Contrary to popular internet speculation, the Secretary of State for Health is not a ‘tosser’. Nor is he attempting to ‘sell’ the NHS. But nonetheless it looks this morning as though his flagship bill on NHS reorganisation will suffer an incongruous death at the hands of his suddenly outraged Lib Dem colleagues.

The politics of this are bizarre in themselves – a party loses local elections and a referendum, thus giving them the capital to strangle a key Government reform – but it is the broader narrative that is most fascinating here. Think tanks, policy wonks and campaigners are prone to decrying ‘ministerial churn’. Demos  published a report looking at the high turn-over of Ministers and Secretaries of State and calling for longer term appointments. The problem, we argued, was that short-term Ministers lead to short-term decision making, lack of specialist knowledge and over-mighty vested interests in the civil service and public sector. Those arguments are as true today as they were two years ago and yet we need only look at Andrew Lansley to see what happens to those senior politicians who actually bother to become experts in their field.

No-one could accuse Lansley of being a fly-by-night Minister. He shadowed the health brief for six years before getting his hands on the shiny red box post-election. During that time he built a vast understanding of the NHS – of what works and what doesn’t, of how the systems produce outcomes, of what might be done to improve it. Having conducted six long years of field research Mr. Lansley wanted to implement what he had found, to make the changes he saw were necessary and to reform in favour of patients. But he now stands forlorn with a Bill killed for expediency’s sake, a media scenting blood and a very bleak future indeed. Because the truth is that British politics is grotesquely unforgiving to politicians who actually know what they’re talking about. This rare breed takes an interest in a particular area, studies it, makes decisions based on facts rather than either gut or biased briefings – then they seek to act. And because they know how bad the problems really are, because they understand that surface change is insufficient, they tend to try to act big and act bold. It is then that the full force of Britain’s public management class comes hammering at their door demanding their head on a platter. It is happening to Andrew Lansley, it happened to Frank Field, Lord only knows which politician will be foolish enough to get on top of his brief next but we know what fate awaits them.

Ministerial churn is a problem. It leaves us with automaton politicians remotely controlled in the interests of their Department rather than their public. But it will not be solved so long as we allow those who stay, learn and then attempt to act radically to be hung, drawn and quartered in revenge. The Prime Minister claims to want to lead a radical Government – he can achieve that but he must allow his Ministers to embrace that radicalism and to take it forward. That means signalling that he will protect them when their pursuit of reform leaves them open to attack. David Cameron must save Andrew Lansley, and his Bill, or risk sending the message to his Cabinet that short-termism, political expediency and blandness will be rewarded whilst expertise and bravery will not.


Nick Denys

I certainly agree with your title, and from a policy perspective I also very much agree with the rest of your blog. The problem with the NHS reforms is not the reforms themselves. The problem is one of political strategy: that the argument for reform was never made until recently, let alone won.

Before the last election the impression was given that if the Conservatives gained power they would not do anything to disrupt our national religion. Cameron invested his personal reputation on the NHS being safe in Conservative hands. He understood that we are all see ourselves as being stakeholders in the NHS

Reforming the NHS is possible but if the Conservatives are it they needs to done in an upfront 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.

Sometimes I felt that Andrew Lansley got frustrated with having to do the politics, but unfortunately for his plan to succeed the politics needs to be as good as his policy.

Max Wind-Cowie

Thanks Nick - agree with much of what you say. But I think Cameron's getting the politics of this very wrong now, whatever mistakes Lansley has made. We simply cannot afford a narrative that says the Lib Dems saved the NHS from the Tories, and that is what is implied (heavily) by backing down. Only by sticking to the guns, making it clear that these reforms are in the interests of patients and refusing to buy in to the 'privatisation' narrative can the Conservative Party prevent itself being portrayed as the party who would have 'sold' the NHS were it not for Nick Clegg's intervention.

Alaric Adair

Unfortunately Andrew Lansley has made the mistake of listening to a small pressure group and ignoring the informed voice of the public masses.

General Practitioners are private contractors not directly employed by the NHS. Giving them the exclusive control of the purse strings for commissioning is bound to lead to allegations of conflict of interest. Only belatedly are the politicians now making vague references to other stakeholders such as nurses being involved in the process.

The suspicion is only raised further when you realise the GP advisors close to Andrew Lansley are also leading the consortia that a currently involved in carving up their local PCT patch.

He has made some fundamental political errors and fully deserves the heat of the public anger.


An interesting piece that is absolutely right to highlight the problem of high ministerial turnover and lack of evidence in ministerial decision making.

However, the case of Andrew Lansley is not a good one to make this argument. Despite his 6 years on the brief the evidence is scant, the idea that he "makes decisions based on facts rather than either gut or biased briefings" is not itself backed up by the facts - see this Guardian article by Ben Goldacre

Also Lansley has been accused of using the evidence to mislead the public

Andrew Preston

Ah, Max, still around I see. I thought that after the election you'd be off , draining the public purse in some advisors job.

