Bad advice: how the jerry can salesman is crippling Cameron's Downing Street

George Osborne may be taking much of the blame for the crisis-a-day budget that has spawned anger from Greggs pasty counters to charity balls. But he shouldn't shoulder the blame all by himself. There is another figure who deserves to share the credit blame with the Chancellor: Francis Maude. When last we heard from the Cabinet Office Minister, he was advising us to stock up on petrol-soaked jerry cans in our garages, in an act designed to show just what he thought of all that silly 'elf and safety advice. Since his wisdom was not received in the spirit of helpfulness with which it surely was intended, the Horsham MP has disappeared.

Cameron will hardly have thanked Maude for his jerry can sales drive, as it added to the narrative of woes that also included his own misremembered pasty-eating escapades on Platform 3 at Leeds Station. But his ingratitude should be extended more widely when it comes to Maude. For he is responsible for most of the Government's woes. Oh, I know, Andrew Lansley must take the fair share of the blame for his crazed health reforms, but since he is so totally lacking in self-awareness, he can't really help it. And Osborne really should have foregone the White House in the week before the Budget, but he knew that his quadmate Danny Alexander was there to do the Budget read-through in his absence, so perhaps he can be forgiven too.

Yet, if Cameron had some politically astute, policy-focused special advisers in Downing Street, at least they could have confined the wayward health secretary to banning labels on fag packets and getting Coca Cola to feign an interest in making fat people thin instead of screwing up the NHS. Had he got somebody wise shadowing the Treasury they might have spotted the dangers of the granny tax, the pasty tax, the charity tax and all those other delights that keep on giving from Osborne's car crash of a budget.

But the reason that he relies instead on a policy unit dominated by civil servants with little political nous is Francis Maude. For it was his bright idea to mock Labour's lavish spending on, er, 84 special advisers across government that as Neil O.Brien of Policy Exchange so shrewdly noted in yesterday's FT cost less in a year than DWP pays in benefits to dead people every week.

People worry about the expense. But peak expenditure on special advisers under Labour was £5.6m a year – less than the government pays in benefits to dead people each week. Advisers enable ministers to grip their department and cut costs. Elsewhere, their numbers are much higher: Australia has twice as many, with only a quarter of the number of civil servants. Germany’s Angela Merkel has a whole chancellor’s department to enforce her will.

Maude decreed that the coalition - especially No 10 - would be purer than pure when it came to special advisers, obviously assuming that they were all straight out of The Thick of It rather than a vital lever of power. Funny enough, the civil service were generally happy enough to encourage him in his delusions. And the result is what it is: a dysfunctional government that is still making headlines with a cost-neutral budget and a government that lacks much sense of direction or purpose despite some progress in education and welfare.

Of course, wiser ministers have simply cocked a snook at the Jerry Can salesman by recruiting like-minded folk as policy advisers or in communications roles to top up their SpAd quota. But, really, why the pretence? It is as utterly silly an issue as the debate over party political funding. Politicians think the voters really care that much, when in fact it is the attempt to raise money from other than taxpayers that causes all the problems or the chaos that comes from not biting the bullet on special advisers that creates chaos.

Here is an issue where there needs to be some common purpose between the parties. Politics and good government need to be paid for. Let them stop treating voters like idiots, and tell it to them straight.

Does Dr Lansley really know best, with his blitz of 60 NHS targets that exclude waiting times?

Today, the Health Secretary, Andrew Lansley, has launched his 60 targets for the National Health Service. This from a Secretary of State who, in opposition, said that he would be getting rid of NHS targets. But, then, this was the same politician who misled voters (and, possibly, the Prime Minister) about his true intentions for the health service. Apparently his structural overhaul plans were hidden in an obscure speech somewhere that sadly didn't make it to the Tory manifesto writing meeting or the script for Conservative candidates.

To be fair, it is hard to find a lot to disagree with in the good intentions behind targets that range from reducing mortality rates for people with several different conditions enhancing the quality of life for carers. Few would argue that the NHS should not be doing all those things. But it is the presumptiveness behind the whole exercise that is more worrying.

Mr Lansley tells us in the same breath that all these measures matter to patients, whereas they care not whether they wait four or twelve hours in A&E on a trolley, or whether they are seen and treated in 18 weeks rather than 18 months by a consultant. On both these measures, of course, he is busily undoing a huge success of the Labour government in reducing patient waiting times drastically, whilst at the same time, incidentally, significantly improving patient outcomes and the quality of many hospitals and GP surgeries.

But, no, the word 'waiting' appears nowhere in the 56 pages of targets unleashed on the NHS today. 'Doctor'
Lansley thinks we mere mortals shouldn't worry our pretty little heads about how long it takes to get seen by a doctor, just as long as they are meeting wider outcome targets. Instead of objective measurable data on waiting times, we are instead expected to rely on the NHS version of those ghastly happiness surveys that have been foisted on us by No 10. Ministers will say that the 18 week guarantee is enshrined in the NHS constitution: if this is to be more than a paper promise, it should at least form one of the 60 targets that the NHS will apparently be judged on. As the Kings Fund has said:

With the spending squeeze beginning to bite, the number of hospital inpatients waiting more than 18 weeks for treatment is already at its highest level for more than three years and waiting times for A&E and diagnostic services have also risen. As the government has said that it is opposed to targets, it now needs to be clear about how this pledge will be measured and enforced.

