It's official-looking: BBC News report the PM's Official Spokesman saying that there will be no "significant changes" to the health policy in the Health And Social Care Bill.

It's also as clear as mud: the PMOS went on to say that the legislation may be amended in Parliament.

Foundation or fudge?
So the question is, which will be uppermost - foundation or fudge?

Foundation means a cosmetic blow-over with concealer; stick on some lippy and liner and hope nobody notices you're asking them to kiss a frog.

Fudge means actually substantially changing the legislation, in line with the new, official Lib Dem party policy on health.

The Lansley Foundation
Liberatin' Lansley's appearance on The Politics Show yesterday (from 16 minutes) make it quite clear that Our Saviour And Liberator is a foundation man.

All three mainstream print media reports published last night suggested that a change of direction was inevitable.

However, this shows no actual sign of being what Mr Lansley thinks.

I'm grateful to a long-standing friend of Health Policy Insight for again binning a proportion of her Sunday to transcribe what Mr Lansley actually said on the BBC yesterday.

The transcribed text appears below, introduced by comments on the same programme from leading Orange Book tendency Lib Dem minister Chris Huhne on the extent to which the new Lib Dem health policy changes the game.

Denial: not just a river in Cairo
Huhne and Lansley both think that essentially, it doesn't.

It's a big gamble on Huhne's part. He seems to be betting that his backbenchers will be easily fooled by a lot of foundation and perhaps a bit of fudge. These Lib Dem backbenchers are unlikely to be fooled - the many opponents of the Bill, including much of the medical profession, will be all over the reworkings to assess their fit with what is now Lib Dem party policy.

As will Labour.

Thus to avoid a potential split in the Coalition, Lib Dem Orange Bookers must risk splitting their own party. Posing the uneasy question: power or principle?

A fresh bucket of uncertainty
It certainly serves up a fresh bucket of uncertainty, in advance of the BMA's Special Representative Meeting tomorrow.

Arguably, it was a strategic error for the Coalition leadership to signal so clearly that they will not change course on the Bill. Uncertainty might have made the BMA's debate far more intriguing and politically challenging.

As it stands, the BMA are looking at a 'foundation-heavy-fudge-light-fuck-you' response. To which they are probably going to have to respond in kind.

Thirty-eight degrees of uncertainty
There is a mordant symmetry that the organisation 38 Degrees, which successfully campaigned against the Coalition Government's policy to privatise forests, has taken up the NHS as its new cause.

Mr Cameron realised that in the court of public opinion, his forest privatisation policy was seen as like kissing a frog with no chance of transformation.

The Great British Public like trees, and a U-turn ensued.

But they love the NHS ... and Mr Cameron seems to be doing his Iron Laddie 'not for turning' bit in response.

Perhaps the Iron Laddie has a tin ear.

Health Policy Insight is 1,001
Oh, and before the transcript, a moment of reflection: this is the 1,001st post on Health Policy Insight.

Which pleasing symmetry means it's time for some thank-yous.

Thanks firstly to you all for reading, supporting, enjoying and arguing with and about what we do here. It's always good to hear from readers (editorial AT healthpolicyinsight.com). Thanks for the tips, jokes, FOI leads, leaks, transcripts and invites that you've sent us.

Thanks also to various individuals for giving up their time for interviews, research, answering questions, who have requested that their identity not be revealed. Your help has been much appreciated.

Thanks also to some individuals whom I can name.

Joint-first-place thanks to HPI associate director Tom Smith (whose advice is always valuable, and who single-handedly kept the site going with his brilliant Health Policy Today column when my workload to subsidise HPI's existence got out of hand); and to health economic guru Professor Alan Maynard (whose equally brilliant The Maynard Doctrine column continues to ask all the right questions and offer many good answers).

Thanks to FT public policy editor Nick Timmins, for an excellent early contribution which raised readership. And thanks to HSJ editor Alastair McLellan, for opening my blinkered eyes to the possibility of Twitter as a medium to extend our reach (@HPIAndyCowper).

Thanks to my colleagues in health journalism whose work I value.

