Much has been made of the failure of Richmond House to communicate NHS reform and many of these criticisms are fair. But less has been said about the role of Number 10, which is often portrayed as riding to the rescue with initiatives such as the pause. Yet, as the Prime Minister accepted yesterday, his team must take their share of the blame for what is unlikely to be seen as an exemplar of how to communicate far reaching changes.
This blog is not about the rights and wrongs of the reform proposals but about how they have been communicated. Let’s be clear, this was a difficult challenge. The slowdown in spending, combined with a general reluctance to tinker with a cherished British institution meant this was never going to be easy. Add to this that the vagaries of coalition were new to everyone and necessitated providing sometimes very different messages to different audiences. Yet, despite this, it is hard to escape the conclusion that, although some of the reforms were inevitably controversial (think competition), the way in which they have been communicated has been a hindrance and not a help – and Downing Street must accept some responsibility for this.
Of course the Department of Health has not helped. A Secretary of State who appeared more prone to anger than empathy in interviews and seemed more at ease talking about technical issues such as tariffs than he did the hopes and fears of patients is hardly the ideal front man for reform. Compare this, for example, to Alan Johnson, the human-talking great soother of any controversial policy. Equally the pro-reform briefing operation was chaotic in the early days, with journalists receiving conflicting information, often without the sensitivity to the politics of reform required for such a challenging and emotive issue. On top of this, the Department machinery was destabilised by restructuring, and arguably deskilled in terms of communicating complex and controversial reform. Even if Richmond House’s comms had been perfect, then this would have been a challenge. But they were not.
Downing Street, however, has also made significant missteps which help explain the Government’s predicament. There are four key issues for which the Prime Minister’s team must take responsibility.
The first failing is not recognising how contentious the reforms would be. There is a sense that Downing Street didn’t quite know what it was letting itself in for, and had allowed itself to be lulled into a false sense of security, with (miniscule) real terms increases in spending acting as an insurance policy against any political threat. If you are going to introduce contentious reforms, then you need to prepare the ground carefully and this needs to be done at a cross-government level. Downing Street failed to recognise the threat and so did not.
Secondly, and knowing his Secretary of State’s limitations as a communicator, David Cameron needed to sell the vision behind the reforms. Paul Corrigan has repeatedly argued that the Government has failed to establish a consistent narrative on the reforms. He is right that there are different and sometimes conflicting explanations about why change must happen. The time to set out the vision was in the first months of the Coalition, using the honeymoon period to get a fair hearing. Once reform had descended into the weeds of complex legislation, the vision thing was always going to be hard to establish. It took until mid-January in 2011 for the Prime Minister to make a substantive speech on health reform – over six months after the publication of the White Paper.
Thirdly, it is not clear that Downing Street understands the intricacies of health or its stakeholders. There is no doubt that the Prime Minister shares his Secretary of State’s analysis about the changes that need to occur in the NHS, but is not clear that his team understand the sensitivities in dealing with such a large, professional and committed stakeholder community – and one which is stacked full of political-sized egos which do require some prime ministerial attention. It is not sufficient to reach out over stakeholders, directly to voters (tempting though this might be). In health more than any other area, stakeholders mediate public opinion. Everyone knows someone who works in the NHS and, by and large, they trust them. The media know this and therefore give greater prominence to the arguments of health professionals than they might do to other groups.
This week’s ‘summit’is a case in point. It is a perfectly reasonable strategy to choose to engage with those groups who are not implacably opposed to your policy. This appears to be the Government’s approach, working on the basis that there is no point in seeking to appease those who cannot be appeased, at least by any concession that you are willing to make. Instead you carry on talking to those who have concerns but are not opposed in principle, seek to improve the legislation and push it through Parliament. However, if this was the strategy, nobody made it clear. Instead the Government endured a weekend of speculation about who was on guest list and why various groups were conspicuous by their absence. The narrative was more akin to gossip about a teenage party than a major piece of public service reform. What should have been a routine opportunity for the Prime Minister to meet people involved in NHS delivery was turned into a ‘summit,’ complete with protestors at the gates of Downing Street and a high profile opportunity to heckle the Secretary of State. A positive was turned into a negative.
The final reason why Downing Street’s communications approach has hurt is that it has conveyed a sense of uncertainty about the Prime Minister’s own commitment to reform. Conservatives love to reminisce about Mrs Thatcher’s “You turn if you want to. The Lady is not for turning” conference speech. Suffice to say, there have been reasons to suspect that this may not be the case for the current incumbent of Number 10. I would contend that the pause, far from resetting the political narrative on reform, simply created the impression that the Prime Minister could be swayed. Recent briefings apparently from Number 10 – denied, but not rapidly enough – about the prospects of both the reforms and the Secretary of State have just added to this sense. Much of the heat being felt at the moment results from stakeholders having the impression that further concessions are always possible.
Why have these problems occurred? Much can be explained by the way that Cameron’s Downing Street works – something which hasn’t gone unnoticed. The Prime Minister likes to receive advice from many different voices, often with differing opinions. These competing voices are creating competing strategies and narratives, meaning that the Prime Minister’s wishes are not communicated through the Whitehall machine. It also means that weaknesses in the Government’s position don’t get clearly addressed and a clear line is not developed. This was the case with the “no top-down reorganisation” claim – something which even advocates of the reforms have long felt was futile to maintain.
This collegiate approach may have worked in opposition, but it is less suited to the pressure of government. The media and political cycle responds to a clear lead from the Prime Minister, but too often the competing visions have manifested themselves in the public domain. It is easy to see how the issues highlighted in this blog have arisen from the confusion. It creates challenges across all policy areas, but has been painfully apparent in health.
There will be many communications lessons to learn from the journey from Equity and excellence: Liberating the NHS to what will become the Health and Social Care Act. Many in Number 10 may bemoan the difficulties they find themselves in on health, but some are of Downing Street’s own making.