The Government has already weakened the A&E target so that hospitals are expected to allow waits of no longer than four hours in 95% of cases rather than 98% under Labour. Yet, even in the summer months, this less rigorous target was breached by 29 hospitals, according to the Kings Fund, while longer diagnostic to treatment waits are creeping up.

The trend since June 2010 for the proportion waiting more than 6 weeks for diagnostics has been upward and the percentage waiting more than 6 weeks has risen from 1.13 per cent in August 2010 to 2.0 per cent in August 2011 – equivalent to a rise in the number of patients from 5,800 in August 2010 to more than 11,400 in August 2011.

The Kings Fund points out that, in 2007, a third of patients had waited more than six weeks, a measure of Labour's success in cutting waits since then. How many more hospitals will ignore maximum waiting times, now that the health secretary has said he doesn't think it matters to patients how long they wait? Meanwhile, we are told in today's document that are no indicators available yet for 'ensuring that people have a positive experience of care' and that these are being 'developed'. In other words, instead of using existing waiting times data as a benchmark (even the laxer A&E data), new figures will be dreamt up and approved by the omniscient Lansley to confirm that things are getting better.

But there is a bigger problem 'focusing' on so much data, and it is echoed to a lesser extent at education. Without a clear focus on a small number of straightforward national targets, one might as well have no targets. In Labour's early years, the Treasury bombarded departments with new targets that were intended to show that the extra money on offer would be well spent. It was only when these were heavily stripped back that they had any impact. Michael Gove has recognised at education, floor targets related to national tests at 11 and GCSEs helped lift standards significantly in weaker schools, just as maximum waiting times in the NHS helped measure systemic change there. Of course, there is always some gaming with any targets, but the reality is that in both cases, most of the improvements have been real and substantial. It is hard to see the same energy being devoted to all of Lansley's 60 targets announced today, not least at a time of real terms cuts in most areas. In the end, we may not be able to see the wood from the trees.

But we don't need to worry, do we? After all, Dr Lansley knows best. Doesn't he?

Fox fiasco, NHS bill chaos. Move Maude.

David Cameron's two big crises of the moment, the Liam Fox/Walter Mitty saga and the slow death of Andrew Lansley's pointless NHS legislation owe a lot to another member of his cabinet and a silly self-destructive piece of gesturist posturing. Francis Maude's obesessive opposition to political advisers in government has led Fox to use unorthodox methods to maintain the advice of his Alanticist soulmate Adam Werritty, while Lansley's ludicrous bill would never have seen the light of day had Cameron enjoyed half-decent political back-up in No 10 while it was being dreamt up.

I hold no brief for the increasingly bizarre Werritty or his politics, and some of the meetings that he set up would not have been appropriate for any political adviser. But a Secretary of State is entitled to have political advice that reflects his political position as a counterweight to the bureaucratic certainties that he will receive from his civil servants. The civil service is fine at offering what it sees as the tenable options on any issue, but it can benefit from radical challenge from political advisers as well as ministers. And the idea that ministers should not have sufficient political back-up to fulfil a democratic mandate is pretty undemocratic. I have no idea whether there is more to Werritty than a go-for for Fox: but if that is all that he is, he should have been able to work for Fox in an official capacity, albeit with fewer luxury hotel visits and first class flights. Had he done so, his role would have been properly defined.

Which brings me to Lansley's bill that is finally getting the scrutiny it deserves thanks to a re-energised David Owen and a canny offer from Andy Burnham, who has made a flying start back at Health by offering to back GP commissioning if the bill is dropped. As Camilla Cavendish points out in an excellent piece (£) in the Times this morning, the bill makes no difference to patients, it will be blamed for the next NHS crisis [which I believe will follow Lansley's equally ludicrous abandonment of targets] and it doesn't actually require primary legislation. Indeed it may even set back the private and voluntary provision already introduced as a result of Alan Milburn's reforms. But all of this was entirely predictable, and would have been seen by a half-competent, politically aware NHS adviser in No 10. Cameron lacked such a figure because the No 10 policy unit was virtually non-existent thanks to the strictures of Maude. Even today, it is filled with civil servants rather than politically astute figures, for the same reason.

Of course, Francis Maude thought he was being terribly clever when he announced a reduction in the number of Whitehall political advisers. And, funnily enough, the civil servants in the Cabinet Office cheered him on, as did the newspapers. It allowed a nice dig at Labour too. All of which would have been exchanged for a day's bad headlines had the coalition increased their number. Some ministers have created policy adviser posts for political appointees (who are subject to the strictures of civil servants on political activity) to get round the rules. But they shouldn't have to. The Prime Minister should have a strong cadre of able well-informed political advisers, and individual cabinet ministers should be able to assemble small teams of people they can trust politically to act in the interests of their democratic mandate.