Health Policy Insight is not far off our third birthday, in June. Our aim remains to contribute usefully to the conversation, debate and discussion around policy, with robust independence and intelligent challenge. (When I was told that senior people in DH regard HPI as "inflammatory", I felt pretty sure we were doing something right.)

We will soon be launching a new weekly summary-and-analysis product, Health Policy Intelligence, which will aim to fit an explanation of the week's key events in policy onto the electronic equivalent of a side-and-a-half of A4.

We will need to charge for subscription to this new product, and I hope HPI readers will support it as a means of supporting what we do overall.

For the past three years, Health Policy Insight has been subsidised 100% by my other work as a freelance journalist and editor. I've been glad to do it, and have learned a lot about producing a daily publication (not a thing I'd previously done).

Over the past eighteen months, keeping afloat amid the policy turbulence has meant more and more of my time being taken up by Health Policy Insight, and I think the result is that our content has become better and better. From the feedback I've had, you apparently think so too.

It's been fascinating. What it doesn't promise to be, going forwards, is sustainable - unless I can earn some revenue from Health Policy Insight.

Selling advertising or advertorial a) is time-consuming; b) is not what I want to do; and c) creates powerful incentives to self-censor that I don't want.

Charging for subscription to a blog seems like a ridiculous concept; but to me, cross-subsidising the blog work by producing a new weekly, paid-for summary for the policy-interested and time-poor feels right to me.

I hope it feels right to you as well.

So if it does feel right, and you'd be interested in subscribing as an individual to receive 50 weekly editions of Health Policy Intelligence for £69 a year, then please drop me an email to editorial AT healthpolicyinsight.com (Discounts for more than one subscription can be arranged).

Thanks for reading - I hope you'll want HPI to continue, and will support us accordingly.

Transcript - The Politics Show BBC1, 13 March 2011
John Sopel [in studio]: Right, let me just come to another area of policy where perhaps the Liberal Democrat membership is rather opposed to what the Coalition is doing and that is on the Health Service. Does Andrew Lansley need to rethink his reforms?

Chris Huhne [at Liberal Democrat spring conference in Sheffield]: Well, I think that whenever you go through a big reform of the sort that Andrew has put forward for the National Health Service, there is always debate, and there is debate as the Bill has gone through, and we’re seeing that Andrew is focusing in on some of those key issues. And I’m sure, since he is a very sensitive and good politician, that he will be taking on board the remarks that were made here as well as some of the other points of the debate and –

Sopel: So you would like him to rethink?

Huhne: – as indeed is already happening. For example –

Huhne: ‘The fundamentals don’t need rethinking … Andrew Lansley’s already taken on board some of the criticism of the NHS reforms here in saying that the competition ought to be about quality’

Sopel: So you would like him to rethink?

Huhne: Well, I think the fundamentals don’t need rethinking but what we – after all, in terms of our values, what we’re focusing on here is patient choice and that patient choice being guided by your GP so that gives you a very clear focus on the needs of the patient and on improving quality and those are points that are already a very fundamental part of the reforms. But remember, too, that in some ways Andrew Lansley’s already taken on board some of the criticism that was made of the NHS reforms here in saying, for example, that the competition ought to be about quality –

Sopel: Sure.

Huhne: – not about price. What we want is –

Sopel: Sure. Do you think –

Huhne: – a world class, top quality National Health Service and, therefore, a local agenda –
Sopel: Do you think there will be more concessions coming?

Huhne: – with local people in charge.

Sopel: Do you think there will be more concessions coming?

Huhne: Well I – look, whenever a Bill goes through the Commons, there are always debates about particular aspects. I think that what Andrew Lansley is proposing with the NHS reforms is a major advance that will give patients more choice, will give local people more control over what’s an amazingly centralised Health Service and, ultimately, it will give us a better, higher-quality, world-class Health Service and that, I think, is something that all of us can support. Now, obviously, there are always debates about the detail, but those fundamentals –

Sopel: OK.

Huhne: – I think we need to hang onto.

Sopel: Right.

Huhne: And I think they were backed here in Sheffield.

Sopel: Fine.

