bill coalition alone will not be a winning combination for Labour on health.
He will also have to cope with gradual public and professional acceptance of reform. We don’t say this because we believe that Andrew Lansley will be proved right, but simply because acceptance of a new reality is an inevitable part of life. Equally, some of the more outlandish claims against the reforms will not come true (the Act doesn’t privatise the NHS) and patients and professionals are unlikely to see any immediate diminution of service quality. As Peter Watt, former General Secretary of the Labour Party, pointed out last week “if in twelve or twenty-four months people are still attending their GP surgery; still having outpatient appointments; still able to attend the A&E Department and still having babies supported by midwives then it will be hard to persuade them that the NHS is no more.”
For their part, many healthcare professionals, in particular, will by and large do what they are trained to: work within the constraints of the system as it is, not as they may wish it to be.
Despite these challenges, Andy Burnham has at least one factor on his side – media interest in the NHS. NHS reform has been a key topic of media speculation and coverage over past months, and the media will likely be receptive to any stories of reductions in service, conflating these with the reforms whether they have been the cause or not. A skilful tactical media operator, Burnham is well placed to capitalise on this. However, to date, uncomfortable headlines for the Coalition have yet to translate to a commanding and sustained lead for Labour on health. Angst at ‘cuts’ alone is unlikely to be enough, particularly with the Coalition committed to spending more on the NHS than Labour is.
Proposing an alternative vision
To get beyond this, Andy Burnham needs to propose an alternative vision to the new reality facing the NHS. Many Labour members and supporters work in, and around, health and social care and activists are unlikely to be content for long with defining themselves in opposition to something rather than in favour of a specific set of changes. The absence of a clear plan on health has long been a frustration for Labour activists, but one which has at least in part been subsumed by their dislike of the Bill, when stopping reform was more important than an alternative. That distraction has now disappeared.
The good news for Mr Burnham is that he has time on his side. There is likely to be health reform fatigue and the economy will probably prove a significant distraction. The NHS will be focused on implementing the transition and over coming months he can make hay over anything that goes wrong. He has some time to build and explain an alternative vision.
As we wrote when Burnham was appointed, he has a good pedigree in health and many experiences and standpoints to draw on from his time as Secretary of State, Minister of State and before that as a member of the Health Select Committee. Such experience is a strength. He understands how many key stakeholders in the sector operate and has many of the relationships so necessary to get by as an effective Opposition. Yet this heritage also poses challenges. Some of his previous positions are now contradictory (is he for or against more national targets? Does he support the role of competition, or would he restrict it?). In untangling Labour’s position on reform, he also needs to clarify his own views. This will be harder to do with a focus on repealing the Act rather than planning a new way forward.
Resetting the narrative and ‘owning’ the quality agenda
As much as Andrew Lansley needs to reset the Government narrative, so Andy Burnham must reset the Opposition’s. He should start by setting out which aspects of Government policy he would accept and improve, enabling him to criticise failures in their implementation effectively, as well as those parts he genuinely opposes. GP-led commissioning and local health and wellbeing boards would be good starting points, particularly given the unease felt by many enthusiasts of professionally-led commissioning towards the centralising tendencies of some in the NHS Commissioning Board.
He should also seek to recapture the Darzi agenda, ‘owning’ quality and positioning himself to make the case that clinical improvement is being sacrificed on the altar of reform. He should seek to identify one or two headline-grabbing (as opposed to details-oriented) policies which will mean something to patients and can be used as a point of differentiation with the Coalition. Potentially strong examples would include waiting times, dignity and respect and cancer.
By identifying a few areas of detailed policy, Burnham can build a skeleton on which to construct Labour’s positive narrative on health moving forward. By doing so, he can avoid calls to develop comprehensive policy probably three years before an election, and avoid creating hostages to fortune.
Tony Blair famously once said that he had no reverse gear, but at the moment, Labour’s position on health can seem like simply a reversal of the Coalition’s reforms. As Andy Burnham seeks to move Labour forward, the question is in what direction? Having shown his tactical prowess in campaigning against the Bill, Andy Burnham now needs to show an equally effective head for strategy as he seeks to develop a forward position for Labour.