Ministers have to be politicians too

Andrew Lansley remains the Health Secretary for now. But, as this blog has long pointed out, he was a disaster waiting to happen. Before the election, he said he wouldn't reform the NHS (apart from in some secret memo that he sent to himself). His initial health reforms were incoherent, and hampered by his daft insistence that he was scrapping Labour's hugely successful floor targets, even though he wasn't quite doing so. This sent a signal to the system that they could push more people onto longer waits. Which they did in too many cases. When he was forced into making a major U-turn on GP commissioning - effectively removing the compulsory element - he pretended he had made no concessions at all. Which was pretty stupid, at a time when his coalition partners were demanding concessions. So, now David Cameron is being forced to expend huge political capital keeping a hopeless minister who doesn't do politics.


But Lansley is not the only political accident waiting to happen. Iain Duncan Smith may be a more likeable character, but he shares some Lansley traits - a lack of political skill and an enormous self-belief - and his plans have disaster written all over them. The Duncan-Smith reforms make perfect sense, of course, and are right in principle. It is right to aim for a single simpler universal credit, and it is pretty indefensible to be arguing that a £26k benefits limit (net) is too low. It would have been better politics to recognise the need for some regional differentials at the outset: call it a London weighting, perhaps. But because Duncan-Smith isn't really much of a politician - his politics, like that of Lansley, is limited to a sneering pretence that nobody else has ever executed any reforms of any worth in this area, especially the last Labour government. And because the echo chamber that is the Tory press cheers him on, he is convinced he will succeed. However, the Treasury expects Duncan-Smith to fail. George Osborne apparently makes no secret of his disdain for a project that relies on one failsafe mechanism for success: Government computer procurement.

Lansley and Duncan-Smith both profess expertise in their fields. But they lack the skill to sell or see through their grand ideas. The last few years may have given politics a bad name, but politics is vital to the successful delivery of change. A good politician exaggerates the concessions he or she has made to win over critics; a bad one pretends he has made none. Health and welfare reform were two of the coalition's big ideas. It is a mark of Cameron's poor people judgement that be put the two ministers least likely to deliver them successfully in charge. The PM is said to have an aversion to reshuffles. And Tony Blair reshuffled too many people too often. But if he wants to salvage either of these key reforms, Cameron needs to overcome his aversion. And he needs to do so pretty quickly.

Cameron must do details

It is not easy being Prime Minister, having to keep on top of lots of pesky details across Whitehall. It can also be a major cause of inertia if you strike the wrong balance between strategy and substance: look at Gordon Brown's first year as PM as a lesson in how not to do it. But you can also go to the opposite extreme, and that has been the characteristic of David Cameron's first year in office. He paid little heed to the plans that his old boss Andrew Lansley was concocting at Health, even though they ran directly contrary to his promises to voters, and more importantly they had too many half-baked elements, such as compulsory commissioning for GPs and the effective scrapping of waiting time targets. He was far too busy to notice that Kenneth Clarke at Justice was turning the idea of the Tory party as the voice of law and order on its head, with promises to release rapists and paedophiles quickly so long as they fessed up. And his inattention has led to several other lesser difficulties too, from the scrapping of sports partnerships at the DFE to the sell off of forests at Defra. And two weeks running, this disinterest has tripped him up at Prime Minister's Questions, to the benefit of Ed Miliband.

To be fair to Cameron, a big reason why he missed a lot of this lay in his foolish acquiescence to the idea that the Blair government's biggest problem was a surfeit of special advisers, so he left his own policy unit in Downing Street woefully understaffed. That, at least, has been remedied and I suspect a count of SpAds and political policy appointments across Whitehall would rival anything from the previous decade. But there are also suggestions that the Prime Minister has the idea that he should float above the minutiae of Whitehall. And to an extent, he should. Tony Blair was very good at seeing the wood from the trees, and getting to the essence of a problem quickly. But that doesn't mean not being informed about potential pitfalls in his Government's policy: Blair used his PMQs preparation assiduously to update himself on such issues and spent plenty of time on detail when a policy was likely to be controversial.