So, if and when Liam Fox goes, and once Cameron finally gets rid of the disaster that is Andrew Lansley [and it gives me no pleasure to note that this blog told you so long before the election], he should also move Maude. And do a U-turn on political advice.

Time for a genuine cross-party consensus on care

Andrew Dilnot has produced an excellent report today on the future of social care for older people, addressing head on the fears of many about the costs of care in their old age. His proposals, that the level above which assets are taken into account should rise to £100k is more realistic than the current £23k, while his proposals for a cap on care costs and on living expenses in care are both reasonable. Ed Miliband offered yesterday to develop a cross party consensus on this issue, a generous offer given the pathetic pre-election attitude of the health secretary Andrew Lansley to imaginative suggestions from Andy Burnham while he held the same post, dubbing it all a 'death tax' in a piece of sub-Palinesque (Sarah not Michael) rhetoric ill-suited to such a sensitive subject.

Now there is again the chance to develop a proper consensus on this issue. David Cameron needs such a consensus as it will involve significant costs, and some difficult decisions about how to pay for it. He has been open to using individual Labour politicians on some issues: it is as important to be open to genuine cross-party working where it is so patently in the wider interest. For Ed Miliband, there is a lot to be gained from being consensual on such an issue. It was politically shrewd to speak to the Sunday Telegraph on the issue yesterday.

But this is, above all, about reaching a solution that is right for a growing elderly population, providing reassurance to those not yet in need of care, but also ensuring quality if they do need to enter care. And a lot more work is also needed to provide a proper quality mark for care homes and to create higher minimum standards, as that is as much a concern for many as cost. It is absurd that the Government is scrapping rather than widening the star rating system: families need a single easy to understand system that is clear on both facilities and standards, and it needs to be regulated and enforced by the government regulator. There should also be an equivalent of TripAdvisor where families can add their views and comments, as Janice Turner suggested in Saturday's Times.(£)

Social care is an issue that will not go away. It is something where politicians can genuinely make a difference - and show themselves in a better light in the process.

Changing the NHS changes

Readers of this blog will not be surprised that David Cameron and Nick Clegg are being forced into full-scale rescue mode for Andrew Lansley's health 'reforms' this week. The attempt to force GPs to become NHS managers was always bonkers, however good the more entrepreneurial GPs may be at managing local healthcare budgets. While Cameron clearly should have known this, he was clearly adversely affected by Francis Maude's decision to deny him a reasonable level of politically-savvy advice within No. 10. The removal of the quasi-accountable role of the Primary Care Trust clearly ran directly counter to Liberal Democrat policy (even if the latter sought to bring local authorities into the picture). It was also inevitable that their initial attempt to create a market based on price rather than quality would have to be reversed, given all the Cameron guff about the 'NHS safe with us' before the election. And the removal of waiting time targets (despite 'guarantees' in the NHS constitution) was always going to affect patients adversely - and it has started to do so.

So, the conjoined coalition twins have a chance to reverse Lansley's mess before the legislation is torn apart in the Lords. But they should not pretend that all they are doing is minor tinkering if they are making the more significant changes that are required. If they really want to win back public support, they need first to apologise for the changes, which were a clear breach not just of the coalition agreement but also of the solemn promises (there were a lot of those, weren't there?) made by Cameron and Clegg before the election. They then need to spell out what they will do and what they will not do, as a result of their U-turn. That should mean at the very least voluntary participation in the fundholding scheme, a residual role either for PCTs or local authorities and competition based firmly on quality. They need also to be rather more honest about the extent of improvement since 2000 - which is pretty obvious to anyone who has experienced the system before and after - as well as the extent to which it still needs to improve. And finally, they need to restore the maximum waiting times until such time as they genuinely are no longer needed, with any Tory who says that they 'distort clinical priorities' being forced to wait on a trolley in A&E on a Saturday night without being seen for a minimum of 10 hours. Only then will they start to convince the public. Anything less is (not very good) spin.

Educating the health secretary

While the battle to protect Libyans from Gaddafi continues, domestic news - bar, perhaps, this week's Budget - is unlikely to get much of a look in. But the weekend saw two further dents in the credibility of Andrew Lansley's grand plans for the NHS. First, the Observer revealed that recent polling showed record levels of satisfaction with the health service, after the reforms and investment of Labour. This information had been suppressed by the Government, which talks a lot about publishing facts but tends only to do so when the facts suit their case. In this case, Lansley apparently preferred 2006 data to more recent figures. The figures bore out the findings of earlier concerns about the government deliberately ignoring an improving trend in health outcomes. Both are shamefully promoted by Lansley. But we need to know the baseline, and trend, so we can judge his changes in the same light.

