“The central task I have set myself and this Party is to be as radical in social reform as Margaret Thatcher was in economic reform” – David Cameron, Conservative Party conference, 1 October 2008

Over the past generation, no Conservative politician since Michael Heseltine has had the electorate’s serious scrutiny as ‘probable next Prime Minister’.

As Thatcher’s assassin, of course, the crown would never be Hezza’s.

Neither Hague, Howard nor Duncan Smith ever looked like troubling Tony Blair – despite the wildly unpopular Iraq war. Most people thought John Major would lose in 1992.

But now we have David Cameron. He and the Conservatives have enjoyed a poll lead over Labour and Gordon Brown stretching back almost exactly a year. His party have brought out clear and extensive policies in many areas, health foremost among them as Cameron’s “number one priority”.

So his speech closing the Conservative Party’s 2008 conference obviously matters.

The economic context had forced his emergency statement of bipartisan political intent yesterday, and for an hour this afternoon, he eschewed the 2007 ‘look, no hands’ note-free performance. Instead we got ‘look, I’m late’, as he entered half an hour behind schedule and carrying his folder of text.

Brand Cameron: to spend or not to spend?
The speech was, essentially, a definition of what kind of a person, politician and Conservative he was. In policy terms, there was little new, but in the context of gloomy economic news, this was the sensible, conservative option.

What was on sale was not micro-level detail of the how, but the particular philosophy – brand Cameron – that he would bring to office.

Much of the speech was sober assessment of the challenging economic conditions that are now certain to lie ahead. Repeatedly, Cameron emphasised that his offer is of a smaller but smarter government.

He repeatedly described his ability to understand people’s hardship and feel their financial pain. And he promised, “I will be asking all my shadow ministers to review all over again every spending programme to see if it is really necessary, really justifiable in these new economic circumstances. But even that will not be enough. The really big savings will come from reforming inefficient public services, and dealing with the long-term social problems that cause government spending to rise”.

He also promised to outsource much of the Treasury’s job by creating a new independent Office of Budget Responsibility.

Cameron also made it clear he does not intend to become a hostage to detail. This was reminiscent of Tony Blair and New Labour’s policy-light approach in 1997, whose few policy commitments were to abolish the NHS internal market, not to raise the basic rate of income tax and to stick to Conservative speding plans for two financial years).

Cameron told delegates, “the test of whether we're ready for government is not whether we can come up with exciting shadow budgets. It is whether we have the grit and determination to impose discipline on government spending, keep our nerve and say "no" - even in the teeth of hostility and protest.

Yet within the first five minutes of his speech, he had already made a major spending commitment on the military. Citing equipment shortages, poor housing for military families and military leave including traveling times home to the UK, Cameron promised “to stop treating our soldiers like second-class citizens”. It will need experts on military policy to outline the true cost of this commitment, but this will not be a small additional resource demand.

State versus society?
An unresolved but interesting theme of the speech was around the proper role of the state.

He described his yardstick for big decisions as asking himself, “Does this encourage responsibility and discourage irresponsibility? Does this make us a more or less responsible society? Social responsibility, not state control”.

Now apart from the very Blairite final sentence-that-isn’t (without verb or object, merely contrasting one noun or adjective against another), and the oxymoron (encouraging responsibility self-evidently suggests the obverse), this suggests false opposition between state control and social responsibility.

Various aspects of state control are certainly also socially responsible – speed limits, universal education and are even popular with Conservative voters – law and order and immigration controls.

Cameron attacked David Miliband’s comment to the Labour conference (Milliband said that "unless government is on your side you end up on your own.") as “one of the most arrogant things I've heard a politician say. For Labour there is only the state and the individual, nothing in between. No family to rely on, no friend to depend on, no community to call on. No neighbourhood to grow in, no faith to share in, no charities to work in.

“No-one but the Minister, nowhere but Whitehall, no such thing as society - just them, and their laws, and their rules, and their arrogance. You cannot run our country like this”.

He echoed Margaret Thatcher’s 1979 election promises of “strong defence, rule of law, sound money”, but also cleaved to his ‘modern Conservative’ approach with an internationalist message, telling delegates “we'll never be truly rich while so much of the world is so poor.”

Fixing the broken society: socialist Conservatism?
Cameron stuck to his allegation that UK society is “broken”, but contended of those who call for “tough punishment, longer sentences and more prison places … to a degree, they're right: we'll never mend the broken society without a clear barrier between right and wrong, and harsh penalties when you cross the line. But let's recognise, once and for all, that such an approach only deals with the symptoms, picking up the pieces of failure that has gone before”.

It remains a bit startling to see the Conservative leader tell his party on criminal justice, “Miss the context, miss the cause, miss the background and you'll never get the true picture of why crime is so high in our country”.

Later he told delegates “when the call comes for a politics of dignity and aspiration for the poor and the marginalised, for the people whom David Davis so vividly described as ‘the victims of state failure’; when the call comes to expand hope and broaden horizons - it is this Conservative Party, Conservative means, that will achieve those great and noble progressive ends of fighting poverty, extending opportunity, and repairing our broken society. Progressive ends; Conservative means.”