There are signs that the some in Government are realising that details should be addressed before they create a crisis: the decision to widen the grounds for legal aid in future divorce cases to include emotional abuse (Clarke had originally intended to confine it to physical domestic violence) has avoided a certain defeat on the question in the House of Lords and an indefensible aspect of the proposals. Cameron has to show a similar attention to detail across all departments, using his policy unit as an early warning system. Otherwise, he will not just acquire a reputation for U-turns and indecisiveness, he could be seen as not on top of the job. And that's not something that people want in their prime ministers.

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.

Not quite heirs to Blair

I have a column in the March edition of Public Finance, explaining why the coalition's public service reforms are not as much in the Blair tradition as they imagine.

David Cameron’s closest coalition colleagues are said to follow a ‘cult of Blair’ on domestic reforms. They proceed with pace, avoiding Tony Blair’s lament that he acted too slowly. They proudly display the scars on their backs from opposition to their changes. And they are extending some New Labour initiatives in health and education. But they have parted company with its ‘investment and reform’ approach in important ways - and that might be their downfall.

You can read the full column here.

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.

Efficiency and independence

The news that Sir Philip Green has been appointed as the PM's efficiency tsar may have annoyed Vince Cable. But it could cause as much angst to Michael Gove and Andrew Lansley. For, Sir Philip has one big idea for efficiency, as he indicated on Today this morning: centralised procurement. This means that local management of schools, independent academies, foundation trusts and GP commissioning are all obstacles to what he would see as the way forward. He simply doesn't understand the point of such diversity in public services.

Of course, in schools, they used to have such central procurement before LMS. It was done by local authorities. It meant that if a headteacher needed to repair a broken window, they couldn't use the local glazier but had to turn to the council's approved provider. Some schools tied to PFI deals are already limited in this way. Of course, there are savings in stationery or computers to be made from procurement: most schools are part of large procurement consortia anyway for such purposes anyway. The difference is that they choose: those that aren't should be encouraged to join them. And I don't doubt a lot could be saved in central government through consolidation of functions and joint procurement, but ministers need to be careful that they don't allow Sir Philip's uber-centralising philosophy to strangle school and hospital independence in the red tape that comes with ostensibly more efficient centralised procurement.

This post also appears at Public Finance.

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.

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?

Will class war win Labour a fourth term?

John Rentoul, who continues to illuminate his blog with examples of questions where the answer is 'No', has already gone a long way to deal with the notion that 'class war' will be answer to Labour's problems. Tom Harris does so well today too.

Naturally, those I speak to in No 10 deny that any strategy so crude is under way. And I wasn't alone in celebrating Gordon Brown's recent return to form at PMQs, when he had a few decent jokes about Eton and Cameron's crew. He and Osborne deserve to have their pomposity pricked a bit, and we need more such humour. But as someone who has been a part of Labour politics since the early eighties, I also know that it would be absurd and self-defeating to craft an election campaign around the theme.

That's not to say that there aren't individual actions that can be vote-winners. The PBR attack on bankers' bonuses is believed by Downing Street insiders to explain last week's remarkable council by-election victories. But it is to recognise that Labour will not win by developing absurd dividing lines which place Labour on the wrong side of aspiration. Becoming a party of aspiration was - and remains - the essential insight behind New Labour's continued electoral successes. And it would be absurd to throw it away on the illusion that a greater number of so-called core voters might be persuaded to turn out in May (the idea that there will be a March poll seems fanciful) if they heard the call to the barricades.

Instead, Labour needs to have a much sharper message about what it can do and what it can't do, as well as what it has done. It is understandable that ministers didn't want to reveal the entire departmental budgets ahead of a post-election spending review. And given the uncertainty of the result, it is quite sensible too. Look at what happened when 'priorities' were revealed in defence this week. However, it was a tactical mistake to try to obscure the overall size of likely cuts in the years ahead in last week's PBR statement when it was patently obvious that the IFS would have its own figures within 24 hours. And the government should have been clearer that decisions to raise national insurance or top rate income tax are a temporary and regrettable measure, not a cause for celebration.