I do feel a little for Andrew Lansley, being compared with Frank Field. As I remember Frank, he just didn't have what it takes to make things happen, as in afterwards being able to say... "Achieved this, achieved that..." He could unerringly point out the deficiences of this and that, one by one by one, dissect everything.
Until there was nothing left to dissect. And you would , point by point agree with each point.... until one morning you woke up, shook your head...., and that's when you realised that Frank was, in fact, on another planet.


Max Cowie argues "these reforms are in the interests of patients". The evidence? Zilch. Just because Lansley repeats this mantra does not make it true.

What we can see with our eyes is that these reforms are in the interests of Tory Party Private Healthcare company donors.

And what is the betting that Lansley will stuff his pockets when the Tories finally fall from power - as they will eventually - by getting himself on to the boards of these anti-Hippocratic oath profit obsessed private heathcare companies. Look at Southern Cross to see the ethics at work here.

Sorry Max being an apologist for this nasty little bunch of anti-social creeps is a pretty disgusting position to take. You should be ashamed of yourself.

Max Wind-Cowie

D'Holbach, I'm not ashamed of myself in the slightest - or at least not for supporting reform to place health commissioning in the hands of people who have actually taken the Hippocratic Oath. I firmly believe that doctors are far better placed to make decisions about health resources that are in the best interests of the patient and that where they buy services and care from are fundamentally less important than why they buy them.

As for evidence I would point you towards this excellent pamphlet by Paul Corrigan who, despite having created the PCTs that are abolished by Lansley's Bill, believes the thrust of the reforms are necessary and welcome:

Finally, I'm not an 'apologist' I'm a supporter.


Right Max so "doctors are far better placed to make decisions about health resources that are in the best interests of the patient". The BMA this week voted overwhelmingly against these destructive NHS changes. So are we to assume you will support this vast majority of GP's decision? Bet not.

The naivety of think tankers and politicians is to believe they can destroy the NHS with the complicity ofthe vast majority of dissenting doctors. Delusional. When will the penny drop. Most doctors DO NOT WANT THESE DESTRUCTIVE CHANGES. And
they will not operate them however hard you argue for them. Watch?

Jamie Hall

Lets call a spade a spade; Lansley is a Tosser. His changes are absolutely nothing whatsoever to do with improving healthcare. They are 100% about lining the pockets of his private healthcare donor friends. Period.
Everyone can see this. The entire body of GP's. The entire body of hospital doctors. Even that old Druid the Archbishop of Canterbury. So Max please stop lying. Greed is the motive pure and simple. We are not fooled by your intellectually specious protestations. Lansley is a Tosser. And so is everybody that argues for these 100% greed driven
arguments which includes you Max....Tosser

Max Wind-Cowie

Jamie, I'm sorry but this is nonsense. By all means disagree with how the implementation of the policy will work, whether it will deliver better outcomes (as I believe), whether a health service that underperforms for cancer patients needs reform etc etc. But please don't accuse me of being a liar. I genuinely believe that patients and taxpayers alike are best served by a system in which their is competition to deliver the best service and competition to drive down cost. The only way of achieving both at once is to introduce new providers and to place purchasing power in the hands of those who best understand clinical excellence - doctors. Not only do I believe it but so did Labour, until they lost the election. That's why they introduced the private sector into NHS surgery provision, that's why they established the NHS internal market, that's why they allowed GP commissioning in Cumbria, where I am from (the model for these reforms btw). It may well be satisfying to call be a lying, greedy tosser - and of course you're entitled to despise me body and soul - but it doesn't really solve the problem we're starting with: How can we continue to provide taxation-funded healthcare as Briain gets older, lives longer and demands more from healthcare?

D'Holbach - one response to your point. The BMA opposed the formation of the NHS too. Should we just drop the whole thing and go back to privatised medicine then? Or could we agree that doctors are really, really good at making healthcare decisions but piss-poor on politics and social policy?

Malcolm Rasala

Firstly Max where is the substantive evidence that we cannot afford
healthcare as the population lives longer. Where are the figues? All we have from you and Cameron and Lansley is an assertion. No facts. No figures. Just PR hype.

No generalisations whatsoever can be taken from this but this morning I saw my GP. I asked him what he thought of the changes. Largely ridiculous he said. Firstly 'I was not trained to be an accountant. And it is not why I entered medicine. Secondly, everyone the PCT's are sacking are being re-employed by the new structures so where is the saving supposedly to pay for the Cameron/Lansley premiss?'.

This individual GP view is not from some old near retirement
set in his ways guy. It is from a relatively young GP. He indicated
that what the polticians wanted is one thing. What the vast majority
of GP's and other doctors would deliver would be something quite
different. The NHS works and it shouldnot be messed up by a bunch of short term limited intellegence PR talking politicians (here today gone tomorrow).

As for the argument Labour believed in the same course so what? Its quite feasible all three parties are equally wrong and short sighted. Its quite feasible all three parties are working from the wrong premiss. Remember Malthus? His take seemed sensible. In practice
total nonsense. Lansley a tosser absolutely. Cameron a tosser absolutely. Max Wind-Cowie a tosser; no just misguided.

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