Before I go on it’s important to clear up one thing first. There are those who believe that the private sector only get involved in public services when they can cream skim and take on the easy jobs in order to achieve a decent margin. In this case, the Hichingbrooke hospital is running a £5m annual deficit and has debts of £40m – so this will be a massive challenge for Circle and they will be providing a tremendous public service if they can succeed.

I’m not applauding this development because I think private is better than public. Both public and private sector providers can do well and can also get into trouble. Too often the debate around public service reform and delivery is approached from the ideological extremes – either the state is best placed to deliver and safeguard services or they should be outsourced wholesale to the independent sector.

It is a mistake to argue that there is a single model of service delivery that is better by default.  Only through a mixed market of different models of provision will balanced service improvement be achieved. By mixed market I don’t just mean some services delivered by the state and others privatised, I mean a genuine mix which also includes substantial numbers of mutuals and social enterprises. Each model has its particular strengths:

• State delivery tends to be free from external financial motives and as such is generally protected from unplanned financial failure (although the hospital in question here proves that this is not always the case!).
• Private provision can create scale, efficiency and system level innovation and can attract much needed external investment.
• Mutuals and social enterprises are usually smaller scale and focused on social value and innovation at a local level.

It shouldn’t be the Government’s job to pick a winning model but it should strive to create a level playing field where a balanced mix of provision can exist and influence each other through their relative strengths. E.g. the existence of state provision in a balanced market place should force the others to have financial safeguards in place, the existence of privately outsourced provision should ensure the others keep improving their efficiency, and the existence of mutuals should put social value (and its measurement) at the top of the others’ agendas.

There was much disappointment recently, which I shared, when the trailblazing public service mutual Central Surrey Health was unsuccessful in bidding for a large contract, which would have enabled them to expand their excellent service. However, Central Surrey Health’s presence in the market as a socially focused competitor would have undoubtedly influenced the proposition put forward by Assure Medical, the private group backed by Virgin Healthcare who ultimately won the contract. This is how a mixed market can work.

When in power Labour saw the benefit of such a mixed market so it’s a shame that they now choose to play politics with this. Although it’s a bit incredible when the person leading the attack on what is essentially the rescue of a hospital is Andy Burnham, the Labour Minister who initiated the process! Our memories aren’t that short Andy!

Andrew Laird is a Director of Mutual Ventures, a social enterprise which supports front -line staff to set up mutuals

To an extent, he is right. The Coalition has great, ambitious plans. The motives are good, the intention is the right one and the goal is commendable. In an ideal world, this sort of reforming attitude and desire would be met with rapturous applause and all-round support.

However, we do not live in an ideal world, and Mr Cameron certainly does not govern in an ideal world. Politics is a strange beast, one that does not function as you would expect.

Take the so-called U-turns that the Coalition has been accused of lately. Ed Miliband is only too happy to reel them off – Forests, NHS, bin collections, justice and so on. The basic criticism of the Government has been that they have published proposals, consulted experts, changed the Bills and moved on. In any other field of life, that would be considered the best way of addressing reform. Surely consulting with those best placed to give advice is a good thing?

As Mr Cameron himself said last week, surely it would be daft to try and reform our services without listening to and consulting with the experts? But he is continually slammed from those on the Left for being unable to get it right the first time round. It matters little that Ed Miliband offers nothing in return; he simply lists the U-turns and implies that he would be a much better Prime Minister, without actually offering an alternative or making a good reason to vote Labour.

More than that, however, and more than the lack of a Utopian world for Mr Cameron to govern in, is the problem of the traditional British mindset. The services that the Prime Minister is attempting to reform are at the heart of what many people feel makes Britain great – the NHS, forests, our military. You only have to look at the rise of charities such as Help for Heroes to see just how important a place the armed forces have in the British psyche.

Few will say that these areas do not need reform. Many back the calls for change and the call to move forward into the 21st century. Equally, however, many see these as national institutions which you mess with at your peril. The old Labour saying of ‘You can’t trust the Tories with the NHS’ is powerful as it cuts through politics and policies and goes right to the heart of the electorate.

Combine this sense of meddling with the best of Britain with the U-turn issue, and the Coalition has a problem. Both the Conservatives and the Lib Dems, but the Tories in particular, need to be aware of this. The gung-ho attitude (think Ken Clarke, a hugely popular and influential Cabinet member) of some members of the front bench has its moments, but it also begins to grate with people after a while.

