Editor's blog Thursday 28 April 2011: The past few days and the future of Andrew 'Transport' Lansley The Magnificent
And there I was hoping for a quiet few days in healthpolicyland. Will I never learn?
(No, probably not.)
Tuesday saw Health Questions in the Commons.
Our Saviour And Liberator Andrew 'Transport' Lansley again forced to mouthe the unpalatable facts of the listening pause: "Following formal consultation last year, and as I told the House on 4 April, we are taking this opportunity to pause, listen, reflect and improve the Health and Social Care Bill. A total of 119 events have already been organised centrally, and the regional and local NHS will organise many more. Those events will allow us to hear a full range of views from professionals, the public and patients".
Click here for details of 'Not even ‘Minder’ Letwin can save The Liberator - Andrew ‘Transport’ Lansley’s political fightback marred by not-wholly competent Beige Arts of propaganda', via subscription-based Health Policy Intelligence.
Other key exchanges in the session were:
Mr Kevin Barron (Rother Valley) (Lab): If the Government do come back with some major changes to the Bill, will those changes go out to public consultation, and will this House have the opportunity to oversee and to look in detail at any further proposals they may make?
Mr Lansley: I think I made it clear to the right hon. Gentleman in the House on 4 April that we were looking to pause, to listen, to reflect and to improve the Bill, and we are taking the opportunity to do so now, before Report and Third Reading.
Mr Stephen Dorrell (Charnwood) (Con): Can my right hon. Friend confirm that in the listening exercise it is his intention, in addition to listening to representatives of local authorities and the public, to ensure that we fully take account of the views of representatives of the full range of clinical opinion within the health service-nurses, hospital doctors and community-based clinicians as well as GPs?
Mr Lansley: Yes. My right hon. Friend will know that we have done that in the past, and we continue to do so. Just as early implementers of health and wellbeing boards have an important voice in how local authorities will strengthen public accountability and democratic accountability, we also now have an opportunity that we did not have in the consultation last year for the new pathfinder consortia, as they come together-88% of the country is already represented by them-to have their voices heard. I hope that the public generally will exercise this opportunity too. I know that groups representative of patients are doing so and very much want to get involved in these discussions.
Ms Diane Abbott (Hackney North and Stoke Newington) (Lab): The Secretary of State will be aware that if Lib Dem MPs were seriously opposed to this reorganisation, they could have voted against it on Second Reading-so how can he expect the public to take these discussions and the listening exercise seriously? Are they not just a device to get the coalition through the May elections, and is he not determined to get away with as little substantive change as he can manage?
Mr Lansley: On the contrary-the hon. Lady should know, because I made it clear on 4 April, that my objective, and that of the Prime Minister, the Deputy Prime Minister and all of the Government, is further to strengthen the NHS, and we will use this opportunity to ensure that the Bill is right for that purpose. The reason Government Members supported the Bill on Second Reading, and Labour Members should have done so, is that, as the right hon. Member for Wentworth and Dearne (John Healey) said, the general aims of reform are sound.
Liz Kendall (Leicester West) (Lab): Last year, the Prime Minister made a very clear pledge to protect front-line NHS services. Will the Secretary of State confirm that in the run-up to next year's Olympics, which will bring around 1 million extra people to the capital, the London ambulance service is cutting 560 front-line staff? Will the Secretary of State also confirm that nationally, A and E waits of more than four hours are up 65%, that the number of patients waiting more than six weeks for their cancer test has doubled, and that more patients are waiting for longer than 18 weeks than at any time in the last two years? Will he now admit that the Prime Minister's pledge to protect front-line care is unravelling even faster than the Secretary of State's chaotic Health and Social Care Bill?
Mr Speaker: There were three questions there, but I know that the Secretary of State will provide a characteristically succinct reply.
Mr Lansley: Thank you, Mr Speaker. None of those questions reminded the House that the Labour party wanted to cut the budget of the NHS, nor that in Wales, a Labour-led Welsh Assembly Government are cutting the NHS budget in real terms-there is no increase at all. Let me tell the hon. Lady that waiting times in the NHS are, on average, nine weeks for patients who are admitted and three and a half weeks for those who are not admitted. That is broadly stable. The hon. Lady will know that the chief executive of the London ambulance service, Peter Bradley, has made it clear that the ambulance service, like the NHS, needs to maintain front-line services while continually improving efficiency. That will happen in the ambulance service and it will happen right across the NHS.
Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op): What amendments he plans to table to the Health and Social Care Bill. 
The Secretary of State for Health (Mr Andrew Lansley): As I told the House on 4 April, we are taking the opportunity presented by a natural break in the legislative process to pause, listen, reflect and improve our plans for modernisation of the health service. We will consider what amendments are required in the light of this.
Jonathan Reynolds: The Health and Social Care Bill is undoubtedly one of the most controversial pieces of legislation being proposed by the coalition. May I push the Secretary of State a little further on some of the answers that he has given my hon. Friends and ask him exactly how he will ensure adequate parliamentary time to scrutinise the amendments that he will bring forward?
Mr Lansley: I am not sure that I necessarily subscribe to the hon. Gentleman's premise. This issue is important and it warrants the kind of attention that we are giving to it, and there is an opportunity to listen, reflect and improve the Bill because we want to ensure that we can thereby strengthen the NHS. On strengthening the NHS, I am surprised that the hon. Gentleman did not take the opportunity to refer to the £12.9 million increase in the budget for Tameside and Glossop PCT this year-something that Labour would not have offered. The truth is that we are going to strengthen the NHS through the Health and Social Care Bill, as we are strengthening it through our commitment to the priorities of the NHS.
John Healey (Wentworth and Dearne) (Lab): How does the Health Secretary square the Prime Minister's promise to pause in his changes to the NHS with the NHS chief executive saying a week later: "I want to stress very firmly that we need... to maintain momentum on the ground." With the Government's health Bill, are we not seeing both rushed pre-legislative implementation and confused post-legislative policy making? If the Prime Minister really gets cold feet about his NHS changes, let me ask the Health Secretary for a fourth time whether the Government will guarantee the extra time needed for this House to examine the changes fully?
Mr Lansley: Let me be clear about the right hon. Gentleman's point. Both things are entirely compatible because there are 220 GP-led consortia that have come together as pathfinders to demonstrate how they can improve commissioning and the service to their patients; 90% of local authorities have come together in health and wellbeing boards; while at the same time, we have to deliver the challenge of improving productivity, quality and efficiency. All of that requires us, on the ground, to continue the momentum of improvement for patients. At the same time, we are listening not least to all those clinicians and members of the public who want to be sure that the Bill will provide them with the opportunities for involvement and the safeguards they are looking for in the NHS in the future.
John Healey: The Health Secretary ducked for the fourth time this afternoon the question of whether he will do right by this House in allowing sufficient time for proper scrutiny of any changes to the Bill that come forward. While he is listening, will he consider the risks he is running with the NHS? The Prime Minister promised a real rise in NHS funding, yet this year more than nine out of 10 hospitals are faced with cutting costs by more than 4%; one in seven by more than 8%; while nearly £2 billion for patient care is being held back to cover the costs of the internal NHS reorganisation. Will he admit that this reorganisation is now piling extra pressure on NHS funding and services so that patients are seeing waiting times rise, operations cancelled and front-line staff jobs cut as the NHS starts to go backwards again under the Tories?
Mr Lansley: I find the hon. Gentleman's cheek astonishing. It was his party which, before the election, announced its intention of making up to £20 billion of efficiency savings, it was his party which told us after the election that the NHS should be cut, and it is his party which is actually cutting the NHS in Wales. It is the coalition Government who have made decisions that will give the NHS £2.9 billion-a 3% cash increase-and, because of the way in which we are tackling the costs of management, will put more people on the front line. Following the election, there are 3,500 fewer managers and 2,500 more doctors and nurses.
Jonathan Reynolds (Stalybridge and Hyde) (Lab/Co-op): The Secretary of State will be aware that, according to the quarterly monitoring report from the King's Fund, waiting times have hit a three-year high. Does he accept that that is a direct result of his actions, particularly the abolition of the centrally managed target in June last year?
