A party striving to make the huge leap from opposition to office must speak with one voice, maintain scrupulous clarity and ensure iron discipline. It must reassure the voters relentlessly, persuading them at every available opportunity that it has changed and that it grasps why it has been defeated in prior general elections. Yet a party that aspires to save the country from economic crisis and to transform its public services must also be prepared to think the unthinkable, and to take deeply unpopular measures.
This is the dilemma facing David Cameron, neatly encapsulated in the controversy over the NHS and the remarks made in America by the Tory MEP, Daniel Hannan, about the shortcomings of the British healthcare system. Invited to respond to those in the US who would like to import a version of the NHS, Mr Hannan said that he ‘wouldn’t wish it on anybody’ — particularly the queuing, rationing and bureaucracy that are intrinsic to a nationalised, socialised system of healthcare. As Labour leapt gleefully upon these remarks, Mr Cameron distanced himself from Mr Hannan’s ‘quite eccentric views’ and emphasised that ‘the Conservative party stands full square behind the NHS... We back it, we are going to expand it, we have ring-fenced it, and said that it will get more money under a Conservative government, and it is our number one mission to improve it.’
To be fair to Mr Cameron, the perception that he is a champion of the NHS has been critical to the revival of the Conservative party’s fortunes. It is easy to mock the ‘brand decontamination’ strategy adopted by the Cameroons, but, without it, the voters would still be suspicious of Tory motives and fretful about returning the party to office. Indeed, there is still much work to be done in this regard. By and large, the voters trust Mr Cameron himself — but they have still have reservations about the party he leads.
It is one thing, however, to celebrate the NHS and its achievements; quite another to limit the options of a future Conservative government in healthcare policy as dramatically as Mr Cameron has. By ring-fencing NHS spending — presently £104 billion per annum — he has drastically confined his room for manoeuvre in other areas of expenditure and created an unnecessary ‘no-go zone’ for Tory policymakers. There is a fundamental contradiction in arguing (as Mr Cameron does) that very tough decisions on spending lie ahead in what he calls the ‘age of austerity’, while simultaneously declaring the largest single category of public expenditure off limits. Why should other departments and agencies of the state transform themselves and the way they do things, while the vast, creaking NHS structure — the world’s third largest employer after Indian rail and the Chinese army — stands intact and protected?
As Nigel Lawson famously observes in his memoirs: ‘The National Health Service is the closest thing the English have to a religion, with those who practise in it regarding themselves as a priesthood. This made it quite extraordinarily difficult to reform.’ To persist with the metaphor, Mr Hannan’s remarks — though entirely accurate — mark him out as a heretic. Mr Cameron, desperate to prove his theological orthodoxy as a worshipper in the church of St Aneurin Bevan, condemns the heresy unambiguously.
Yet what the NHS religion needs now is not unquestioning doctrinal traditionalism but its equivalent of the Reformation: a revolution in practice and the distribution of power within the faith, away from the ‘priesthood’ to which Lord Lawson refers, and towards the parishioners — that is, the patients themselves.
The pressures bearing down upon the 21st-century health service — demographic, technological, fiscal — mean that the status quo is not an option. Indeed, the preservation of that status quo is fundamentally at odds with Mr Cameron’s commitment to make hard and unpopular decisions as Prime Minister. The lesson of this Tory squall is that the present Conservative position on the NHS, whatever its tactical usefulness in opposition, is an unsound blueprint for office. Those who truly value the health service understand that what it needs now is not lazily glutinous adoration, but tough love.