As has been said before, the reforms and the changes the Government is proposing could be genuinely transformative. The problem that keeps arising however is that David Cameron cannot seem to get them off the ground without a battle, which makes them less and less appealing. Each mini-conflict is a piece in the wider jigsaw of this fight, and they are mounting up.

The Government and David Cameron must continue to press forward with reform – to turn back now would be nothing short of a catastrophe. However they must do so with caution, and an acknowledgement that they are dealing with serious issues in a world that is far than ideal.

The American conservative commentator George Will is quoted as saying ‘conservatism is true’, by which he means that traditional conservatism is grounded in reality, an awareness of were people are at and a recognition of the need to keep your feet on the ground. For the time being, that would be a good position for the Conservatives to take.

I’ve pondered this before, but from a different angle – asking whether the Coalition agreement was being progressed through so fast that there would be little to do in the later years of the Parliament. My conclusion was that these things were all necessary, and that they needed to show improvements in peoples’ lives by 2015 in order to go into the election with any chance of success.

As I’ve said before, this government is not communicating its narrative properly.I would FAR rather they governed well than just talked about it, but they can’t ignore the press, nor voters’ concerns, and they need to talk and talk and talk about what they are doing and keep explaining how it makes sense.

The reforms in education, health and local government in particular are about enabling people to have more choice and control in their lives. The welfare reforms are about making sure that the welfare system is a safety net, not a “hammock” as I’ve heard it described. Changes to the tax system are feeling their way to reducing taxes for everyone once it’s affordable, making them fairer, and shifting them from ‘good’ things (work, saving, investment) to ‘bad’ (consumption).

The best statement I’ve heard from the government on why all these changes are necessary was in response to the Archbishop of Canterbury’s comments a couple of weeks ago. But, once again, that was defence, not an all-out making the case pre-emptively. As I’ve said before, until there is a crisis, there seems to be an unwilllingness to really make the case.

As I’ve argued before we need, as a society, to have a serious think about what we think the state should do, and what we think is affordable and fair, and what we think we can do better for ourselves.

Far from being concerned that the government is doing too much too soon, I wonder whether they are in fact doing enough? Is giving way on so many (relatively) small parts of the agenda going to undermine the sum of its parts? Is the machine of government, vested interests and the loudest complainants going to defeat the ambitious but necessary programme that the silent majority understand and support?

The government needs to take people with it on its reform programme. Explaining why it’s necessary, what will happen, why it will make things better is a key part of that. People fear the unknown; they can be enthused by the radical ideas of this government. But only if the government stands up for them – and, crucially, actually delivers them. For too long, we had politicians who talked about making life better but failed to do so. This government seems unwilling to talk but – if you read the manifestos and the Coalition Agreement – really does want to make Britain better.

He’s got a point. I’d add that Norman Lamb’s threat to resign and the Lib Dems’ sudden vocal opposition (their MPs did, after all, vote the Bill through its first stages) smacks just a bit of taking an opposition mindset into Government – which can’t help.

Except, if Lansley’s had a raw deal, it’s important to place it in context.

He might feel poorly treated by No.10. But this understates just how far Lansley has alienated healthcare professionals, health bodies and the health policy world at large. He might feel entitled to support from the upper echelons of both Coalition parties – but surely they are not the only groups he should have to listen to (leaving aside the general public, for the moment).

Of course health reform meets opposition at every turn – read any memoir covering the early Labour years and it’s clear senior Ministers being given a kicking by public service unions and conferences isn’t a new phenomenon. Any reformer should expect booing from vested interests.

But there’s a big difference between creating manageable dissent (which is probably inevitable), and taking a course that dismantles any support for reform, antagonises the agnostics, and gifts ammunition to opponents (which is not).

To take one example, have a look at the DH’s consultations from late 2010. They’re dangerously vague – which is fine if you’re consulting on blue-sky proposals, but is not if it’s for a Bill, due a few weeks later, that proposes major changes to the NHS which are (literally) life and death.

Or the publication of the Bill itself: delayed, delayed again, and then published while the consultations were still ongoing. Or the review of arms-length bodies, which was perceived as abolishing or merging bodies without any consistent logic.

This is the nitty-gritty of health reform. None of it inspired confidence, and it gave the impression that ministers were fuelled by a toxic cocktail of intransigence and naivety. A creeping dread grew across the autumn that these reforms just hadn’t been thought through, or developed with appropriate input from health experts.

That might be inaccurate, and painfully unfair on Lansley, given this has been gestating for several years – but the process of enacting the reforms has only cemented this impression. It was entirely avoidable, and the fact the Bill’s pause comes with a ‘listening exercise’ surely betrays that not being seen to listen is recognised as the problem.

