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.

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?

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.

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?

The truth behind Tory health policy

An excellent new poster for the Labour Party NHS campaign. It is about time that the reality behind the Tories' patient unfriendly policies for the health service were given a proper airing. Voters need to realise that when they get Ashcroft-funded leaflets from Tory candidates pledging to scrap terrible Labour targets, this is what they really mean. I hope there's a lot more where this came from.

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?

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.

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.

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.

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.

Success on MSRA

I do hope people notice this amidst the prevailing economic gloom. MRSA cases have been halved. And for the benefit of the churlish BMA spokesman/shadow health secretary for life Andrew Lansley, it has been done as a result of clear targets and strong government action combined with the work of dedicated NHS staff. This is a real success story.

Taking on the Tories

While the media have been obsessing about whether David Miliband will be PM or Alan Milburn his Chancellor, it has been left to two junior ministers this week to show their colleagues how the government should take on the Tories, whatever happens after September.

Until now, the Tories have been getting away with murder in their claims about Labour's record. Jim Knight's combative and accurate exposition of the government's record on improving education for the poor in the face of Michael Gove's selective statistics on Monday's Today programme and Ivan Lewis's brilliant defence of the NHS this morning against Andrew Lansley's characteristically cretinous smears both offer an object lesson in what has been so patently missing from government ministers over the last year.

Of course, the Government needs to set out a sense of direction. It needs clear policies. And it needs to address economic and housing worries. But it also needs to defend its record. This it has largely failed to do recently. Ministers too often refuse to debate their Tory counterparts, giving them a free run. Which is why the contributions of these two ministers this week were so refreshing. Exposing Tory misrepresentations about Labour's public services record over the last decade with facts and candour is an essential part of any fightback. Let's have more of it.

One year on: Gordon is proving his reform credentials, but nobody is listening

The newspapers are full of their anniversary analyses. Few of them offer tributes to Gordon Brown a year after he became Prime Minister. Those columnists who spent their time rubbishing Tony Blair from the left have abandoned Brown with even more vehement opprobrium. But the best assessment of what is happening comes not from the dire mid-term polls or the failure of the voters of Henley to put Labour in third rather than fifth place. It is given by Peter Riddell in today's Times who recognises that the government has developed an appetite for reform in recent months that is largely passing the voters by.

This is important, not just because Brown is taking the right long-term decisions for schools, health, energy and welfare. On the latter, even Fraser Nelson in the Spectator admitted that the Tories plan merely to claim credit for work begun by James Purnell. This week's dreadful Tory health policy which failed to recognise the need for any maximum waiting times - because the BMA don't like them - stands in stark contrast to the strong NHS reforms being introduced by Alan Johnson and the best of Brown's imported ministers, Ali Darzi. The academies programme has been speeded up and a radical programme to lift the fifth of weakest schools is underway. He is being radical on the environment and energy policy. Other big reforms are on the way in the coming weeks. The Tories have yet the show a very convincing hand: despite the credulity of some, their schools' policy lacks Labour's practical and ambitious edge and their health policy is simply anti-patient.

But, of course, all of this has been obscured by the loss of credibility endured after the last party conference and particularly by the economic downturn. Unless the economy picks up relatively soon, there is little chance of Labour recovery. But if it does - as is possible in a two-year period before an election must be held - the reforms being introduced now will stand the government in good stead. And the government must continue to show the sense of purpose evident since Christmas however gloomy the polls and pundits.

When the Tories say process targets, patients say waiting lists

Could somebody explain why BMA spokesman and shadow health secretary for life Andrew Lansley was allowed to get away with such transparent obfuscation on his health 'policies' on the Today programme this morning? His made up figure of '100,000 lives saved' from Tory policies was given prominence on the news bulletins even though Lansley himself admitted that this was not a target, or even a promise, just a figure which might happen if the doctors are left alone.

Then, his pledge to scrap 'process targets' was left unquestioned. Let us be clear what he actually means.

• First, the Tories plan to allow waits of twelve hours and longer in accident and emergency wards just so they can scrap 'process targets' that require a 4 hour maximum.
• Second, the Tories plan to allow waits of six or twelve months for hip replacements and many other operations as they will scrap the 'process target' of 18 weeks consultation to surgery that the Labour government is close to meeting.
• And third, they would have no 'process target' on hospital cleanliness, despite 'clean hospitals' being one of their five main goals at the last election.

Instead, they will cross their fingers and hope that the doctors will do the decent thing. Just as happened when GPs were given a whacking great pay increase in the hope that they might provide a better service for patients out of hours. None of this was revealed on the Today programme, where Mr Lansley was allowed a freedom to say what he pleased - and talk in jargon - that is denied any minister.

Labour is getting it right on key issues

Today's Sunday Telegraph poll may confirm the dismal findings of earlier recent polls. But within today's Sunday papers, there is also a very clear sign that the government is getting it right on three of the most important policy areas.

First, the government is right to want to have the precautionary maximum 42-day detention period. Jacqui Smith gave a characteristically fluent account of the measure this morning. But its best defence comes from Matthew D'Ancona in the Sunday Telegraph. And the measure is supported by a majority of the public.

Second, Alan Johnson delivers a cracking case for his plans for more extensive GP surgeries and polyclinics in the Observer. The idea that it is worse for patients to be able to get an X-Ray or ECG on site, or to get minor injuries dealt with locally rather than hanging about for four hours in A&E, is such common sense that once delivered, patients will wonder what the fuss was about.

And third, the Government's plan to push for a rapid turnaround of underperforming schools with the support of successful heads and a big extension of Academies is exactly what is neededd for such schools. To those who say 'the government should have done this sooner', ministers can point to the fact that where one in two schools used to get 30% or fewer five good GCSEs, the figure is now one in five. But one reason why this policy is superior is its use of floor targets, one of the most successful policies of the last ten years, accompanied by structural reform.

What these three policies also have in common is that they are opposed by the Conservatives. Aside from Lord Tebbit and Ann Widdecombe, the 42 days are publicly opposed by the party. Tory health policy is being shamefully written by the BMA. And on education, the Tories would scrap targets, even when they are so patently a lever for improvement - and for pushing the sort of structural reform with which, at least, they share Labour's ambition.

The more the government can show the sense of purpose evident today, the more likely it is that they can recover their poll position. If, in the process, the bareness of Cameron's policy cupboard is also exposed, that would be no bad thing.