The second dent came in an article by the independent-minded GP and Tory MP Sarah Wollaston, in the Sunday Telegraph. She is particularly concerned about the impact that stripping out Primary Care Trusts and handing £80 billion of public money to GPs will have on the NHS. There should be as much concern about the premature removal of floor standards over waiting times, which are likely as budget cuts bite to lead to longer waits for treatment and a return to the trolley patients of the late 90s. As I have argued before, the issue is not whether reform is needed or even whether GPs can be entrusted with primary care budgets, but the utterly mad way in which these reforms are being introduced. There is no evidence they will work: it is all based on a hunch, which might be OK with a £5 bet at Cheltenham but not with an £80bn wager on the NHS. There is no distinction made between enthusiastic GP fundholders and unwilling conscripts. There is no proper transition with targets and primary care trusts. The whole thing has failure written all over it in large letters, and it is astonishing that neither David Cameron nor Nick Clegg can see it.

The absence of any proper No 10 policy scrutiny is evident in the way these changes are being introduced. And if the new policy wonks drafted in to the PM's Policy Unit have any sense they will immediately propose several changes to the Lansley lunacy. If they want a better model of reform, they could ask Michael Gove at education who has adopted this approach with academies and free schools. First, make fundholding a gradual process available to those who want it and have the skills to deliver it. Second, retain PCTs as a smaller but important strategic oversight until there is universal fundholding. Third, keep some floor standards - maximum waiting times for treatment and A&E - and use them as part of the accountability package. Fourth, be absolutely clear that competition will be on quality with fixed prices for treatment. That is the model that Gove has adopted in education - pace but choice on academies and free schools, residual local authorities, GCSE and Key Stage 2 floor targets and fixed per student funding (still linked to area) with adjustments for poverty and special needs (albeit with spending cuts). Lansley could do worse than learn from his education colleague. The rest of us could do a lot better if he did.

Time for a few more U-turns

I'm afraid I hadn't got around to stirring myself into a righteous rage about the management of the forests before David Cameron ruthlessly hung the hapless Caroline Spelman out to dry over the ill-communicated and poorly considered proposals. He badly needs to get a grip from No 10. But I am sure that its impact would have been far less damaging than two other government plans that remain a core part of the coalition project: forcing GPs to take over most of the NHS budget and the scrapping of the EMA. Both require swift retreats or they will lead to future problems when it is too late.

As I have said here before, there is nothing wrong with GP fundholding, where GPs actually want to hold the funds and where certain services that they will have no interest in commissioning are provided elsewhere. There is a lot wrong with simply handing over £80 billion of our money to consortia on the hunch that it might be a bit less bureaucratic or a bit more efficient. After all, the King's Fund has shown decisively that the Government's rationale for change is wholly bogus. Some GPs may have a natural aptitude for strategic decision-making. But just as some are lousy at diagnosing diseases, some will be hopeless budget-holders, at least when it comes to dealing with such large sums. This policy has disaster written all over it. Like the forest sell-off, it has no real support except from a few keen fundholders (and if they are keen, let them do it). In his heart, the PM must know this. Since he's in u-turn mode, here's what he should do. First, slow the reform timetable and the abolition of primary care trusts to allow reluctant fundholders to join as volunteers rather than conscripts, as with academies. Second, make the policy permissive, so that those with good business plans get the right to commission and those without must go back to the drawing board. Third, introduce a quality threshold alongside price into the value-for-money criteria, so that the policy doesn't end up replacing good provision with weaker but cheaper alternatives. Oh, and give Andrew Lansley another job where he can be less destructive.

On EMAs, it is a little different. This is a policy driven not by ideology but by funding. Ironically, the determination to pretend that school budgets were not being cut to fund the pupil premium led to the destruction of a proven, targeted measure to encourage ambition and achievement for poorer pupils to fund an untried, untargeted pot of money that will merely be used to plug funding gaps in schools that receive it. Michael Gove told school leaders six months ago that he wanted to persuade the Treasury that EMAs should stay. He clearly didn't succeed. But now that we are seeing the combined impact of government policies on young people, he needs to try again. Not least because without it, in the absence of compulsion when the participation age is raised, there will be nothing to persuade poorer young people who should do so to stay in further education when that is a better long-term option than a badly paid job with statutory part-time training tacked on. I know poorly paid young people lack the voting power of weekend forest-goers, but if the government cares about social mobility, it will make important changes.

Here's what Gove should do. First, all students who received an EMA in Year 12 should get one for Year 13 or the college equivalent. Scrapping an EMA mid-course is unforgivable: have university students been asked to pay a higher fee mid course? This will also avert another court defeat if a legal challenge takes place. Second, savings are needed, so the EMA should in future be made available to all students entitled to free school meals while at school whose family income remains low. This would encourage students to claim FSM at school, helping schools in areas where there is a stigma about FSM to claim the pupil premium. But it would still save money by confining eligibility to the poorest students. Third, the EMA's requirements for study and attendance should be strengthened, with rewards for those gaining good qualifications. Fourth, there should be a differential transport element depending on where students go to college or school. Such a scheme could be introduced at lower cost than the existing EMA but it would make a direct link with the pupil premium and bridge the gap between school and university, where poorer students receive significant support.