Huhne: I think the overwhelming opinion of the conference was to make sure that we do have those values that we want – patient choice, the patient at the heart of this process, with a high-quality Health Service and local control – as being the two key aspects.

Sopel: Just let me ask you one final question. Shirley Williams has said, following that vote, which opposed large chunks of it, you see: “It means that Nick Clegg has to go back to Lansley with the other Lib Dem members of the Cabinet” – like you – “and say ‘I can’t get this through my party, we will have to make amendments’.” Are you going to be part of a delegation?

Huhne: Well that wasn’t the lesson, I have to say, that I took out of the NHS debate. I thought that the motion very clearly stated that this party wants to stand on the founding principles of the NHS, that it should be free at the point of need for anybody who falls ill, that’s absolutely crucial, and that that is respected. And I think that clearly is respected in what the Government has put forward.

Sopel: Chris Huhne, speaking to us a little earlier. So, difficult times then, perhaps, for the Health Secretary. We’ve heard about opposition to his plans from the Liberal Democrats, but it doesn’t end there. This week the BMA will debate a motion of no confidence in Mr Lansley, and there’s even talk of industrial action over the proposals. So, is it eyes fixed firmly ahead and keep on walking, or will he be swayed?

[cartoon insert of Lansley on a high wire]

Andrew Lansley is the Cabinet’s man on a wire, refusing to sway as he pushes through his controversial health reforms. Lansley’s boss, David Cameron, has confessed that the plan to hand about £80 billion of the NHS budget to GPs is risky – and the political tightrope has been raised higher because the new commissioning plans did not appear in the Coalition Agreement. But the Health Secretary has refused to climb down, even in the face of cat-calls from the medical establishment. With the BMA, the Royal College of GPs and, this weekend, the Lib Dems, raising fears that patient care would suffer because of increased competition and fragmented services. But Lansley’s high-wire act has won applause too, not least from GPs enthusiastic about commissioning services. The big idea is that they’ll be best placed to make decisions in the interests of patients. So, despite the best efforts of his critics to make him wobble, the Health Secretary is holding his nerve, convinced that, like all high-wire walkers, making a u-turn is simply not an option.

[studio]

And the real Andrew Lansley joins us now in the studio. Thanks very much for being with us. So, are your health reforms under review?

Lansley: ‘David Cameron and I have made absolutely clear, before the election, our absolute commitment to the values of the NHS, that it is a service that should be comprehensive, available to everybody, free, based on their need, not on their ability to pay, and that those values will be sustained in the NHS in the future, and we said we would protect the NHS’

Andrew Lansley: What we’re setting out to do – let me be clear about this – what we’re setting out to do, as Chris Huhne said from Sheffield with the Liberal Democrats – we want to achieve world-class results for patients through the National Health Service. David Cameron and I have made absolutely clear, before the election, our absolute commitment to the values of the NHS, that it is a service that should be comprehensive, available to everybody, free, based on their need, not on their ability to pay, and that those values will be sustained in the NHS in the future, and we said we would protect the NHS. Remember the Labour Party, before and after the election, said we should cut the NHS, cut the budget of the NHS – we didn’t. We put –

Sopel: Let’s talk about your proposals.

Lansley: Well, this is part of the proposals.

Sopel: I want to talk about – I want to know –

Lansley: Protecting the NHS, giving the NHS £10.6 billion additional resources over the next four years is part of the commitment we have to the NHS and it’s terribly important people recognise that that central commitment doesn’t change as a consequence of the modernisation.

Sopel: Alright.

Lansley: The modernisation is about using those resources far more effectively to deliver better results.

Sopel: But that wasn’t my question, which was: “Are your proposals under review?”

