It has been a tempestuous time for the NHS. Reform, restructuring and delivering unprecedented levels of savings have sapped the energy of the health service and those leading it. The summer of 2012 represents a turning point, as the reforms shift from legislation to implementation and the efficiency agenda moves from national action to local delivery. Yet the Health and Social Care Act has now passed. After one of the hardest fought and most controversial debates over legislation in the modern era, a reassessment of Andrew Lansley’s role in driving through one of the most radical pieces of public service legislation ever is already underway. This is not simply a story of a clumsy politician who stumbled his way through. Instead it is one of a man who used his knowledge of the machinery of government, who took advantage of the peculiar circumstances at the beginning of the Coalition and who (no really) was able to compromise to tie in the Liberal Democrats. Whatever you think of the reforms and their communication, it was some legislative achievement.
Often dismissed as a dead man walking, the Coalition’s recent travails have also put Andrew Lansley’s own communications difficulties into context. He could be forgiven for wanting a quiet summer to reflect on his momentous and often fractious spell in Richmond House, safe in the knowledge that his flagship legislation is unlikely to ever be repealed in its entirety. However, if that is his wish, it is unlikely to be granted.
Passing the Act may have been difficult, but the hard work has only just started. Delays in passing the Act have slowed momentum in the transition and there is catching up to do. This will be a difficult summer for many in the NHS who are still uncertain about where they will work in the new system (if they will work in it at all). The enthusiasm of clinical commissioning groups is about to meet the heavy hand of the authorisation process, which for many will feel like it is yanking them back to a reality they are less than comfortable with. On top of this, literally thousands of pages of secondary legislation will have to be considered by Parliament, filling in the (often devilish) detail behind the Act.
Also, the Coalition will have to grapple with the running sore that is social care. Although the media focus has been on funding, there are also significant issues with the legal framework for social care, the way in which it is commissioned and the manner in which quality is measured. Scandals such as Winterbourne View are only the tip of the iceberg. Beyond the plain illegal, social care has become a race to the bottom, with costs being cut at an unsustainable rate, squeezing margins and compromising quality. There is a consensus that this cannot continue, but the question of how to address it remains controversial. There will undoubtedly be a political temptation to delay action, but there is an increasingly vocal lobby arguing that change cannot wait. Ministers will be wary of ignoring it.
Yet the most politically difficult challenge will be posed by hospital reconfiguration. This is a polite phrase for moving, merging or closing some services. The public are unlikely to be appeased by a gentler sounding phrase. The simple truth is that there are many underperforming (and in some cases unsafe) services and something needs to be done about them. Reconfiguration may often be clinically (as well as financially) justified, but that doesn’t make it any easier in political terms, particularly as many of the struggling hospitals are in marginal seats. In truth, they have probably survived so long precisely because they are in marginal seats, but, given the financial constraints facing the NHS, the luxury of ducking the decision no longer exists. There will have to be some tough and politically painful decisions. Effectively communicating these could make selling the Act seem like an easy task.
The risk for the Coalition is that reconfiguration may become conflated with reform which in turn may be confused with ‘cuts.’ This would be a politically toxic brew indeed. Andrew Lansley may have less time than he might have expected to enjoy the Jubilee and Olympics.