A wise education secretary would make the change before a beefed up Number 10 policy and strategy function works out what a disaster EMA abolition will prove to be - and before he loses another court case.

Cameron's NHS roulette

David Cameron deserved every moment of his rough ride on the NHS this morning. For he simply lied to the electorate about his plans before the last election. No ifs, no buts. He lied and Andrew Lansley lied. They said that they would not engage in any 'top-down reorganisations' of the system. And that is precisely what they are doing.

It would be one thing if Cameron were simply extending choice by engaging more private providers, which is one more sensible part of the Lansley agenda. It might be OK if they were allowing more GPs to band together to establish fundholding co-operatives to complement commissioning by primary care trusts. That isn't what they are doing. They are forcing GPs to run the £80 billion NHS budget, whether they want it or not. That is more than a brave experiment. It is a reckless gamble with the whole health service.

I support free schools and allowing schools to become academies. I support more private choice within the NHS. But I think this experiment is profoundly mistaken because it is being imposed. It is not evolutionary, it is destructive. And it comes at the same time that the coalition are tearing up the biggest success story of recent years - greatly reduced waiting times - which could see the return of the trolleys and excessive waits. I spent some time in hospital before Christmas and saw the benefits of those changes compared with my last visit ten years before.

It is one thing to press ahead with radical reform where there are clear benefits from doing so, or there are strong structural reasons for doing so. Continuing - and accelerating - the direction of travel of Labour's reforms (as Michael Gove has done to an extent in education) would have made sense. Throwing everything up in the air and seeing where it all lands is madness. It undoes ten years of solid improvement for no obvious gain. Not only will Cameron and the coalition come to regret this. So will the rest of us.

This post also appears at Public Finance. It has been highlighted at the Guardian and Stumbling and Mumbling.

Ministers can't ignore the boring details

The many twists and turns in the school buildings fiasco (many of which have been ably exposed by Ed Balls) seem to point to a major flaw at the heart of the coalition's approach to government: a failure to bother themselves sufficiently with the details and a wish covertly to continue in opposition rather than accepting the trials and tribulations of government.

The wholly unfair Sunday briefings against Tim Byles, an able leader of Partnership for Schools who pushed the capital programme back into shape, suggests an ugly tendency among some in government towards smears and childish oppositionism. But the fact is that whatever capital programme emerges to replace Building Schools for the Future will need someone to run it and keep the costs in check, and that expertise does not exist within the Department for Education, nor is it easy to find outside it. Michael Gove has deservedly been praised for his willingness publicly to accept responsibility for last week's fiasco; one must hope that he can equally publicly disown the trashing of Byles and PFS, and put a stop to similar such briefings.

The lesson that he - and his fellow ministers - should draw from last week's affair is that they need to look in much greater detail at the implications of decisions, and recognise that the simple slogans of opposition do not always easily translate into the effective policy of government. That is not to say that the ministers should accept everything they are told by the civil servants, especially where their advice could scupper the coalition's radical reforms; rather it is to recognise that without proper checks, without a recognition of the delivery mechanisms and agencies needed to effect policy, and without a clear message, the government will come seriously unstuck.

Civitas has rightly drawn attention to the likely three year setback that will result from a rapid rush to GP commissioning, a view largely echoed by the excellent Chris Ham from the Kings Fund on Today this morning. And the idea that the independent Food Standards Agency should simply be absorbed into the DoH beggars belief. Here are two accidents waiting to happen. And they won't be the only ones unless ministers recognise that they need to take charge and get behind the important details, rather than operating like a permanent opposition.

It may be boring, it is certainly time-consuming, but without greater focus on details the coalition will not last nearly as long as many people think.

Targetless Standards

The Home Secretary, Theresa May, made great virtue of her plans to scrap policing targets yesterday. No longer would the police have to answer 999 calls quickly, or bother themselves with such trivia as patrolling on the beat or their public reputation. Instead, they should just focus on bringing down the crime rate. Her colleague, Andrew Lansley had a similar outlook a few weeks ago as he consigned an already long limit on A&E waits of no more than four hours to history, and abandoned one of the most successful public sector reforms of Labour's years, the 18 week waiting time target. Instead consultants and trusts could pretty much decide for themselves whether to be bothered about patients suffering on trolleys or facing extra months in agony awaiting treatment.

Both moves will lead to a serious decline not only in the quality of the police or health services, but particularly in the rights of victims of crime and patients. A shared insight of the Thatcher/Major and Blair/Brown years was in the importance of customers of public services and their rights, and a recognition that producer or professional interests did not always know best. The most important change Labour introduced was in delivering minimum standards (in schools, expectations of minimum GCSE or test results delivered huge improvements in the most disadvantaged areas). Now the Coalition in a zealous attack on an admittedly excessively target-driven culture has thrown the baby out with the bathwater.