Mr Lansley: I can tell the hon. Gentleman that waiting times in the NHS are stable. The average waiting time for patients who are admitted to hospital is nine weeks, and the average waiting time for out-patients is three and a half weeks. I think that people in the NHS might reasonably say that it is not fair to cite February 2011, when patients waiting for elective operations could not be admitted because critical care beds were occupied in the immediate wake of a severe winter and the largest flu outbreak since 1999.
Diana Johnson (Kingston upon Hull North) (Lab): Given that, according to the King's Fund, waiting times are increasing as a result of the reorganisation, does the Minister expect things to improve now that the financial squeeze is starting to bite?
Mr Lansley: As I have already explained, I do not accept the premise; but would the hon. Lady apply the same logic to the fact that the number of cases of hospital-acquired and health care-acquired infection has fallen substantially over the past year, the fact that access to services for strokes and transient ischaemic attacks has improved, and the fact that diabetic retinopathy and bowel cancer screening are improving? Would she argue that those developments are a result of our reforms? No, because our reforms have not been implemented., but we are making the investment in the NHS that the Labour party would not make, and we are giving the NHS the credit, which the Labour party would not do.
Gavin Shuker (Luton South) (Lab/Co-op): The Secretary of State has just appeared to blame the rise in waiting times on, as it were, the wrong kind of snow. Can we infer from that that if waiting times continue to rise over the coming months, he will reinstate the targets that brought waiting times down and kept them low?
Mr Lansley: The point I made was that average waiting times are stable. Maximum waiting times continue to be a right of patients under the NHS constitution. I recommend that the hon. Gentleman should go to Luton and Dunstable hospital and discuss with the staff there how they dealt with a combination of circumstances which led to there being unprecedented pressure on critical care beds. He must know that if hospitals do not have critical care beds immediately available, it is not in the patients' interests for the hospitals to bring some patients in for elective surgery. That had an inevitable consequence on waiting times for a small minority of patients.
The hearing-but-not-listening exercise
However, coverage in The Guardian of Deputy Prime Minister Nick Clegg's appearance at one such listening exercise at Chelsea And Westminster Hospital added to the sense that as we have previously stated, this is a listening-but-not-hearing pause.
Rowenna Davis and James Meikle report Clegg as telling the event, "I have lots of questions about whether choice works – in practice it's difficult but the idea you should be able to choose is well established. We shouldn't have presented this as something new – if we did that was our mistake. We are not talking about revolution.
"We haven't yet persuaded enough people in the NHS and elsewhere that what we're trying to do is good for the NHS. We've taken this unusual step to do precisely that. To stop, and to listen, and to learn.
"Let me stress this, it's not a gimmick, it's not a PR exercise. We will make changes, we'll make significant and substantive changes to the legislation which at the moment is – if you like – it's suspended in the House of Commons, in order to make sure that those who perhaps develop some very serious and legitimate doubts about some of the details of the plans feel that it's now on the right track again and then we can move forward together.".
The messages are incorrigibly mixed: Clegg emphasises that this PR exercise is not a PR exercise; and yet that its aim is to have the doubters "persuaded ... that what we're trying to do is good for the NHS ... to make sure that those who perhaps develop some very serious and legitimate doubts about some of the details of the plans feel that it's now on the right track again".
The use of the words "persuaded" and "feel" is very telling.
Fail to prepare ...
Wednesday saw the Commons Public Accounts Committee publish its sobering NHS Landscape Review, which reminded anyone whose mind it may have slipped of the staggeringly high-risk nature of Secretary Of State For The Time Being Andrew Lansley's NHS reform plans.
Regular readers will remember the magnificent appearance of NHS Supreme Soviet chair Comrade Sir David Nicholson and DH permanent secretary Una O'Brien at the PAC evidence session back in Februrary. The report does not disappoint.
Committee chair Margaret Hodge is unsparing: "It was clear from the evidence we took that many critical issues have yet to be resolved. Most important, for instance, the Department has not yet got a framework to deal with failure in the system, be it on the provider side or the commissioning side".
