Policy post-mortem: understanding what went wrong with the health and social care act

Nicholas Timmins’s report, Never Again? aims at explaining how the coalition, which had promised an end to top down reorganisations of the NHS managed to end up presiding over the biggest reorganisation since it was founded; and in doing so lost the Conservatives the credibility David Cameron had so painstakingly sought to build up on health. It makes clear that at the moment it is only possible to judge the political failure to date; that view might need to be revised if, against all the critics’ expectation, the policy ‘delivers’ the permanent change Andrew Lansley wanted to see. There are many sources of failure: a relatively closed process of policy making in opposition – and a decision to go quiet on the reforms before the election; the lack of health expertise in the negotiation of the Programme for Government; a lack of subsequent effective challenge, especially from a denuded centre, to a ‘man in a hurry’ determined to produce a white paper within 60 days and get a bill onto the statute book early. These are all themes that the Institute for Government has studied before but which are brought into sharp focus in the case of the health reforms. Our commentary, ‘Learning the lessons from Never Again?’ sets out what needs to change to reduce the likelihood of a repeat. The first message is to use time in opposition well – not just to draw up policy proposals, but to build a coalition of support. Although there was a lot of the former with the development of detailed plans, Andrew Lansley did little of the latter. He also did not engage with the internal Implementation Unit – or colleagues who had been health secretary – to road test his reforms before the election. Second, there was no airing of the issues during the election. No party had an interest in an honest discussion of what the next five years threatened for health. If there had been, the Achilles heel of the reforms – the lack of a narrative would have been exposed. But there would also have been more clarity on what the government was proposing and why – so the changes would have come as less of a surprise when they emerged. The Department of Health had done a lot of preparation for the arrival of Andrew Lansley – to avoid a repeat of 1997. At one level it was a success: they won the confidence of their new secretary of state. But while they raised questions over the detail of their new secretary of state’s plans, and wanted him of the potential rows, they could and did not stand in his way. The plans then glided through the Cabinet Committee system with no decisive policy or political challenge. The decision to weaken the centre meant that there was not even any challenge on the lack of explanation on how these changes would benefit patients – or make it easier for the NHS to deliver its huge efficiency challenge. More effective challenge from departments is a big theme in the Civil Service Reform Plan – the next ‘Lansley-type plan’ will be the acid test of whether that can work. But civil servants in the department cannot bear the sole burden, particularly before relationships and trust have been given time to form. We have argued before that an underpowered centre is a false economy. The lack of health expertise in No.10 contributed to the mangled proposals on health in the coalition agreement – and the lack of challenge from the prime minister. Both need to change. Prime ministers need to be able to challenge departments – and negotiators in the future need to realise the importance of putting commitments into the coalition agreement which can work and have the support of departmental ministers. Finally, the biggest failure in ‘Never Again?’ was a political failure. We have argued that all policy making has to blend the political and the technocratic. The health and social care bill was a technocratic solution to an undefined problem. The secretary of state opted out of the politics – the strategic politics of setting the vision and the tactical politics of listening and engaging with interested parties. Junior ministers – not least Lord (Freddie) Howe made up some of the deficit, but that is no substitute for effective communication from the secretary of state. In no other field could a leader rise so high without being forced to develop those skills. In the absence of an official investigation, we hope that all those engaged in policy making, in government and opposition will read, reflect and learn.