EDITORIAL : THE GUARDIAN, UK

         

 

Health reforms: Love but not logic

The decision to press pause was right but, unless a stronger argument is found, it will be time to press stop and start afresh

Six weeks after pressing the pause button on health reform, David Cameron yesterday hinted where he was heading with a Beatlian ring. To sweeten Andrew Lansley's medicine, the prime minister seemed to be saying, all you need is love. At a London hospital, he poured praise on medics, and said the whole nation was besotted with a "precious" three letter ideal, before reaffirming his own NHS devotion.

The health secretary's passionless presentation frustrates No 10, and this seemed a good moment for the love drug. After all, Mark Britnell, one of the wise men Mr Cameron had unwisely summoned to Downing Street, has been revealed to have been telling corporates they will have "big opportunities" in the new-look NHS, and has also been arguing for forcing patients to pay. Ruling out such new charges, which were never in the pre-pause legislation, was one of several straw men the prime minister felled. As he wafted purple prose about the health service brand over every specific dilemma that must be faced before the play button can be pressed again, it almost sounded as if Mr Cameron had reverted to his past career in public relations. But expert listeners spotted a few informative patterns in the haze.

Even if "choice for patients, not competition for its own sake" sounds like empty rhetoric, the phrase suggests the duties of the regulator will be qualified in law, to make plain that it is not obliged to punt treatment away from public hospitals, a potentially important concession. Fears of privatisation, however, will not be assuaged until the reckless idea of outsourcing commissioning itself is laid to rest. The prime ministerial promise to integrate health and social care more effectively was also new, although how he hopes to achieve this within the current package of reforms when the Dilnot commission into financing care has not even reported is unclear to say the least. Then there are the purse strings. Mr Cameron now suggests they should not be stuffed into the hands of GPs alone, as Mr Lansley had first proposed, but instead held by some mix of family doctors, nurses and consultants.

The last point, in particular, confirms that this is a new political strategy, as opposed to re-engineering of the reforms on the basis of principled argument. Keeping the doctors close to him, by giving them all a piece of the financial power, will no doubt reduce the volume of the reporting on the evening news. However, asking medics on hospital payrolls to be both purchasers and providers at the same time muddies the water of the new healthcare market. There is a coherent case for reverting to integrated central control, as there is also for imposing a strict purchaser/provider split. But giving hospitals back the power they traditionally had, and sometimes used to block worthwhile change, makes no sense in the new world of autonomous foundation trusts run on semi-commercial lines.

The root confusion is that the half-rewritten health and social care bill is now a solution in search of a problem. There are of course desperately serious challenges in nursing an ageing society, but these are inherently long-term. By talking up overlaying problems such as obesity which are getting worse, while ignoring things like smoking which are improving, the prime minister whipped up a more immediate crisis. But if there is a crisis, it is one of funding, and whatever benefits the right reform may ultimately bring, instability will aggravate this at first. Likewise, if Mr Cameron's shaky statistics about cancer and stroke deaths underlined anything, it is that there is already too much variation in care. Neutering Nice and leaving individual consortia to decide what treatments they fancy footing is hardly going to help.

Pressing pause was right, but unless a stronger argument is developed, it will soon be time to press stop. And then start again on an entirely new bill on a saner timetable.

In praise of … the people's port

In Dover, a Tory MP and the Unite union are working together to fight the sell-off of the port originally proposed by the last Labour government

Politics can produce odd bedfellows. In Dover, a Tory MP and the Unite union are working together to fight the sell-off of the port originally proposed by the last Labour government. Yesterday, they came a step closer when the transport secretary, Philip Hammond, re-opened consultation on the future of Britain's nine trust ports. Dover, the largest and most famous, the gateway to England beneath the white cliffs, has been run by a harbour board since 1606, but needs investment. The Treasury would like to sell it, probably to a foreign owner. The people of Dover are backing a plan for a "people's port" instead, owned in part by the town. This scheme, which won 97.5% local support in a recent referendum, ticks many fashionable boxes: it is a mutual, localist, self-financing, small state exemplar of the "big society" and a test bed for the coalition's claim that it doesn't think the market is the best answer to everything. The challenge is that simply privatising the port would almost certainly raise more money in the short term for the Treasury, and the community scheme will anyway need to raise around £200m of private investment. The transport secretary now says any successful bid will have to show an "ongoing and significant level of community participation" – a success for Dover MP Charlie Elphicke, who has been pushing the scheme. Next, on Mr Hammond's list perhaps, could be mutual, not-for-profit railways – or British Rail, as they used to be called.

Libya: Caught in a vice

Airstrikes and arrest warrants may suggest the jaws are closing around Gaddafi - but they could just as easily be losing their grip

If a vice is indeed closing in around Muammar Gaddafi, as General Sir David Richards, the chief of defence staff claimed, then its jaws have some way to travel before they meet. They could just as easily be losing their grip. In two months the general has swung from justified caution about the aims – clashing with Downing Street over whether the object of the mission was regime change – to the opposite stance of pressurising other Nato countries to escalate the bombing and widen the target list. Why the change? It could be that after 2,000 strikes, 300 of them British, the general realises that the mission is no closer to its achieving its aims and that the performances of his forces in Libya could be subject to the same sort of critical scrutiny that Basra and Helmand attracted, particularly from the Americans. Or his planes could be running out of targets.

The rhetorical vice was given a further twist yesterday by the chief prosecutor of the international criminal court who named Gaddafi, his son Saif and his brother-in-law and intelligence chief Abdullah Senussi as war crimes suspects. In both the targetting of airstrikes and in Luis Moreno-Ocampo's presentation of requests for arrest warrants, a theme has emerged: the west is letting it be known that it is getting help from insiders, either recently emerged, such as Moussa Koussa, who is telling Nato where the bunkers are, or serving officials contacting the prosecutor's office from Tripoli. The subtext of this is that rents are emerging in the tent of Gaddafi loyalists. Let us hope they are. But what if they are not?

Mr Moreno-Ocampo said his investigation into war crimes was continuing, and this could have a deterrent effect on those in Tripoli contemplating life after regime change. But the chief prosecutor is not requesting the intervention of international forces to implement the arrest warrants . He said that the Libyan authorities – whoever they now are – have the primary responsibilty to arrest the three. This means that nothing will happen until either the regime falls or a deal is brokered and the warrants are not enforced – the Sudan model. Either way, we are no further forward in breaking the stalemate.

The third option, expounded by the International Crisis Group, is to sue for a ceasefire. As they rightly argue, Nato's strategy is confused. To insist that Gaddafi must go in a new democratic order, is one thing. But to insist he must go as a precondition for any negotiation is to render a ceasefire all but impossible. To insist he leaves the country and stands trial in the ICC is to ensure he will go down fighting. That leaves only a military option, and with it the prospect many, many more civilian casualties.