These days, it is rare for cabinet ministers to know much about the departments that they are appointed to lead, but health secretary Andrew Lansley was an exception.
When he arrived at Richmond House in May 2010, he had been shadow health secretary for a number of years. More than that, he had used his shadow role to become immensely knowledgeable about the NHS and how it worked, and to work out detailed objections to successive waves of Labour reforms.
That, coupled with the Conservative Party’s very public pledge during the election to avoid “unnecessary” and “top-down” reorganisations of the health service led many working in the NHS to hope that he would be a safe pair of hands.
Yet, within months Lansley had launched a white paper that tore up much of the NHS’ existing management and commissioning structures, promised to extend and inject new vigour into Labour’s foundation trust and private-provider reforms, and reworked public health as a local government and industry problem.
Opposition to the ‘Liberating the NHS’ reforms built slowly, as the NHS’ different professional tribes worked out what the white paper –and the sprawling Health and Social Care Bill that followed it – would mean for them.
Yet, eventually, concern about the cost of implementing the reforms at a time of financial strain, and the potential impact of the ‘any qualified provider’ aspects of the reforms, forced the government into an unprecedented “pause’ in its legislation.
Professor Steve Field, the immediate past president of the Royal College of GPs, was appointed to lead a ‘listening exercise’ and Lansley was forced to spend a lot of last spring watching as others reassured the NHS and public about the drift of the reforms.
Prime Minister David Cameron himself led a charm offensive, visiting hospitals and promising that there would be “no privatisation of the NHS” and “no US-style health system where they check your credit card before they check your pulse.”
Yet, as the Guardian’s long-serving health correspondent Sarah Boseley wrote on a visit to Frimley Park Hospital in Surrey, it looked as if the PM, a former PR man for Carlton Television, had decided only that his health secretary needed “help in explaining the package.”
There were, at the time, no real suggestions that Lansley would be replaced. And at the end of the listening exercise the principles of the reforms emerged intact, with only a few additional structural changes to placate critics.
The Health and Social Care Bill subsequently sailed through Parliament and became law in March; while the NHS Commissioning Board got on with the job of setting up new bodies on the ground.
Despite his reform woes, Lansley won grudging respect from many in the NHS for his self-evident passion for the health service and his deep understanding of policy and financial issues. He invariably took questions at events and was never lost for a detailed response to a detailed point.
Indeed, this may have contributed to his demotion to Leader of the House. Cameron’s reshuffle of middle and junior government ranks suggests that he wants a Cabinet that can ‘sell’ the government’s economic and social policies, not one that can argue out the nuances.
Lansley also had a positive impact on NHS IT. In opposition, Cameron described the National Programme for IT in the NHS as the NHS “supercomputer.”
Lansley took a more nuanced approach to its future, launching a review that eventually decided to retain much of the infrastructure and many of the national projects that it had got in place, while relaxing the grip of the local service providers on the provision of systems to trusts.
With a nice irony, one of the big pieces of unfinished NPfIT business appears to have been finished just as Lansley packed his boxes at Richmond House.
On Tuesday afternoon, just as Jeremy Hunt stood in Downing Street announcing that he was “honoured” to be taking up Lansley’s job, the DH announced a new agreement with CSC for the North, Midlands and East of England.
CSC will lose its monopoly on delivering an electronic patient record – Lorenzo – to the region. But there will be central support and funding for trusts that still want to take it.
At the same time, Lansley was genuinely interested in the need to deliver better information to clinicians and patients, to improve quality and to make the NHS more responsive to its users. He oversaw the production of an information strategy intended to drive progress in these areas.
And he was an early supporter of the EHI CCIO Campaign, which was set up to encourage all NHS organisations to appoint a clinical leader for IT and information projects. Indeed, he launched the CCIO Leaders Network that was set up subsequently to support the chief clinical information officers that are now being put in post.
Beware of what you wish for
The many critics of Lansley’s health service reforms have not been backwards in coming forwards with their assessment of his time in office.
Unison head of health Christina McAnea said: “The coalition government presided over the most damaging piece of legislation that the NHS has ever seen in the Health and Social Care Act, and this will be Andrew Lansley’s legacy.
“Changing the name on the door will not change our opinion of the Act. Our opposition will continue as long as this Tory-led coalition’s assault on the NHS persists.”
Yet time may offer a more nuanced view. Lansley’s always insisted that he did not want to “dismantle” the NHS or open it up to the kind of right-wing, free market assault that the unions accused him of.
The problem with his complex and badly articulated reforms was that they could be read in several ways; and their ultimate impact will now be decided by how they are implemented on the ground.
A lot will now depend on who holds power between the revamped DH, the NHS CB, the slick and confident Monitor, and the clinical commissioning groups that are about to start work.
A lot will also depend on how future ministers, managers and regulators interpret the requirement to bring in private providers only where this will benefit the NHS and patients.
On this front, the appointment of Jeremy Hunt in a reshuffle that most commentators have interpreted as a rightward shift in the government is unlikely to cheer fans of the NHS as it has been.
Within hours of his appointment, tweets were already circulating pointing out that in 2009, he co-authored a book calling for the NHS to be dismantled.
In a book written with Michael Gove and Greg Clark – ‘Direct Democracy’ – Hunt said the NHS was “no longer relevant.”
In a tweet in response to this morning’s reshuffle news, the deputy chairman of the British Medical Association, Dr Kailash Chand, said: "Very likely replacement is Jermy Hunt – I fear [a] more toxic right winger [who is likely] to follow [the] privatisation agenda. The disaster in NHS carries on."