At the same time, Labour must do more to highlight its approach to the public services - and its successes which get routinely rubbished by partisan pundits. Despite some criticisms by my friends at Progress, Andy Burnham's health statement last week was a decent attempt to explain a clear approach to NHS reform, even if it was a bit neutered by attempts to please some of the unions. Tessa Jowell has interesting ideas on mutualism. Andrew Adonis is doing remarkable things at transport, showing what Labour should have done ten years ago. Peter Mandelson has grappled the question of university fees and produced a decent plan on skills (just a shame there's no money with it). But elsewhere, the government's approach suffers from a confused message and a perverse willingness to cede ground to the Conservatives on Labour innovations, particularly on schools and academies.

Despite a lot of talk about failures to narrow the gap under Labour, the truth is that chances have been considerably improved for the working classes as opposed to the 'underclass' - those who voted for Labour in 1997, 2001 and 2005 - with the greatest improvements in health and education for those groups. [See here for example, go to the Excel table 4.1.1]. They might resent the bankers, but they're not interested in class war or dodgy dividing lines (something Cameron could suffer for as much as Labour). But crude attempts to compare the top and bottom 10% social groups don't bring out their improvements. And those voters do want some straight talk from the Labour government that many of them elected, which means an honest appraisal of the last 12 years and an honest assessment of what could be done with a fourth term. And they need to hear it from all the Government.

It may not have quite the same ring to it, but a message to ministers to give it to the voters straight could help bring back many of those who now say they will vote for other parties. It is rather more likely to do so than recreating the Tooting Liberation Front.

Betrayal?

Today's Daily Telegraph editorial repeats the lie that standards in health and education have got worse under Labour, claiming that this amounts to a 'betrayal' of voters. Really? In health, waiting times are down to an 18-week maximum, where 18 months was common in 1997. A&E waits are down to four hours and trolley crises have disappeared. In education, just 52% of primary pupils got a level 4 in both English and Maths in 1997. This year, despite a small drop, 72% did so. In secondary schools, there were 1600 - or half of all secondary - schools in 1997 where fewer than 30% of pupils gained five decent GCSEs including English and Maths. This year there were just 270. There are over 1500 new schools built and lots of new hospitals and GP centres.

The argument on 'education productivity' is ludicrous. Using the definition favoured by ONS it would be possible to achieve greater educational productivity by increasing class sizes (which have fallen) and by replacing experienced teachers (whose numbers have grown) with classroom assistants. Had the Labour government done so, it would indeed have been guilty of betrayal. And, incidentally, if the Tories increase surplus places to allow new schools, they will find that it may increase choice, but it will also probably reduce 'productivity'.

Statistical niceties

It is right that Dr Foster highlights the differential death rates for hospitals. And it is also right to highlight any disparities between their findings and those of the hospitals inspectorate.

However, it is noticeable that one important fact, buried in the Observer report, has been studiously ignored by the BBC and most follow-up reports:

Overall, the hospital standardised mortality ratio (the actual number of deaths against the expected number) fell by 7% last year. That means 14,500 saved lives.

Of course poorer hospitals should do better for those patients who experience sub-standard safety and cleaning, and on the finding that across the system, to quote the Observer again:

5,024 people died after being admitted for "low-risk" conditions such as asthma or appendicitis, of whom 848 were under 65. A proportion of those deaths will be linked to safety errors.

But is it too much to ask for some context in reporting the whole story?

This post has been picked up by John Rentoul.

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

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.

Senior Tory attacks Cameron's localism: shock?

A rising star in the Conservative Party today launched a scathing attack on his leader's policy of localism. Shadow health minister Grant Shapps denounced David Cameron's plans to extend a postcode lottery in IVF treatment.

"Prioritisations must be made equitably," the rising Tory star declared. But this runs counter to the rousing declarations of support for decentralisation made by Cameron. "Decentralisation isn't just some theory - it really matters," the Tory leader has declared. "We're not control freaks, we're enablers."

