Coalition government and health: one year on

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Before the election result was announced just over a year ago, few people guessed we would be governed by a coalition of Liberal Democrats and Conservatives. Even once the coalition was formed there was much speculation about the policies that the new government would pursue. So what has been the impact of a coalition government on the process of reforming the NHS?

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?


Malcolm Morrison

Retired Orthopaedic Surgeon,
Comment date
17 May 2011
Certainly there are problems in the NHS - as there have been since its inception! One of the problems (which the politicians dare not address) is that 'demand exceeds supply' - hence the need for some sort of RATIONING (a word that is missing from politicians' dictionaries!)
Doctors should ADVISE on the sort of service needed and how to make it work locally but they should NOT become the purchasers (commissioners) of health care - because it brings about a conflict of imnterests; and because it lets the politicians off the hook in deciding HOW MUCH they can 'afford' to purchase. It would be playing into their hands if we are seen to have to take the blame for any shortcomings!

david dawson

workwise{suffolk] limited
Comment date
19 May 2011
I met a GP practice yesterday who had no idea what the future arrangements would be for commissioning mental health services[our organisation provides employment/training services].They said that this was a critical area for the integration of health and social care and they were concerned that this would not be acchieved.

Karen Taylor

Comment date
19 May 2011
Like the mosaic analogy I have been thinking of the reforms as akin to a giant jigsaw with the outcomes of the various national reviews like Dilnot and the Hughes-Hallett palliative care funding review as key pieces; but the question remains as to which piece will be laid first and will the others then still fit? Furthermore how long will it take to piece it all together in the absence of a clear picture on the box!


Comment date
26 May 2011
GPs and hospital physicians all over the country are over stretched with both central and local govt deadlines to beat and not to mention the never ending paperwork, the Nhs i believe was designed to cater for a small britain at the time, with the recent population trend on the rise pushing the service to its knees, it would be pointless not to deal with the work load for the real mechanics of the system and burden them more with financial accountability, liability, purchasing care packages and service implementation....But there has been alot of negative less speculation on what the changes would mean for the clinicians and the politicians...maybe we all need to take a deep breath and find ways of making these changes work for all residents of the united kingdom...poor, rich, policy makers and that person who has travelled to the island purposely to receive treatment for which they might or might not be entitled.

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