Does Cameron mean this? While attacking Conservative libertarianism in his speech, his voting record (against the hunting ban, the smoking ban, 42-day detention of terror suspects and ID cards) suggests otherwise.

His progressive views are a more mixed bag: he voted moderately for equal gay rights, but for reducing the upper limit on abortion from 24 weeks to 22 weeks and to make IVF clinics consider the need for a father and mother before allowing women to start fertility treatment.

In health policy terms, he strongly opposed the creation of foundation hospitals.

There is, of course, no way of knowing whether this is just impressive PR – Cameron’s former job. And it remains unclear how much of the Conservatives’ poll lead is associated with Gordon Brown’s personal unpopularity. At the least, they appear alive to the fact that the country’s social values have become more progressive.

The depth of conviction in Cameron’s and his party’s progressive reinvention is difficult to plumb.

The NHS bit
“Labour have taken our most treasured national institution, ripped out its soul and replaced it with targets, directives, management consultants and computers. … I'm afraid Labour have had their chance to show they can be trusted with the NHS, and they have failed. We are the party of the NHS in Britain today, and under my leadership that is how it's going to stay”

Cameron’s speech had a long passage on the NHS, focusing around the death of a constituent’s wife – suggestedly associated with her contracting MRSA in hospital (though the wording of this in the speech is unclear, as is the condition for which the woman went into hospital). It also hinged on a staggeringly ill-considered reply Cameron received from Alan Johnson’s office, having forwarded the letter.

He restated the party’s policy on abolishing all targets, and again sought to portray the Conservatives as “the party of the NHS in Britain today” faith with the hysterically impudent more-in-sorrow-than-in-anger formulation, “Labour have had their chance to show they can be trusted with the NHS, and they have failed”.

Other than historical knowledge about the creation of the service, there is one potential fly in the ointment on Brand Cameron adopting Brand NHS: as was observed in Andrew Lansley’s session two days ago, many Conservative activists don’t seem very comfortable on this territory.

When Cameron mentioned the NHS as “the public institution I value most”, prior to this main health-specific section of his speech (which is reproduced below), just one person in the hall spontaneously applauded.

Andy Cowper
Editor, Health Policy Insight

Extract from David Cameron's speech
“Let's be straight about what's happened to our NHS. Money has been poured in but maternity wards and A&E departments are closing. Productivity is down. The nurses and doctors are disillusioned, frustrated, angry and demoralised.

“I know from personal experience just how brilliant and dedicated the people who work in the NHS are. But they have been terribly, terribly let down. Instead of a serious long-term reform plan for the NHS, working out how we can deliver a free national health service in an age of rising expectations and rising healthcare costs, never mind the rocketing costs of social care, we've had eleven years of superficial, short-term tinkering. Top-down target after top-down target, with another thirty-seven targets added last year.

“Endless bureaucratic re-organisations, some of them contradictory, others abandoned after just a few months. Labour have taken our most treasured national institution, ripped out its soul and replaced it with targets, directives, management consultants and computers.

“In August, I got a letter from one of my constituents, John Woods. His wife was taken to hospital. She caught MRSA and she died. Some of the incidents described are so dreadful, and so degrading, that I can't read you most of the letter. He says the treatment his wife received "was like something out of a 17th century asylum not a 21st century £90 billion health service."

“And then, as his wife's life was coming to end, he remembers her "sitting on the edge of her bed in distress and saying 'I never thought it would be like this'."

“I sent the letter to Alan Johnson, the Health Secretary. This was his reply. "A complaints procedure has been established for the NHS to resolve concerns. Each hospital and Primary Care Trust has a Patient Advice and Liaison Service to support people who wish to make a complaint. There is also an Independent Complaints Advocacy Service. If, when Mr Woods has received a response, he remains dissatisfied, it is open to him to approach the Healthcare Commission and seek an independent review of his complaint and local organisation's response. Once the Health Care Commission has investigated the case he can approach the Health Service Ombudsman if he remains dissatisfied…."

“A Healthcare Commission; a Health Service Ombudsman; a Patient Advice and Liaison Service; an Independent Complaints Advocacy Service. Four ways to make a complaint, but not one way for my constituent's wife to die with dignity. By God, we need to change all that.

“But here is the plain truth. We will not bring about long-term change if we think that all we have to do is stick with what Labour leave us and just pump some more money in.

“Instead of those targets and directives that interfere with clinical judgments we'll publish the information about what actually happens in the NHS. We'll give patients an informed choice about where to go for their care, so doctors stop answering to Whitehall, and start answering to patients. This way, the health service can at last become exactly that: a service. Not a take-it-or-leave-it bureaucracy.

“I'm afraid Labour have had their chance to show they can be trusted with the NHS, and they have failed. We are the party of the NHS in Britain today, and under my leadership that is how it's going to stay”.