Lansley: Well, our proposals are always under review. Who imagines as you put – as Chris said, as you put a Bill through Parliament you look carefully at how the legislation delivers in the context of the reforms that we set out. Now, we’ve already made changes. You know, we’re not sitting there going “oh we must know the answers and nothing can change”. So, for example, people said to us “we think the way the legislation is structured” – which, actually – where we’d carried forward the Labour Party’s policy that there should be sometimes a maximum price – “that that could lead to price competition at the point where patients are being referred for treatment”. So we’ve changed the legislation, so it’s absolutely clear, that the NHS will have a national tariff, or a local tariff, but at the point where GPs make a referral or patients exercise choice, the price will be the same amongst all providers –

Sopel: Well let’s –

Lansley: – so they will choose on the basis of quality, so it really is competition on quality to drive up standards right across the service.

Sopel: OK. And there are worries that GPs will contract out commissioning work to private bodies. Are you going to rule that out?

Lansley: Do you know how much Primary Care Trusts, who are the existing health bodies, spent on external management consultancy in the year before the election? Do you know that?

Sopel: Well I – no. We could go into –

Lansley: Let me tell you.

Sopel: – statistics –

Lansley: £250 million! They increased by eighty per cent in two years the amount that the NHS managers contracted out to private sector external consultants. So let’s get it in proportion. Firstly, the NHS has been buying a lot of external advice when actually the GPs, properly engaged, are themselves in the strongest position to be able to design clinical services. The Labour government brought in the private –

Sopel: But I’m just wondering whether there’s any chance that you will rule that out.

Lansley: – sector and paid the private sector more than they would pay NHS providers.

Sopel: So that’s going to stay?

Lansley: We’re going to stop that.

Sopel: Right, but on the worry that GPs will contract out their commissioning work to the private sector, that stays? That policy –

Lansley: What do you mean? I mean, the GPs will have collectively – because I think people, I think, should understand that this is not individual practices, this is GPs coming together. We’ve got Pathfinders, 177 of them, who are covering 35 million patients across England, so there is now an immense body of work being done by GPs to put together these local consortia, on average representing 200,000 patients. They must secure the best commissioning support they need. Now they will be using managers from within the existing primary care trusts as they – as through the transition. But they, like the existing primary care trusts – they will have the discretion to look to the voluntary sector or the independent sector for support.

Sopel: OK. Alright. Fine. What about – OK. What about GP consortia taking decisions about spending millions of pounds of NHS money in private. Is that OK?

Lansley: “In private”? How do you mean?

Sopel: Well, is there going to be public accountability? Will we –

Lansley: Yes, of course. ’Cause they will be accountable –

Sopel: Full transparency?

Lansley: No, they’ll be accountable to the NHS Commissioning Board, who will hold their contracts and will be assuring themselves that they spend money properly, that there is transparency about their contracts – and they have to publish their contracts – and that they deliver results. There will be scrutiny by the local authorities’ overview and scrutiny and we’re extending the remit of scrutiny to General Practice and to private providers, which doesn’t apply at the moment, and all of the plans –

Sopel: The phrase I used was “full transparency”. Will there be –

Sopel: ‘For GP consortia taking decisions about spending millions of pounds of NHS money in private … (will there be) full transparency?’
Lansley: ‘No … actually, in terms of accountability, we’re really extending accountability’.

Lansley: Well, hang on a minute, I’m explaining it all to you and if you don’t let me finish then people will not get the whole picture. And we, for the first time, are putting in place, through Health and Wellbeing Boards in local authorities, the means by which the local authority can be directly involved in agreeing what are the strategic needs in their area, and that the GP commissioning groups’ plans meet those needs, alongside the local authority’s responsibility for public health and social care. So actually, in terms of accountability, we’re really extending accountability. Including – you see, when we got together with the Liberal Democrats after the election, one of the central things that happened was that, in addition to our determination that there should be clinical leadership – and we set out in our manifesto very clearly how GPs would be responsible for commissioning – but the Liberal Democrats were also very clear that there had to be local democratic accountability. And we’ve got local authorities all over the country who’ve applied to be the early implementers of that policy.

Sopel: I haven’t wanted to interrupt you because I knew you wanted to explain. How well would you say that explanation is going with the country at the moment?

Lansley: Well, across the country, for example, most local authorities want to be early implementers. The majority of GP groups have come forward very rapidly in order – to want that to happen. When you ask the public do they think that GPs are best placed to decide what health services should be provided for them locally, two-thirds of the public agree. When you ask the public do they think that it’s most important for them that they can have access to high-quality healthcare through the NHS and from whoever is best placed to do it, the overwhelming majority of the public do agree.