So, it might be correct to say that Lansley got a raw deal from No. 10. The problem is, that’s exactly what many people in healthcare think they got from Lansley.

Need to do it in the right way

During the last twenty years polls have shown that the public has not trusted the Tories to look after public services. This opinion was fuelled by the underlying belief that Conservatives are only interested in looking after the interests of the rich elite, not to protect services the majority use. That is why the modernisation project placed so much emphasis on the ‘new Conservatives’ being a fan of the public service closest to the British people’s heart, the NHS.

Andrew Lansley had been shadowing the health brief for six years. That is a long time to spend watching, researching and ruminating on a single policy area.  He is a man who knows his brief and spent considerable time working on a plan. This makes it all the more surprising that the NHS reforms currently going through Parliament were not communicated to stakeholders, the most important of who is the public. One has to wonder whether the leadership knew about Lansley’s plans when they placed Cameron’s face on posters promising to protect the NHS.  One also has to wonder whether anyone in Number 10 actually looked at the proposals before they made their way to Parliament and assessed their political impact.  James Forsyth has written on the possible damage this will cause.

“The result is a massive problem of trust with the voters on the issue, as the Coalition’s internal polling shows. The public wants to know why they weren’t told about the reforms before the Election. There are now lots of Tories privately urging the Coalition to back away. Shortly before going into Downing Street as Cameron’s chief political strategist, Andrew Cooper told friends that he wouldn’t carry out NHS reforms now.”

Creating a CSJ for the NHS

Reforming the NHS is possible, but more than any other issue, if the Conservatives are going to do it they need to do it in the right way. By contrast, in the five years before the 2010 election Iain Duncan Smith’s welfare reforms were researched in public; the ideas and proposals placed in the open for debate. This meant that when IDS took became a secretary of state everyone – the civil service, press, Labour, our coalition partners, the public – knew what he wanted to achieve. There were no surprises, thus a broad consensus was formed on a potentially toxic issue for Conservatives.

Compromise

Now is the time for compromise. Some in the Party are rightly worried that compromise will be presented by the Lib Dems as a victory for them – against the evil Tories – and a victory for coalition governments in general. Unfortunately this reaction is inevitable, but it can be mitigated. The adaptation of the Bill should be led by DR Sarah Wollaston, the Conservative MP who was chosen to be a candidate in an open primary. Wollaston was a practicing GP before becoming an MP. She has complained publicly about the Parliamentary whipping process that has tried to constrict her views on the NHS reforms.  By allowing her to reform the reforms the Conservatives will show that they are both embracing new politics and that as a Party they can be flexible.   This tactical retreat will create few days of negative headlines but it will be less bad for the Conservatives than months of negative comments questioning the real motivations behind the reforms. Those Conservatives who are disappointed at the reforms being stunted could put their energy into setting-up a NHS reform think-tank, along the lines of the Centre for Social Justice, which can adequately prepare the ground for further reforms to take place post-2015.

Patience is a virtue – sadly, one not generally held by the media or indeed by the public who eagerly consume the daily news. The media industry favours a steady flow of announcements and decisions and they have had years of plenty – but the truth is many of these announcements and decisions never made it outside the Westminster bubble. Big Society is the antithesis of this approach. It is not press-release friendly, and the Government is getting a pretty hard time because of it.

This does not make it a flawed idea.

Writing on these pages, Nat Wei rightly said there needs to be “an acknowledgement that the Big Society will take time to foster and grow”. I have made a similar point on the Big Society Network blog when describing the Emergent nature of Big Society.

This will be very different from the familiar top-down approach to Government, which is usually driven by a small group of Whitehall policy advisors and then imposed on the rest of us (if it doesn’t get lost on the way somewhere). For sure, Government should set out a direction of travel and desired high-level outcomes – but it is then up to communities and those delivering front-line services to define the details in a way that best suits local needs. This activity won’t fit nicely into a timetable or central grid but the good news is that it is starting to happen.

Let’s take an area of Big Society reform with which I am particularly familiar – the mutualisation of public services. This is about letting front line staff form their own independent mutuals and other forms of social enterprise to deliver public services. This genuinely frees up front line staff to deliver services in a more flexible and responsive way.

