In which I consider how David Cameron is really surprisingly bad at politics

Last week saw a cabinet reshuffle at Westminster. Cue lots of twitter jokes about rearranging deckchairs on the Titanic, and lots of Newsnight footage of MPs in varying states on promotion and getting-sackedness. It was a truly amazingly terrible reshuffle, pretty much whatever point of view you look at it from. There are essentially four reasons for reshuffling a cabinet: 1) To make your government look more public-friendly and re-electable; 2) To shore up your leadership with the party faithful 3) You have no choice, because someone high profile quits or; 4) Because you want to announce something truly horrendous on the same day and it’s a handy way of distracting the media.

This reshuffle was in the middle of a paralympics, so I don’t think it was 4). We’ve had a summer absolutely tailormade for burying bad news, so why not save your reshuffle until you really need it? It’s not 3) either. Everyone who’s gone or been demoted appears to have gone unwillingly. So let’s assess the esteemed Mr Cameron’s success on points 1) and 2).

1) To make you government look more public-friendly and re-electable.

Let’s put aside the fact that we didn’t actually entirely elect this government. It’s looking increasingly likely that the next general election will be a good old fashioned two-horse race, the Lib Dems having thrown away the longer electoral war for the short-term “victory” in the Battle of the Coalition Agreement. Given that, if Cameron was looking for a reshuffle that would improve public perception of his government, how’s he done?

Let’s start with the positives. Andrew Lansley, formerly Secretary of State for Health was kicked into the political semi-retirement role of Leader of the House. That’s going to be popular in most circles. The year’s Health & Social Care Bill (on which I had views here) was astronomically unpopular, and the decision to present poorly people with bedside video of his big old head was, entirely inexplicably and unpredictably, met with some derision.

Other positives? No. None at all really. Let’s look at a fairly significant group in the electorate with whom the Conservatives are vulnerable, a full 50% of the population: the Lady-women. Now, astoundingly, despite being ruled by our wombs and prone to fits of fainting and hysteria, women in the UK are permitted to do voting. Historically, going back to the immediate post-war period, women were seen as much more likely to vote Conservative than men. That big gender disparity has largely broken down (as demonstrated in this analysis of the 2005 election polling and result), but Cameron still can’t afford to annoy half the electorate. His “Calm down, dear” comment during PMQs coupled with MPs’ schoolboy responses to comments about Nadine Dorries MP’s “frustration” have rather combined to create an impression of a boys’ club government, slightly confused that not all women around them are solely focused on perfecting their victoria sponge and selecting soft furnishings for the nursery. This was an opportunity to shuffle some women into the cabinet, but actually the number of women has gone down from 5 to 4 and a half (Baroness Warsi is still allowed to attend cabinet but can’t vote – one can only assume her role is to bring the biscuits and sit quietly).

But what about wider electoral issues for men and women? The political orthodoxy in the UK says that you win General Elections by occupying the centre ground. Even the most vilified of right-wing leaders, Margaret Thatcher, was able to present herself, accurately or not, as more middle-ground that the very left-wing Labour Party of the time. Tony Blair brought Labour back into government by steering the party sharply to the right and occupying the centre position left vacant by the Tory’s descent into infighting and obsessive preoccupation with the EU. This reshuffle can only be seen as a shift to the right. The cabinet (and indeed the Tory party’s) highest profile moderate, Ken Clarke, has been dumped from the Minister for Justice post and made Minister Without Portfolio, a position which doesn’t really mean anything very much at all. The architects of many of the most electorally difficult policies (Gove at Education and, of course, Osbourne at the Treasury) have stayed in post.

So, this isn’t a reshuffle to shore up Cameron’s position with the wider electorate. Maybe his focus is on…

 

2) To shore up your leadership with the party faithful

Moving to the right will be popular here. There’s real resentment amongst Tory rank and file at having to pay lip service to funny new fangled Liberal Democrat ideas, so the perception that Cameron is recommitting himself to core Tory values is likely to go down well.

But for these purposes you’ve got to question whether Cameron has gone far enough. More than anything else, this reshuffle looks kind of lame. He’s managed to only half-sack Lansley, Clarke and Warsi, which makes him look like a deeply indecisive and unconfident leader. Does he want them in the cabinet or not? In addition, he tried to get Ian Duncan Smith out of the Department of Work and Pensions, but Duncan Smith was able to leverage his popularity with the party to politely (or not) refuse. There’s no other context in which a boss can try to dismiss you and you get to just go, “Er, no thanks mate, if it’s all the same to you.” The papers, this week, are full of pre-party Conference gossip about stalking horse candidates and a possible return to the Commons for Boris Johnson, something of a perennial thorn in Cameron’s side. This is a time when Cameron needs to look strong as a leader – on the evidence of this reshuffle he just looks a bit meh.

