Navigating the politics of health care reform

Reform of the NHS is rarely as successful or enduring as its architects intend. The reforms of Thatcher, Blair and Lansley – for example – all ran into political difficulty, were blunted in the resultant compromises and were all ultimately unwound, at least in part. If this government is to succeed where its predecessors failed, their reforms need to be accompanied by a serious political strategy to see them through. Such a strategy needs to chart a path through the obstacles that make the politics of health reform uniquely hard.

The first obstacle is that public concern for the NHS is high but public understanding of how the NHS works is low (and always will be, that is the public’s prerogative). Any level of controversy thus has high potential to unsettle the electorate. And hence to unsettle parliamentarians, whose support for reform can ebb dramatically.

The second obstacle is that, if reform is meaningful, it will challenge incumbent producers – and these producers are uniquely powerful. They are much-loved hospitals and GP practices – represented by groups who can lay fair claim to ‘speak for the NHS’. These groups can be sophisticated Whitehall players – and if the Department of Health and Social Care does not listen to them then they can make the Treasury and Number 10 listen to the fiscal and political risks they articulate instead. And if Whitehall isn’t listening then they can take their case to the public. The power of these producers makes any cross-government consensus for health reform uniquely fragile.

The third obstacle is that opponents of reform can mobilise clinicians against it, which lands ministers in a ‘doctors versus politicians’ row. This is never a safe place for ministers to be, for the simple reason that they will lose. If a clinician says a reform is clinically risky, a politician saying otherwise will always be less trusted.

How can a political strategy mitigate these risks?

The first necessary element is to ensure complete alignment between Number 10, the Treasury and the Department of Health and Social Care. Unless the three march in lockstep, opponents of reform can play them off against each other. And given Number 10 is the institution most sensitive to the politics, and most prone to wobbling, it falls to them to ensure the Prime Minister is completely alive to the risks inherent in any reform process. The Prime Minister must know what they are getting themselves into, and the three institutions together must collectively take all major decisions as the reforms progress.

The second element is to build a clear case for change: if the status quo is indefensible it will be harder for opponents of reform to defend it. To their credit, Labour did the right thing in commissioning the Darzi review to illuminate the problems, and in investing in a mass engagement exercise to further socialise the message. It is therefore remarkable that having gone to this effort the government pursued a formal reorganisation of the NHS as its first landmark reform, even though the Darzi review explicitly concluded this was neither necessary nor desirable.

The third element is to marshal clinical allies. Ministers stand a chance in a ‘doctors versus politicians’ row if they have at least some doctors on their side. And the government has considerable power of patronage to persuade them, which it needs to use.

The fourth element is to buy off losers. Despite what the Treasury might hope, it is not possible to reform in a revenue-neutral way – because reform creates winners and losers, and the losers need at least some compensation to keep them quiet. The government must therefore purchase reforms that offer the greatest efficiency and productivity improvements over time – and if it doesn’t have sufficient funds then the answer is to do less reform. It cannot be bought on the cheap.

The fifth and most important element is to pick fights carefully and sequentially. Health care is full of powerful and organised professional groups, and this dynamic can be made to work in reformers’ favour – but only if fights are not with everyone, everywhere, all at once. If we are about to witness the rebirth of foundation hospitals then it will be advisable not to shake up GPs at the same time. Or vice versa. And if reform of everything is unavoidable, it should be piloted in the worst-performing area first – where it is harder for opponents to argue against. This naturally has an impact on a reform timetable: wholesale reform requires at least two parliaments, and governments should accept that.

And if the government is going to the trouble of picking fights carefully, there is no point advertising them in advance – for example, through a details-heavy 10 Year Health Plan or through legislation, which is always best avoided. The NHS Plan of 2000 presaged nothing of the landmark reforms – such as foundation hospitals and Payment by Results – that Blair happened upon later. Instead, the plan – signed by the trade unions that then mobilised against these later reforms – simply set out a number of performance ambitions alongside a mishmash of motherhood-and-apple-pie initiatives dressed up as radicalism. The 10 Year Health Plan would do well to emulate it: a sense of the destination is fine, but it does not need to set out exactly who the government intends to fight and when.

But there is one final constraint on reform that a political strategy cannot address. For all the talk there might be right now of structural change, commissioning, regulation, competition, integration and incentives, without reform of the workforce their potential will always be limited – because change is hard in any organisation if it requires bargaining with trade unions and professional bodies, and if the workforce is trained inflexibly. And workforce reform in health care – because of the training lead-in times, because of the high barriers to entry and because the workforce is fundamentally scarce – is especially hard.

Reforming how health care professionals are trained, how they work, and even deciding how many there are is not solely in the gift of ministers, because so much of workforce policy is professionally-led – and progress thus relies on consensus. But if the Government wants to deliver successful and enduring improvement in the NHS, it would do well to focus its efforts here.