Francis Maude and the Cabinet Office have been running a successful Mutualisation Pathfinder programme which has seen clusters of public service innovators popping up all around the country. A nurse-led therapy unit and a further education college are among the most recent pathfinders to begin the journey to independence. These are the Trailblazers who are prepared to step up to the mark and accept the risks and rewards associated with being the first movers.

To ensure that these and other groups of innovative staff aren’t thwarted by the system, Francis Maude has also established a Mutuals Taskforce, led by Professor Julian Le Grand. The Task Force, which has the personal support of the Prime Minister, will work to ensure central departments are doing all they can to facilitate other front-line staff groups to follow the same path.

This is a concrete example of Big Society reform and of how Central Government can effectively facilitate bottom-up action. I personally don’t think the Government has received enough credit for facilitating the considerable progress that has occurred in such a short space of time.

There is much more to come – we just need a little patience…

Nothing new was announced, Cameron reiterated that services will be “more competitive, local and transparent” with greater involvement from new and existing private and voluntary sector providers.

Regarding the NHS this is the sort of measure that will be described as an attack on its “founding principles.” However, it is in fact very much in tune with what we might call its “pre-founding principles” – the vision of a comprehensive but mixed-economy and locally run system planned during the war. The highly centralised, completely state-run monolith built by Aneurin Bevan 1946 was never the “consensus position,” even, arguably, in the Labour party.

First of all consider the views of the medical establishment. The British Medical Association and Royal Colleges produced a report on medical planning in 1942, which can be viewed, after free registration, on the BMA website. This report contains some revealing attitudes.

For example, it says that patients should have “as wide a measure as possible choice, including the right of a patient to change a doctor” – and indeed the other way around. GPs were even to have a certain degree of what we now call commissioning power: they should choose which consultants to send patients to, albeit on a regional basis.

The report also rejected the idea of all hospitals being directly controlled by the state, voluntary hospital should remain independent because they “embody traditions and standards of service which should not be allowed to disappear.”

Then there is the 1944 White Paper, produced by the wartime Coalition, or Conservative-led war-winning government if you prefer. This, published by the sadly largely forgotten Conservative wartime health minister Henry Willink, gives us a strong idea of what a Conservative created NHS would have looked like. The Paper was strongly endorsed by Labour – even though elements of it would provoke outrage on the left if suggested today. A copy can be found online courtesy of the Socialist Health Association.

The opening line of this document demolishes the idea that the Conservatives opposed the principle of free universal care:

“The Government have announced that they intend to establish a comprehensive health service for everybody in this country” and access to these services “shall not depend on whether they can pay for them.”

The paper was a move towards centralisation: but within limits: it warned against “over-organisation.” The paper accepts the role for localism, and crucially, mixed economy of supply.

The service was to be run mainly by county and borough councils, because there was “no case for departing from the principle of local responsibility” which would “run counter to the historical development of the health services.” There would only be enough centralisation as to deliver coherence and consistence.

The commitment to the mixed economy in healthcare delivery is clear: the voluntary hospital system was also to be retained (though it wasn’t in 1948 of course), not only for its specialist resources, but also strong community roots.  Here the White Paper gets slightly big society, noting that the voluntary system:

“Attracts the active personal interest and support of a large number of people who believe in it as a social organisation… …It is certainly not the wish of the Government to destroy or to diminish a system which is so well rooted in the good will of its supporters.”

One of the most revealing parts of the White Paper is on the matter of funding, which was to be mostly through taxation but in part by “whatever social insurance scheme is in operation.” This was what Beveridge also recommended in his separate report.  Social insurance would have provided a quarter of funding overall.

This idea would of course be a political minefield today – but it is revealing that Labour accepted it in 1944.  Again it would have left the NHS in the mixed economy mainstream of international healthcare systems.

The White Paper called the existing system a “patchwork. This was the local and voluntary hospitals great sin: they did not fit in the orderly centralised vision, which, since created, has spent so much time on the edge of crisis. There was nothing inevitable about the precise structure built by Bevan in 1948, and nothing whatsoever in what Cameron has proposed that undermines the principle of care available to all.

I would consider myself a fairly close follower of government policy and proposals. Most I like, some I don’t, others I don’t really care.

From these NHS reforms, I like the idea that I will be able to choose which GP I go to – whether it’s near home, or work, or whatever. I like that I will be able to decide whether I go to a hospital that is near home, or near my parents, or which has the absolutely best surgeon in the UK for my operation, or whatever. I like that my GP will be accountable to me and will help me to choose the best treatment for me. And I like that my treatment will still be free at the point of use when I need it – and I don’t care who provides it as long as their standards are high.