Hodge does no less on accountability: "Establishing strong, effective systems of governance and clear lines of assurance and accountability supported by robust flows of information will be key to ensuring that public money is safeguarded. There is a continuing need to provide accountability to Parliament and for information and assurance to be aligned with new funding channels. There is a natural tension between this and the decentralisation of key funding and spending decisions closer to the ‘front line’, which needs to be reconciled in a way which satisfies Parliament that every pound of taxpayers’ money can be followed and accounted for. The lines of accountability must be explicitly clear.
"Ultimate accountability for the performance of GP consortia, and for the money they spend, will rest with the new NHS Commissioning Board and its Chief Executive, Sir David Nicholson (currently the NHS Chief Executive). Consortia themselves have considerable room for manoeuvre in developing their internal structures, but can only function with the Board’s approval. The consortia also have a duty to consult their local communities when planning and commissioning services. They are accountable primarily to the NHS Commissioning Board for their performance".
The Tory-dominated committee intends to act in loco parentis to the reforms (which may make for interesting overlap with the health select committee, whose chair Stephen Dorrell promises near-real-time overview of NHS reform). They promise, "to review the progress of the reforms at regular intervals and this report signals the sorts of issues we will want to examine in future".
Cameron's a Winner, at last
Wednesday also saw the NHS dominate Prime Minister's Questions: a feat only rivalled by PM David 'That Nice Mr' Cameron managing to think that quoting Micheael Winner's Halifax TV ad catchphrase of "calm down, dear" to Labour MP Angela Eagle passes for Parliamentary wit. (Cameron also got his facts wrong about Howard Stoate, who resigned his seat and did not lose it to a Conservative candidate.)
The 14th Earl Of Home, must be turning in his grave. Does Eton do refunds?
The future of Andrew Lansley was the subject of a PMQ, with the following exchange:
Kevin Brennan (Cardiff West) (Lab): Is the Health Secretary's job still guaranteed?
The Prime Minister: The Health Secretary does an excellent job. Let me draw a little contrast between what the Health Secretary is delivering here-real-terms increases in health spending-and what is happening in Wales. The Labour-led Administration in Wales are cutting the NHS in real terms. Everyone in Wales needs to know that if they get another Labour-dominated Assembly, they will get cuts in the NHS, whereas in England we will see increases in the NHS because of the magnificent work of my right hon. Friend".
Waiting times got another airing at PMQs, with Labour leader Ed Miliband going on them thus:
Edward Miliband: Can the Prime Minister tell us why 98.7% of nurses have no confidence in his health reorganisation?
The Prime Minister: Inevitably, when you make changes in public services, it is a challenge taking people with you. But that is the whole point of pausing the reforms and then trying to get them going again with greater support from doctors and nurses. What we are finding is that 90% of the country is covered by GP fundholding practices that want to see these reforms succeed. I would say to the right hon. Gentleman that if he wants to make some constructive suggestions, why not have a try?
Edward Miliband: Dearie me, that wasn't a very good answer, was it? I asked the Prime Minister why 98.7% of nurses have no confidence in his policy. It is because it is a bad policy, a policy nobody voted for. It is a policy that was not in the Prime Minister's manifesto, it was not in the Deputy Prime Minister's manifesto either at the general election, and it was not even in the coalition agreement. Perhaps one of the reasons why nurses have no confidence in his policy is that two years ago, he went to the Royal College of Nursing and said there would be no more pointless, top-down reorganisations.
Next question: why is it that hospital waiting times fell year on year under the last Labour Government, but have risen month on month under this Government?
The Prime Minister: That is simply not the case. If we look at out-patient waiting times, we find that they fell in the last month, so the right hon. Gentleman is simply wrong about that, as he usually is. I have had the opportunity to study his representations about the reforms, and I have had a good look at them. He says that we are introducing EU competition policy for the first time; we are not. He says we are allowing GPs to charge; we are not. He says that patients will be left without services; they will not. Why does he not realise that instead of frightening people, he ought to make a constructive contribution.
Edward Miliband: Another totally hopeless answer! I asked about waiting times. The Department of Health figures are these: waiting times are 20% up for those waiting more than 18 weeks, and A and E waits are at a record level compared to six years ago. One of the reasons why waiting times have gone up is that the right hon. Gentleman is diverting billions of pounds from patient care into this costly reorganisation. Let me make this suggestion: just for once, why does he not listen to the doctors, the patients and the nurses and scrap his reorganisation?
