The agonisingly tortuous progress of the government's health and social care bill has made the coalition's NHS reform agenda one of its most controversial. Here's a quick overview of the proposed changes - and the bitter, protracted battle over the government's ideas.
What's all the fuss about?
Something, so the cliché goes, has got to be done. Whoever was in government in this parliament would have to shake up the NHS' structures to a certain extent, to help the health service cope with dramatically changing demands on its services. We're all getting older. So less hospital treatment, for example, is critical as the ageing population demands more care in the home.
On top of this comes financial pressure. The coalition protected NHS spending in real terms in its comprehensive spending review, but is forcing through £20 billion of efficiency measures by 2015 to redistribute the savings more effectively. Not a straightforward context, then, for the decisions made by the 2010-15 government.
That government's proposals were unveiled for the first time in August 2010. They were, to put it mildly, something of a surprise. The Conservative general election manifesto had promised no top-down reorganisation of the NHS. How surprised we all were, therefore, when the Conservative-Liberal Democrat government, with Tory health secretary Andrew Lansley at the helm, proposed exactly that.
Rather than let know-it-all managers make decisions about which resources should go where, ministers proposed handing the power to commission services to consortia of GPs. Some GPs liked the idea of this extra work. Others were appalled. What mattered, the government insisted, was the end result: the creation of a market dynamic within the NHS, reformed and shorn of its primary care trusts. At the heart of the coalition's proposals were moves to make competition the driver of more effective health services.
Contested competition
This wasn't the first time the NHS got itself worked up over the benefits and perils posed by competition. Kenneth Clarke's drive in the early 90s to introduce internal markets to the health service prompted massive anger from health organisations. It's no surprise that these are the same ones now fighting Lansley's changes. As the head of the BMA, Dr Hamish Meldrum, explained in May 2011, what's happening today is "almost part of the same argument, the same battle if you like, the same disagreement on how best to organise and make the NHS run more efficiently".
The coalition did not expect the levels of resistance which they have encountered. Their thinking was that these moves towards choice and competition were actually extensions to the piecemeal changes pushed through by the New Labour government. Yes, the coalition wanted to accelerate this shift towards the private sector - but the reforms were not coming completely out of the blue.
That did not stop them attracting huge opposition. For many, the proposal to give healthcare regulator Monitor responsibility for promoting competition at the expense of all else proved a step too far. It summed up the government's thinking, excited by the possibilities offered by innovative new providers and greater choice. Many feared that such untrammelled market factors would only lead to some losing out - and overall standards of patient care suffering.
The unprecedented 'listening pause' - and how it didn't work
It had never really been done before. But, taking advantage of the extra-long first parliamentary session, on April 6th 2011 the coalition announced a 'listening exercise' in which it would reconsider key parts of the bill. Two months later, on June 14th, David Cameron, Nick Clegg and Lansley put on a brave face as they presided over massive concessions. Monitor's competition duty was scrapped. Instead choice and competition would rely on pre-existing competition panels, rather than being embedded in its day-to-day operations. The pace of the changes was also slowed - no more scrapping of PCTs by 2013 - and the role of the proposed national NHS board was expanded.
These were big adjustments - a humiliating experience for Lansley and Cameron. Less so for Nick Clegg, who was able to paint the changes as being the direct result of Lib Dem influence in the coalition. This was a painful episode for the government, but it genuinely hoped to have ended the debate. As the summer of 2011 slowly progressed, it looked like the NHS reform furore had finally subsided.
How wrong the optimists were. The listening pause was a hugely punishing hors d'oeuvre for the main event. Lib Dems, led by veteran Shirley Williams, made clear at the party's autumn conference they would not budge an inch on a vast swathe of remaining objections - including the legislation's rather vague approach to who is actually responsible for the NHS. Throughout the autumn the health and social care bill dragged its way through the Lords. The reforms remained a huge headache for the government.
An unfinished war of attrition?
As 2012 began the situation looked bad. But it was about to get worse as, in mid-January, campaigners sarcastically marked the first anniversary of the legislation's arrival in parliament. Groups like the Royal College of Physicians and Royal College of Midwives, which had previously been happy to work with the government to improve the bill, decided it was better if ministers now scrapped it completely.
The first weeks of the year were seeing a new crisis for Lansley and co. So, in another sizeable set of concessions, they tabled 137 amendments to the health and social care bill in early February. Demands to clarify the ultimate responsibility of the secretary of state for the NHS were met. So too were measures involving greater patient involvement, better arrangements for education and training, extra measures to tackle health inequalities and strengthened integration between NHS services.
Was this enough? Not really. Ed Miliband began returning to the issue again and again in prime minister's questions, effectively using the controversy to lift his struggling leadership. There was a real sense that these reforms might falter, after all.
But the stakes remained high. Following the listening pause, the Lib Dems were more closely tied into these reforms than they had been before. Such was their significance that a failure to push them through would be a hammer blow to the government. Perhaps this explains why ministers are now refusing to back down, in the teeth of huge opposition. The long, attritional fight shows no signs of ending soon. The government's resolve may be teetering, but it has not yet collapsed. Will ministers be able to hold on until the bitter end?
Alex Stevenson, politics.co.uk