In one sense, this could be said to be understandable, at least in the police. By removing public expectations, the police can be 'freed' to concentrate on other matters. Yet in saying this, May seems profoundly to misunderstand the nature of the relationship between police and public. Most crime has fallen significantly in recent years (though some violent crimes are up) so the expectation that the police treat victims and the public better has not been at the expense of this core task. But it is also the case that the police are more than crime-fighters: their presence and that of community support officers makes people feel safer, particularly at night; their willingness to respond reassuringly to victims is as important in some crimes, like burglary, as the knowledge that the criminals will be caught. This has particularly been true in community policing. What these targets said is that the police recognise that they are funded by taxpayers, and are not a law unto themselves. Gene Hunt was being consigned to the past.

Andrew Lansley seems equally in thrall to professional interests. Despite polling clearly showing that waiting times are very important to patients, he is abandoning the maximum waits and allowing consultants to adopt a 'doctor knows best' attitude that was beginning to be challenged by the success of the targets. The point is not that most medical professionals don't believe they put patients interests first; it is that the default position of too many in the medical profession is to ignore what patients say they want. Without minimum standards, patients' concerns can too often be ignored. And the frustration and anger that follows will not be good for their health - or the NHS.

So, why is Labour not making more of such profoundly regressive steps? One reason is the preference of too many leadership contenders for attacking a record they should celebrate more - or at least offer a balanced assessment. Having failed to defend our record over the last few years, it is also harder to revive it now. But the bigger reason is the failure of the party to level with voters about where it would cut and what it would protect before the election (of course the other parties blatantly lied to voters but they are now in government and getting away with their dodgy reinvention of history). Had Labour followed Alistair Darling's advice, it would be in a stronger position to challenge those policies that will harm patients, parents or victims. But even those weaknesses should not prevent the party from trying harder: unless it does so now, history will have been rewritten by the coalition. And when the 8 hour trolley waits return, and the delayed 999 responses soar, the reasons will be lost in the mists of time.

Hopi Sen has a valuable follow-up to this post here.

Health improvements at risk

Today's report from the Kings Fund highlighting the extent to which there have been real improvements in access and speed in the NHS under Labour shows what is being put at risk if the Tories scrap the patient guarantees that have helped deliver these improvements. Isn't about time these issues were debated in this election campaign and that the BMA spokesman and Tory would-be health secretary Andrew Lansley was asked to explain the full effect of his returning the health service to the state in which the Tories left it in 1997?

Putting posters over personal care

If there is one issue that requires a cross-party consensus, it is social care for the elderly. As the numbers of older people continue to grow with medical advances, it is both a costly and long-term issue that doesn't lend itselt to crass sloganeering and cheap political advertising. So it was good that the three parties were prepared to sit down to discuss the issue. And it is quite frankly inconceivable that any solution will not involve a contribution, through insurance or otherwise, from those who would benefit from a more equitable system of social care.

One idea is that there should be a deduction from pensions, another that we might emulate Singapore's stakeholder funds, and another that homeowners should leave a fixed sum to the state upon their death. All have their strengths and weaknesses. But no sane person would want to rule them out and whinge if others declined to do so. Yet that is precisely what the BMA spokesman and shadow health secretary Andrew Lansley appears to have done. By not allowing a potential cross-party agreement on social care to develop, simply so that he could preside over a juvenile poster stunt, confirms that this man is simply up to any great office of state. As older people continue to sell their homes to fund social care, perhaps Mr Lansley could console them by explaining that their plight is worth it because it has made for a topical poster.

Dave's tribute to the BMA

John Rentoul is rightly disdainful of the producerist health policy reannounced by David Cameron today. The policy - which would scrap maximum waiting times for patients - has been developed by the BMA's spokesman Andrew Lansley, who occasionally fulfils the role of shadow health secretary, and it has been well documented on this blog.

So, there really is no excuse for anyone buying Dave's attempt to pretend that his sorry docment a great piece of radical thinking rather than a huge step backwards for patients. Yet the whole policy is being sold deceitfully to the electorate with a compliant media failing to explain what it really means. For example, I recently received a lengthy 'questionnaire' from William Rees Mogg's eccentric lad, Jacob, whose dad tells us in his Times ramblings each week is destined to become my local MP, asking whether we liked the Tory policy of getting rid of 'wasteful and harmful NHS targets' - or what today's 'draft manifesto' calls 'politically motivated process targets.'

I doubt many voters understand that what this really means is moving from 18 week to 18 month waiting times for treatment or from 4 to 12 hour waits in A&E, or scrapping cancer treatment targets. But then they'll surely be thrilled to know that while they languish on a hospital trolley they can go online and see if any other A&E had a better record the previous year. Isn't it about time the Tories' ludicrous 'health policy' got the scrutiny it deserves?

Playing politics with the law

Michael Gove has been on Today bemoaning the level of 'electioneering' in today's Queen's Speech, suggesting that such tactics would have been beyond previous Prime Ministers. I presume Michael was having a laugh. Otherwise, I must have been dreaming when John Major invented 'a grammar school in every town' just ahead of the 1997 election - the policy Michael and David Willetts have wisely binned - and extended assisted places in their last legislation as a way of creating silly dividing lines with Labour on education (which we managed to turn to our advantage with a policy of cutting infant class sizes instead).