The Prime Minister: The right hon. Gentleman asks me to listen to doctors, so here is one doctor I am definitely going to listen to. I hope Opposition Members will remember Howard Stoate, who was the Member of Parliament for Dartford. He is no longer an MP because he lost the election-because of the Conservative candidate, I am afraid. He is now a GP- [Interruption.] Calm down, dear. Listen to the doctor. Howard Stoate, GP, says "My... discussions with fellow GPs... reveal overwhelming enthusiasm for the"- [Interruption.] I said calm down. Calm down, dear-and I will say it to the shadow Chancellor, if he likes. [Interruption.]
Mr Speaker: Order. Let us briefly have the answer and move on to backbenchers, whose rights I am interested in protecting. I want a brief answer from the Prime Minister.
The Prime Minister: This is a very brief quote from a Labour MP who is now a GP. He said, "My... discussions with fellow GPs... reveal overwhelming enthusiasm for the chance to help shape services for the patients they see daily". That is what Labour MPs, now acting as GPs, think of the reforms. That is what is happening.
John Woodcock (Barrow and Furness) (Lab/ Co-op): Rather than losing his rag because he is losing the argument, will the Prime Minister explain why waiting times have been rising in my constituency and across the country?
The Prime Minister: The hon. Gentleman is simply wrong about waiting times. I quoted the figures. Waiting times have been broadly stable over the last couple of years-that is a fact. The key point that I would make to the hon. Gentleman, who is meant to be a moderniser, is that if he wants to see waiting times come down and stay down, the best answer is a system that involves greater choice, and enables patients to choose where they are treated and establish how quickly they can be treated. The hon. Gentleman used to be a moderniser; there is still time to get on board.
Training also got a mention, via open-primary-selected Tory GP Dr Sarah Woolaston:
Dr Sarah Wollaston (Totnes) (Con): In 2007, the Labour Government implemented the Medical Training Application Service, or MTAS. Junior doctors will remember what a disaster it was. That large-scale, disruptive and untested system had disastrous consequences for junior doctors in training. Is the Prime Minister aware that there are concerns that the current proposals to reorganise medical training and workforce planning could have similar unforeseen consequences?
The Prime Minister: I must say to my hon. Friend that she is a lot better at getting them to shut up than I am. I think that she is a future Speaker in the making. I can absolutely guarantee to my hon. Friend that we will not make the mistake that the last Government made in respect of medical training. They created an utter shambles.
The future of Lansley The Magnificent
The future of Lansley The Magnificent has also become the subject of speculation on BBC Newsnight political editor Michael Crick's blog. Crick reports Tory rumours which posit a straight swap with Philip Hammond at transport, or perhaps Jeremy 'Spoonerism' Hunt at culture.
Mmmm. Maybe - Crick has access to good sources - but Lansley seems a prouder man than that. Telegraph health correspondent Martin Beckford tweets that Lansley unambiguously told the RCN Congress that the only job he wants is health, and he had told That Nice Mr Cameron so.
Lansley gave an interview in Total Politics magazine, which contains various interesting phrases, including the memorable opening line from his SpAd Jenny Jackson "I don't think he's coming back" as Lansley The Magnificent walks out after a question he does not like.
Lansley The Magnificent tells Caroline Crampton and Ben Duckworth, “What we’ve been hearing, with a single exception, points to a fundamental agreement with the bill. I think people, on balance, broadly support the general practice-led commission and clinical engagement in commissioning”.
Lansley refutes the journalists' suggestion that there has been a failure of communication on the message of the reforms, describing the BMA's opposition as premeditated: “The BMA did this before the election. The ‘Keep the NHS public’ was a BMA campaign before the election, and they’ve just carried it on ... Basically, it’s a trade union monopoly thing”.
He also tells Total Politics, "the principles of the bill are not going to change ... The coherence and integrity of the bill is not going to be compromised".
So why the pause for the hearing-but-not-listening exercise?