Sopel: Well I haven’t heard any concessions so far. You said you’re listening, but what you’ve then done is give a trenchant defence –

Lansley: Well you haven’t asked that question.

Sopel: OK. What are the concessions you’re thinking of making?

Lansley: OK. Well, because – I mean it is very clear that there are concerns on the part of Liberal Democrats that were expressed in Sheffield on issues surrounding our being absolutely clear that competition won't lead to fragmentation, that we want to be sure that the GPs and others can have really integrated services or, for example, that the process of accountability does deliver what we need in relation to local authorities and democratic accountability, as well as transparency through the Commissioning Board. We’ll bring all that back and that’s what my colleague in the health team Paul Burstow made clear yesterday and Nick Clegg has made clear. The other thing I think people want, you know –

Sopel: So where might there be specific concessions, then?

Lansley: Well, we’ll look at if, in the Bill, we can make clear that some of the things that people are concerned about will not happen: fragmentation or –

Sopel: What about cherry-picking of services?

Lansley: Well, we’re clear that that should not happen. And there are various ways in which in the Bill I think we can stop that happening. So, for example, the integration of services stops people taking individual procedures. Separately, we’re developing payment by outcomes so that you can't just pick out one procedure and do that. And we have to make sure that the price that is paid by the NHS for individual operations, for example, doesn't allow for cherry picking.

Sopel: OK. That’s very interesting.

Lansley: So we’re actually operating through the NHS to try and avoid that kind of –

Sopel: So, no –

Lansley: – advantage for the private providers which, actually –

Sopel: Sure.

Lansley: – the NHS at the moment does offer that to some independent sector providers.

Sopel: So no private provision if it jeopardises an NHS service?

Lansley: I’m sorry, I don’t understand what you mean.

Sopel: Well, if, for example – if you – I don’t know – hip and knee replacements, you could do – I could set up a production line doing simple hip and knee replacements. The more complex ones would then only be done at an NHS hospital, but the NHS hospital might then – can’t afford to keep that service going.

Lansley: Well that’s my point, you see. Under the Labour government, they did set that up and they let the private sector do it and they paid the private sector more than they would’ve paid the NHS for it. So what you need to do, which is what we’re doing, is making sure that the NHS get the right price for that, that if you do more complex operations, for example, you get paid more for it. You don’t just put it into one lump called “every kind of hip replacement” and the complex ones end up in the NHS hospital and are paid the same as the straightforward and routine ones – mind you, no hip replacement, frankly, is entirely routine, but anyway – But, actually, we are working on that to make sure that, actually, what has happened in the past under a Labour government doesn’t happen in the future.

Sopel: But why are you running into such a wall of opposition? I mean, you know, the BMA debating industrial action this week and motions of no confidence in you; the King’s Fund, massively sceptical about some of the implementation; the Royal College of General Practitioners also –

Lansley: Well, you’ve got to – No, no.

Sopel: – deeply concerned.

Lansley: No, come on, be fair – ’cause actually, you know perfectly well –

Sopel: Name me one public body that is a hundred per cent behind your reforms.

Lansley: ‘we are engaged in a discussion … if we can see that we can clarify and amend, in order to reassure people on some of these issues, then we will do so’.

Lansley: People are neither a hundred per cent for or a hundred per cent against. We’re engaged in a debate. The BMA are supportive of the principles of the modernisation in the NHS – that we do devolve decision making closer to the front line, they’re in favour of General Practice-led commissioning, they’re in favour of a greater emphasis on outcomes, rather than the process targets the Labour Party had. They are in favour – and many of the organisations are entirely in favour of – giving patients better information, more choice and more control. But we are engaged – let me be clear about this – we are engaged in a discussion.

Sopel: OK.

Lansley: And we will, if, as we have done up to now already – if we can see that we can clarify and amend, in order to reassure people on some of these issues, then we will do so.