In fact, today's measures are surprisingly strong for a government that is supposed to have run out of steam. The new national care service blueprint is a long overdue way of addressing a major concern for many families. The earlier guarantee of an 18-week waiting time for treatment shows how far the NHS has come since 1997, and matters hugely to patients, but it does challenge the BMA spokesman and part-time shadow health secretary Andrew Lansley who would happily see waiting times back at eighteen months, if it kept his consultant chums happy. The parent and pupil guarantees may be more reflective of what already exists, but they are an important statement of measures that matter. And the commitments on fiscal responsibility answer the charge that the Government is not ready to cut the deficit. There is no reason why the Tories should oppose any of them - or object to their introduction.

However, when Michael Gove told us what crucial legislation he was planning, the best he could do was to declare more powers of confiscation for headteachers. Since heads have had significantly extended powers in this area under Labour, it is doubtful these are quite as crucial as he pretends. The measures he wants could probably be introduced through secondary legislation or ministerial guidance. But then if he is elected, he will want to have a first education bill to give the impression that he is 'changing' things 'radically'. How shocking it would be to see such blatant politicking with legislation and Her Majesty's precious time.

How the BMA wants to prevent prevention

Andy Burnham, the health secretary, has provided further evidence of life in the Labour government today with a sharp reformist speech on the NHS. His headline plan to allow patients to register with whichever GP they wish is a good one, not least for commuters who otherwise have to give up half a day to see a doctor.

The BMA's spokesman Dr Laurence Buckman generously is not opposing the idea outright - after all their lead parliamentary spokesman claims the idea as his own - but has helpfully presented lots of difficulties, as the BBC reported.

"What will happen to their practice if they're destabilised, because some of the younger, healthier patients have gone elsewhere?" [he said] The union says that a mix of patients, some of them not visiting their doctor often, helps general practice to be cost-effective. It warns that if younger people register near their workplaces, some practices could be left with patient lists mainly composed of those with long-term conditions and complex illness.

In other words, we are being paid to have lots of people on our books who can never see us because it is too inconvenient for them to do so. We must stop them from seeing doctors near where they work even if it prevents them getting more serious illnesses, so that we can continue doing things the way we always have done, with our generous new contract.

Andy Burnham must make sure this plan is in place ahead of the next election - in the interests of the health of all those people who work and pay taxes to cover GPs' salaries

Mandelson sets a reformist tone for pre-election debate

A very good speech from Peter Mandelson in the Progress event at the LSE today. He rightly emphasised Labour's reform record and credentials, and cleverly set up serious dividing lines with the Conservatives over minimum standards.

There was much talk of academies and foundation trusts, and a sensible exposition of the differences between the two parties on the role of the state, not least on issues like minimum waiting times for treatment. By providing such context, he has made it much easier to explain the different approaches between the parties to savings and cuts that will be needed in the future.

We start from a position of credibility given that the big success story of British social democracy in the last twelve years has been the rescue, revival, and rehabilitation of public services as a vital part of our national life. Britain's welfare state and public services survived the Thatcher/Major era – but only just.

Since 1997 Labour has, in effect, saved the NHS, transformed educational standards and dramatically widened access to educational opportunity. These achievements are now taken for granted, almost discounted by those to the right and left of us. It has led to public service innovation, with the introduction and dramatic expansion of Sure Start and Children's Centres, for example, and modernised the delivery of existing services with for example, the establishment of NHS Trusts and academies.

And all this has required a huge injection of additional cash. The New Labour mantra of "invest and reform" summed up a policy which has seen public spending on the NHS double in real terms since we took office. Per pupil funding in schools has also doubled. At the same time public service delivery has been opened up to a diversity of providers with a new range of choice for patients, parents and service users.

So, while the headlines may be about belt-tightening, the subtext is a much more important repositioning of the Labour argument towards a reform agenda, and away from the rather unproductive early efforts to appease its leftwing critics.

Labour, then, have always been committed "state reformers" and should feel no nervousness about the label. Rather, today's challenges require us to accelerate the pace of reform......The way forward is not to get rid of individual service entitlements as the Tories propose. It is to set a framework that allies these entitlements that the public rightly expects to the creation of a greater space for our public servants in how they deliver the services for which they are responsible.

To be fair, Ed Balls, who has been criticised for his attitude to reform, effectively pre-empted this repositioning with his academies blitz last week, as Mandelson reminds us. Alastair Darling has already shifted the spending argument and Andy Burnham at health is a strong reformer by instinct.

Once the argument is coherently and consistently framed again in these terms, Labour is in a stronger position to deal with the details of Michael Gove's school proposals and the vacuousness of BMA spokesman Andrew Lansley's health policy. This speech could prove to be a very important turning-point in the pre-election debate.