That's not quite how the news that some health authorities have chosen not to offer three IVF cycles to infertile couples was reported (though Jim Naughtie did ask some searching questions even if he got some disingenuous answers).

But if Tory would-be ministers insist on getting cheap headlines by criticising the government for not imposing more central control over local institutions, shouldn't they have to spell out exactly what they would do themselves to rectify the situation. Or stop talking rot.

Strong reform continues at health

The commitments on health in Gordon Brown's plans for the future are particularly strong and clear, with the promise to give patients
enforceable rights to high standards of care, including hospital treatment within 18 weeks, access to a cancer specialist within two weeks and free health-checks on the NHS for people aged 40 to 74.

The promise of a legal entitlement to healthcare within a defined period is an excellent reinforcement of a huge achievement of Labour's time in Government - the lower waiting times achieved by clear targets - and will cause a real headache for BMA/Tory spokesman Andrew Lansley, while giving patients real certainty and the chance to go private where the NHS fails to deliver.

Despite the sniping about money and the predictable criticisms from political opponents, the overall package is a welcome indication of life within the government. There are clear objectives that can be delivered in the coming year, and some dividing lines that have meaning. For them to have real effect, the government should be as candid about the public finances, even if the absence of a full spending review.

The next year for Labour

The leadership crisis seems to be settled. Gordon Brown has reasserted his authority on the parliamentary party. He now faces the bigger challenge of reconnecting with erstwhile Labour supporters who deserted the party in droves last week.

Today's announcements on constitutional reform are a start, and the Tories are being churlish to argue that electoral reform shouldn't be debated. But we need more than debate at this stage: we need action. So, Brown should pledge a referendum on the alternative vote - which would ensure that MPs enjoyed at least the partial support of 50% of their constituents - or a variation which provided some proportional top-up. That referendum should take place on the same day as the next general election, or it is meaningless. At the same time, the Government needs to ensure that all the expenses issues are quickly resolved.

And Brown is right to say that his other two priorities are the economy and public services. On the economy, there are signs that the measures which he and Alastair Darling took last year are starting to pay off. The UK economy is in much better shape than the German one. Banks are starting to pay back their Government loans. Manufacturing output is improving. Sterling is back up to over $1.60. Whether the government gets any credit for this will depend on unemployment starting to level off and fall, and the extent to which public service cuts are needed in the future. And on the latter point, we need some candour about the tightness of the public finances and their likely impact.

On the public services, he needs to renew the reform agenda. Health policy remains strong, and Andy Burnham should continue to deliver it. He must also sell what the Government is doing much better, and explain the importance of lower waiting times and what the Tory abandonment of them would really mean. On education, the government has a good story to tell on schools which it has obscured since Andrew Adonis was moved to transport. The new schools minister Vernon Coaker has a chance to make the academies programme and other aspects of school diversity, including the specialist schools lauded in a PwC analysis yesterday, a central part of the government's story, and stop ceding ground to the Tories. A major rethink is also needed on the bureaucracy surrounding Every Child Matters, with a focus on common sense solutions rather than the endless meetings forced on the system. And in both cases, Labour must show clearly how it is on the side of patients and parents (and children or pupils) once again.

Whether it is too late for all this to have any impact remains to be seen. Despite the dismal results, there are two reasons to think that it might. The first is that the voters are very volatile, and have not yet fallen for the charms of Cameron, such as they are. 28% for the Tories in the Euro poll is hardly landslide territory. The second is that the Tories' policies are remarkably poorly thought through, as BMA/Tory health spokesman Andrew Lansley's bluster on Today this morning demonstrated, and once the media finally starts to scrutinise them, their lack of preparation may start to show.

But above all, the public needs to see a much more straight-talking group of ministers who are ready to level with them and to engage with them in a very different way. That is the biggest challenge facing Gordon Brown and the true test of whether MPs were right to give him the reprieve that he has won.