But if you were a normal person watching the news, I don’t think that’s what you’d understand from these proposals. I think you’d think that the government was abolishing the NHS, taking away your treatment, privatising everything, and closing your local hospital to boot. And probably introducing euthanasia by the back door.

Why is that? Partly, of course, it’s the fact that  it’s easier to oppose than to suggest sensible alternatives. Partly, it’s because of the ‘evil Tory’ myths which have built up over the years and which still haven’t gone away. Those are things we can only fix over time.

But in the immediate term, there is a serious problem of communication from the government. Nothing is put into an overall narrative of why the government is doing what it’s doing (I had a go at this over New Year). Nothing is explained in pithy sentences that are clear and easy to understand. Too much is phrased in terms of what a policy is not, rather than what it is. And because of that, opponents of a policy have a much easier time of it. Basically, the government is always defending rather than attacking. I’ve written before about why this is so damaging.

You can debate whether it’s because there is so much going on, or whether it’s because there is no central authority figure pushing back so that a proper communications strategy is in place on every single policy from every single department, or whether, far from having fewer special advisers as promised, the government should employ more.

But whatever the reason, if this government and coalition are to be a success, it’s something that’s going to have to improve.

Plenty of comment about the behavioural psychology that forms the basis of the announcements made by Andrew Lansley today.  The Times suggests that there will be a ‘beer tax to nudge a healthy lifestyle’ and David Blackburn, at Coffee House, says that Andrew Lanswley has “given us a nudge.”  It should be remembered though, that there is more to modern behavioural psychology than nudge theory – although that may not suit a media narrative looking for a simple message.

The FT (£) has an excellent piece today about what they describe as the “breakneck coalition”.

Guido thinks that the Telegraph have made the wrong decision going behind the paywall – pointing out that the Times paywall has reduced online readership but done nothing  to reverse the decline in newspaper sales.

Over at Next Left, Paul Richards has an interesting piece about  Labour’s mutualist roots and traditions.

Following the formation of the Coalition Government, the Conservatives and Liberal Democrats set out key policy objectives, with the aim of promoting “freedom, fairness and responsibility”.

Achieving that will require radical reform in all sectors, not least in social care. With an ageing population, and at a time of austerity measures, change has to be embraced. Anchor – England’s largest not-for-profit provider of housing and care to older people – has worked with Counsel and Care – the national charity working with older people, their families and carers to get the best care and support – to run fringe events at all three of the main party conferences.

As an apolitical organisation, we’re clear at Anchor that addressing the needs of older people is too important an issue to leave to party politics. There does, at least, appear to be consensus that the current system of funding care in old age is broken. The need to fix it is made more urgent by three key factors:

• Increasing numbers of older people who are living longer and facing increasingly complex care needs, including dementia;
• Declining public sector funding for social care; and
• The personalisation agenda in which individuals are gaining control of how they spend public subsidy

Rather than the political point-scoring that characterised the pre-election debate over care funding, we believe it is imperative that politicians are honest with older people and acknowledge that limited public funds will mean that older people will have a greater responsibility for paying for their own care.  With a million people in the UK predicted to have dementia by 2025, a massive culture change is needed if younger generations are to start planning realistically for their old age.

If individuals and the state are to share responsibility for funding services, urgent reform of public funding for care is also needed. In line with the localism agenda, we believe that funding decisions should be made at a local level, with allocations in proportion to the local cost of care. There are tensions though between a localist approach and the need for a clear and consistent system. A national framework should therefore be developed by April 2012 to calculate local funding allocations and ensure they are in proportion to the local cost of care, which can vary significantly across the country.

It is essential that the nation reduces its deficit. However, this must be done in a way that has the least impact on older people and the services that they require. Local authorities are already making significant cuts which threaten to have a massive impact on older people and unintended consequences for the Big Society.

The Government should look towards implementing more preventative measures to create long-term savings. The success of the Big Society will be built on low-level funding for small community-based work that enables older people to remain part of their community. Funding for wardens in retirement housing, for example, helps ensure people are able to remain independent for longer – without needing to move into more costly residential care.

Most importantly, of course, many older people have seen tough times before, having lived through the austerity years after the war. When struggling with difficult decisions on where cuts should be implemented, politicians would do well to listen to those who helped rebuild the nation once before.

Posted by Administrator on behalf of Sara McKee, Chief Operating Officer for Anchor, England’s largest not-for-profit provider of housing and care to older people. For more on Anchor visit www.anchor.org.uk or call 0845 140 2020