Westminster politics usually results in a majority government and gives the governing party the ability to bring in sweeping reforms. In contrast countries such as Germany and the Netherlands – where grand coalitions are the norm – find it more difficult to make big bang reforms. Changes to the health care system have been incremental, gradually shifting over time as a result of political compromises. Although Lansley had his plan – a grand design for the reform of the NHS which he had spent many years in opposition developing – without a majority in parliament, this plan has been (and continues to be) subject to negotiation and compromise with the coalition partners.
The rapid negotiations between the parties resulted in the publication of the programme for government. This set out at a high level the main policy objectives of the new government including those for the NHS. It mixed together ideas from both sides, with agreement on the need to abolish quangos and reduce administration costs. However, although scrapping strategic health authorities featured in both manifestos this was not explicit in the programme for government. On social care there was compromise: the Liberal Democrats got their independent commission to look into funding options chaired by Andrew Dilnot, the Conservatives got their Independent NHS Board.
In the rush to put forward their plan, the government failed to set out a clear account of the shortcomings of the NHS and the challenges it faces. The Prime Minister has belatedly rectified this in today's speech. Further compromises were made during the preparation of the White Paper which had to pass the scrutiny of the coalition committee. The abolition of primary care trusts (PCTs) were not foretold in either manifesto or the programme for action. Although the Conservatives were committed to devolving real budgets to GPs, PCTs were still to remain as the statutory commissioning authority responsible for public health. Speculation has it that this left the Lib Dem policy of elected representatives to PCTs looking weak. The compromise was to hand greater responsibility for public health to local authorities and abolish PCTs. Thus GP commissioning consortia (as statutory bodies) and Health and Wellbeing Boards were born.
Few changes were made to the proposals following the formal consultation despite concerns from stakeholders – perhaps a missed opportunity in hindsight? And the Health and Social Care Bill was introduced to parliament in January. In April – in an unprecedented move – the government 'paused' the legislative process in order to conduct a listening exercise.
While coalition politics (and a growing unrest among Lib Dem MPs and the wider party) have probably played a major part in bringing about this pause, there are other factors too. The government seems to have underestimated the level of popular and stakeholder opposition (as it did with the forests). Many of the individual policy proposals were rightly understood to be completing the unfinished business of the Labour government's reform, but taken together the scale of the changes was seen as revolutionary and risky. Add to that the financial context and the pressure on government to rethink was great. With vocal criticism in the Lords, including high profile cross benchers, the government could not be confident of the Bill's safe passage.
There are many sceptics of the public listening exercise. Yet there is little doubt that there will be changes, more likely as a result of political compromise between the coalition partners than through listening. If ever one needed reminding, policy-making is a messy process, perhaps, more so under a coalition government. The result, in the words of Carolyn Tuohy, is a 'mosaic' rather than 'blueprint' for NHS reforms. The question is will the different pieces of the mosaic fit together to make a coherent picture?