Sarah Sands: I’m just puzzled, for instance, that this looks very good for GPs, this devolution of power, which – everyone should be for it – why they’re against it. You know, why someone like, sort of, Shirley –

Lansley: Sorry, our GPs aren’t against it.

Sands: Well, you’ve certainly had individual opposition from GPs, because it seemed to be popular –

Lansley: Course, individuals – People are allowed to have individual views –

Sands: Yeah, yeah, of course, but I don’t know why –

Lansley: – without being characterised –

Sopel: Let Sarah ask the question.

Sands: – if it isn’t sort of obviously wonderful, why people are so suspicious of it – almost comes down to the idea that we know that the National Health Service is sort of imperfect but we know people love it. Do you need to – Is this necessary when you have everything else going on?

Lansley: Well, let’s – OK.

Sands: Why take it on? Why take someone like Shirley Williams on?

Lansley: I think it’s a fair point. Because change is difficult and people perceive this – I mean, frankly they perceive it as a bigger change than it actually is, ’cause a lot of this is evolutionary. You know, we’ve got things like practice-based commissioning groups and so on.

John Kampfner: But people don’t get it –

Lansley: But when you ask the public, when you – as I think the Nuffield Trust did just the other week – when you ask the public do they think the NHS needs change in order to improve in the future, the answer is, I think, about three-quarters of the public do say yes. And when you look at the results of the NHS in comparison with the leading health economies around the world, we know there’s a gap. The Public Accounts Committee just last week published a report on cancer and our performance in terms of cancer survival rates and said there’s still a persistent gap. So we do need to meet demand and increase results by ensuring – and I personally think it’s absolutely critical here –

Sopel: John, John.

Lansley: – is to transfer more responsibility to frontline clinicians.

John Kampfner: ‘You were shadowing this brief for many years while Labour was in government, and you’re very versed in the subject – so you didn’t do this on the back of an envelope. If that’s the case, why was this not in the Coalition Agreement? Moreover, why did the Coalition Agreement say “no top-down reorganisation of the NHS”?’

John Kampfner: Liberal Democrats’ objections, as you know, are in two forms: one is the policy, which John has grilled you on in some respect, but particularly, as Evan Harris and Shirley Williams keep on talking about, the use of private providers, private contractors. We’ve discussed that through, to a degree. The other area is the politics. This was not, emphatically, in the Coalition Agreement. You’re not a new kid on the block, you were shadowing this brief for many years while Labour was in government, and you’re very versed in the subject – so you didn’t do this on the back of an envelope. If that’s the case, why was this not in the Coalition Agreement? Moreover, why did the Coalition Agreement say “no top-down reorganisation of the NHS”?

Lansley: Well, you say “why was this not in Coalition Agreement” – Let’s step back for a moment. I mean, you’re absolutely right, I was Shadow Secretary of State for more than six-and-a-half years before becoming Secretary of State and, to that extent, people say “oh well you didn’t talk about this before the election”. We did! We talked in detail about this – but with significant changes after the election, because we and the Liberal Democrats came together. And the Liberal Democrat contribution to the policy after the election was significant. It made a big difference in terms, for example, of accountability. It made a big difference in terms of the involvement of local authorities; and that had consequences. And the truth of the matter is – and we’ve said this time and again – the Coalition Agreement at the point at which it was published represented –

Sopel: OK.

Lansley: – the two parties’ policies on things like – and, actually, on things like the Liberal Democrats and ourselves agreed in our manifestos that –

Kampfner: I just –

Lansley: – patients should have access to whichever provider –

Kampfner: So if you agreed on so much, why was it not in the Coalition Agreement?

Lansley: – the point – No, when you say it wasn’t – The only thing that wasn’t was that, because we were going to use GPs to commission healthcare services locally, and local authorities to be responsible for public health and social care that, actually, the primary care trusts would be abolished as the consequence of it. The abolition of strategic health authorities came in from the Liberal Democrat manifesto.

Sopel: OK. And there we will leave it. Andrew Lansley, we’re grateful to you.

Lansley: Thank you.

Sopel: Thanks very much indeed for being with us.