 

There’s other things to be concerned about in this reshuffle too. Realistically, it doesn’t look like there are going to be any major policy changes on the Big News economic stuff. There might be policy shifts in other areas – Transport is the obvious one here, where the vexed issue of London’s airport capacity has shot right to the top of the agenda. But, essentially, the cabinet doesn’t make policy anymore anyway. Including those people, like Ken Clarke and Baroness Warsi, who don’t really know why they’re there, the new cabinet meetings will have 32 attendees. Anyone who’s ever sat through a meeting with more than about 8 people will know that a group of 32 ain’t going to be a well-oiled decision making machine. And this reshuffle underlines the practice of policy being made by a inner circle of PM, Chancellor, their special advisers and possibly a handful of powerful ministers – Michael Gove and Ian Duncan Smith look like the men who’ve come out of this with influence in tact. Accepting that ministers don’t make policy, means that it’s fine to have ministers who know little or nothing about their area of responsibility. The position of Justice Secretary is a case in point. The post was created in 2005 when Tony Blair got rid of the post of Lord Chancellor. Previously the Lord Chancellor had to be drawn from the legal professions. The new post, as with any other cabinet position, was entirely in the gift of the PM. Up until now, all the occupants have been former barristers. Chris Grayling has no legal background or training, but he’s the minister responsible for Britain’s justice system. Knowing about stuff no longer matters, because it’s no longer the role of ministers to make decisions. It’s the role of ministers to appear on Question Time and try not to accidentally say anything controversial or interesting. It all makes me a bit sad really.

Oh and, Jeremy Hunt is the new Health Secretary. Jeremy Hunt supports homeopathy, apparently opposed the NHS tribute in the Olympics opening ceremony, supported the takeover of hospitals in his own constituency by Virgin Care and co-wrote a 2005  pamphlet which recommended healthcare system based on insurance and individuals choosing their own healthcare provider. In 2010, David Cameron claimed that the Tories were “the party of the NHS.” In 1997 Tony Blair promised us that things  could only get better. Reader, they lied.

Where I explain why the Health & Social Care Bill is a Bad Thing in five easy to understand numbered points.

The Health and Social Care Bill is currently at the report stage in the House of Lords. The Lords’ amendments are going to bounce the bill back to the House of Commons and the bill will find itself in a game of Parliamentary ping-pong between the two houses as further amendments are debated and agreed (or not).

This means that both MPs and peers are likely to have further chances to amend or vote out this bill, and if you’re a Liberal Democrat parliamentarian (which I’m assuming most of you are) you really should be making use of those chances. Here’s why:

1. It ain’t broke…

Sometimes we need to take a step back and remind ourselves what an incredible achievement the NHS is. Comprehensive healthcare, free at the point of access, provided to everyone dependent on clinical need with no regard to ability to pay. That’s an impressive goal and one which the service largely delivers. It’s not perfect – outcomes are better for some areas of disease than others, and as a country we could still do more in the area of preventative medicine (particularly relating to alcohol and obesity), but actually it’s pretty damn good.

Looking at the OECD‘s figures on health we can see that our health system stands up pretty well to comparison to other countries. We spend approximately half as much per head of population on healthcare as America, and, on average, live for two years longer. Taking a couple of examples from within Europe, we also spend less than Ireland and Denmark, and enjoy higher life expectancies. The only country that enjoys significantly higher average life expectancy (83 compared to our 80.4) whilst also spending less per head on healthcare is Japan. That’s not all down to healthcare – Japan has very low rates of obesity and places a high cultural importance on health and wellbeing. There’s a quick overview of how the Japanese health system works here. What’s interesting is that, although the Japanese system includes some private funding,  all the competition has been removed from the market – more on that point later.

So, our health system isn’t perfect, but neither is it fundamentally broken. This bill proposes high level change to the way the system is organised and delivered – to put through that level of change I’d suggest you need to be pretty sure that what you’re doing at the moment isn’t working. Actually, the evidence we have suggests that it works pretty well.

2. …and this won’t fix it.

The list of groups who actively support this bill is tiny-wee. The against list is almost overwheming. The Health Select Committee, for example, think the change will be too disruptive on top of the current tightening of funding. The BMA, who initially supported the idea of health care being commissioned by clinicians, now say that “the positive vision of clinician-led, patient-focused, locally sensitive and accountable commissioning is being lost in the huge amount of often chaotic change taking place.”

The key elements to the bill that create this feeling of chaos are the shift towards healthcare being commissoned by local groups of GPs and the introduction of a requirement for competition in the provision of some services. For me, it’s this competition that’s the real problem. Competition is a market concept – it works where there is a clear market and a consumer that can choose between different products or services based on quality, price, convenience etc. A good way of thinking about how competition will work in a given situation is to ask yourself two questions. “Who’s the customer?” and “What’s the product?”