The value of universal healthcare

Janice Turner's column in this morning's Times is one of the sharpest defences of the NHS and best indictments of the shortcomings of American healthcare that I have read:

I happened to read Senator Grassley’s statement that in Britain the 77-year-old Ted Kennedy would not have received treatment for his brain tumour, at the bedside of my 86-year-old father. Mr Grassley’s view that “when you get to be 77, your life is considered less valuable under these [NHS] systems” seemed rather surreal, as my old pa, who collapsed at home, was brain- scanned until it was discovered that he had suffered a minor stroke. As a consultant attended him, physios assessed him and he was found a place in a rehabilitation unit, where he will spend a month recovering, I thought how the life of this elderly man — no high-born statesman but a person of modest means — was treated as immensely precious. Throughout this difficult week, in which I was plunged abruptly into the dark labyrinth that is geriatric care, I gave thanks that the least of my worries — and more importantly my father’s — was money.

Of course, the NHS needs reform, and the Labour government has done - and is doing - much to introduce choice, shorter waiting lists, cleaner and more pleasant wards. Indeed, a danger of the crudity of the debate as it has been framed by the 'eccentric' Daniel Hannan is that the Conservatives retreat further into the dishonest bubble of complacency on health policy that has been effortlessly occupied by BMA spokesman Andrew Lansley since he became shadow health secretary.

An end to entitlements on waiting times, as the Tories propose, will bring back the extreme examples of waits that have so exercised the Republican right. There will be plenty of A&E horror stories again, and an end to the 18 week diagnosis to treatment guarantee.

Nevertheless, the great principle of the NHS, as Turner says, is its underlying principle of universality. Preserving that is what matters.

Progressive Conservatives?

George Osborne has chosen to eschew the hospitality of Nathan Rothschild this year - or more likely the other way around - in order to speak to us about the Conservatives as the new progressives. But they are progressives with a twist: as a result of their belief in reform, they will also save cash, he says.

Let's take these propositions at face value. On reform, the record is pretty patcy. It is true that Michael Gove has some interesting ideas on schools, though his structural school reforms largely build on Labour academies and legal requirements for more providers in schools. The big difference is the cost. An extra 220,000 surplus school places are promised, and are essential to deliver the promised changes, at a cost of £1 billion a year. Some £4.5 billion of capital would be raised from existing plans to replace or renew schools. So, no savings there.

But, as we have seen, education reform is not matched in health. Indeed the BMA spokesman and shadow health secretary Andrew Lansley is determined to push up waiting times, demand less from doctors and assume that patients will prosper merely because they (and the hackers of Russia) can access their patient records on Google. He has also declared that NHS spending will rise without this reform.

Equally, on political reform, the record is just as patchy. The Totnes primary was a good idea, and Labour should embrace primaries. I'm backing the Progress campaign there. But it is hardly cost-free. And more to the point, David Cameron has set himself resolutely against electoral reform, even though it would with the Alternative Vote or Additional Member System do more to ensure that voters had a direct say over who was their MP than the current system. Again, hardly a bastion of progress.

But, there is a reason they're still called the Conservatives, isn't there?

Lansley the lingering liability

Fraser Nelson asks how long David Cameron can keep the BMA spokesman Andrew Lansley in his shadow health post (let alone make the man health secretary if he wins a general election).

On the Marr sofa (or the Sophie Raworth sofa as it was today), he announced that the Tories are planning "real term increases to the NHS year on year." Well, David Cameron has only said he would protect health from cuts - but he has not specified how long for. It could be as little as one year.

Nelson worries that he has gone native on NHS spending, after a series of gaffes and unapproved funding commitments. Cameron should be equally worried that Lansley is opposed to any sensible accountability or reform for that money. After all, his every pronouncement is an echo of what the BMA says, and apart from shoving patient records securely on Google, he shows no interest in what patients experience at the hands of their members.

Lansley was promised the job by Cameron for some reason best known to himself. But having changed his mind on virtually everything else he has said over the last two years, surely it can only be a matter of time before Cameron finds a new shadow health secretary?

UPDATE: And even his Google Health wheeze seems to have fallen flat.

A good time to bury Tory U-turns

With the news dominated by moats and house-flipping, not to mention David Cameron's selfless spin on the subject, the Tories have been quietly performing a big policy U-turn. Regular readers of this blog will know my views about BMA spokesman Andrew Lansley, who has an occasional sideline as Cameron's health secretary in waiting. While Labour - with Alan Johnson - has been pursuing a resolutely patient-focused health agenda, Lansley has shown as much disdain for patients as the haughtiest consultant.

So, it is a pleasant surprise to see the Tories finally admitting that they got it wrong over polyclinics, Labour's plans to improve patient services by locating a range of GPs and specialists under one roof. Needless to say it has been left to an underling, Mark Simmonds, to admit that when Lansley and his protector Cameron claimed a year ago that one in five surgeries would close as a result of the new centres opening, they were talking utter rubbish.

Perhaps the perceptive Mr Simmonds could turn his attention to his bosses' belief that patients' interests would be well served by scrapping maximum waiting times and bringing back eighties-style waiting lists?

This post has been picked up by John Rentoul and Liberal Conspiracy.