If you go to a store to buy a loaf of bread it’s easy. You’re the customer. The bread is the product. You choose the type of bread you want – white, granary etc. – you might also look at the size and price of the loaves, and then you buy your selected product. It looks simple in a healthcare situation as well, but actually it’s not. At face value, you might think that the patient is the customer and the medical care is the product, but that’s not quite right. The medical care is the product, but the customer is whoever is paying for/commissoning that medical care, whether that’s central government, local Primary Care Trusts or groups of GPs. The seller of the healthcare, whether that’s an NHS hospital or a private provider, has to make their offering the most attractive to the commissoning group, not the most beneficial to the patient. The market is skewed, so that the individual receiving the product isn’t the person it’s been tailored towards. Going back to the shop analogy, the patient isn’t the product or the seller or the customer. The patient is the carrier bag.

3. … and the arguments in favour of the bill are stupid

Now I know that this isn’t actually how parliamentary democracy works, but in principle the group that make the best arguments and provide the strongest evidence should win the debate. I understand that actually the party (or parties) that hold a parliamentary majority and whose Whips’ office work most effectively win the day, but let’s just pretend that the debates might influence someone.

Firstly, the fact that the Health Select Committee oppose the Bill should be a fairly big reason to vote against it. Otherwise what’s the point of the committee stage in the passage of any bill? The idea is that, at the committee stage, a smaller group of MPs examine bills more closely, identify any major problems and iron out the kinks. In this case the relevant committee has come back and essentially advised that this bill just won’t work at the moment. That’s strike 1.

Secondly, your own deputy leader wants the Health Secretary to move on. Simon Hughes suggested that Andrew Lansley should move on after the bill was passed on the Andrew Marr Show. This is a very odd thing to suggest. Hughes isn’t saying that the bill shoudn’t be passed, but he’s suggesting that the architect of the bill should lose his job. I don’t see any other way of interpreting this other than that Hughes is saying, “Yes. It’s a terrible idea, but we have to put up with it, and then do everything we can to try to forget…” Well, you don’t have to put up with it. There is no inevitability about the passage of this bill. You could vote against it. Then Andrew Lansley would almost certainly lose his job as Health Secretary. It’s a win:win. That’s strike 2.

Thirdly, the government’s main argument in favour of the bill is now that the changes just need to be voted through as soon as possible to give people as long as possible to forget before the next general election. It’s not really a position marked by huge idealogical commitment to a vision. “Let’s just get it over with…” is a legitimate position if you’re talking about ripping off a band aid, but not if you’re planning to pull out the underpinnings of one of the most effective public healthcare systems in the world. Strike 3.

4. It’s technically the right thing to do

Ok, so you’re a Lib Dem MP. You might not like this bill, but you are in coalition with the Tories and part of coalition is accepting things that might not have been your first preference for the greater good. Well, you don’t have to accept this.  It wasn’t in the Tory manifesto at the last general election. It’s not in the coalition agreement. In fact the coalition agreement says that the government will “stop the top-down reorganisations of the NHS that have got in the way of patient care.” So there you go. It’s not that you personally want to scupper this bill. It’s that you have to. It’s in the coalition agreement. Voting against this bill is what you signed up for. Technically, you have no choice.

5. It’s politically the right thing to do.

Now, you do understand that the Liberal Democrat vote is going to evaporate at the next election, don’t you? Those of us to the left of the party are going to follow the boy wizard over to Labour in punishment for your buddying up with Dave and his massive shiny forehead. Anyone towards the right of the party has got a Conservative government anyway, so they might as well actually vote for them next time.

You need to set yourself apart from your coalition peers, and this is the issue to do it on. Nigel Lawson viewed the NHS as the closest thing the British have to a religion, and he wasn’t far wrong. We moan about it but suggest that we might change it, suggest, horror of horrors, that we might have to pay directly for health care, and all of a sudden we are unquestioning believers in the one true way.  Positioning your party as the protectors of the NHS might be your best bet to stave off electoral ruin next time around.

So there we go, five reasons for any Lib Dem parliamentarians to get behind the opposition to the Health and Social Care Bill. You can pick whatever reason works for you – ethical, intellectual, technical or self-interested. I don’t really care why you vote against it, just make sure you do.

And that’s me done getting my politics on for this week. Apologies for the lack of recent bloggage – my work life went a bit manic for a while, but normal(ish) service should now be resumed, so, as ever, if you like please subscribe and you’ll get a lovely email letting you know when there’s something new to read. The plan is that if you come back at the end of the week there should be some lovely crime fiction reviews here waiting for you all. Happy days.