Is a narrative for complex health reform impossible?

On Monday 31 January, he sits on the 7.13 from Cambridge reading The Times, in which David Cameron sets out to tackle five “myths” about the government’s health reforms. Later in the day, the prime minister’s official spokesman will admit: “We have a lot of work to do to explain these proposals.”

Cut to the evening and a stormy House of Commons. Mr Lansley is battling his way through constant interventions. Eventually he snaps: “Time does not permit me to explain the extraordinary ignorance of that series of questions!”

And there we have the key fault line in the government’s reforms. The plans encapsulated in the Health and Social Care Bill are bewilderingly complex, largely concerned with the removal and addition of powers exercised by bodies involved in directing and supplying NHS care.

With those authoring the plans feeling their way and acknowledging they are creating a permissive system in which different execution could deliver a range of outcomes, the “coherent narrative” that many say is needed over the future of something with the emotional and political weight of the NHS is almost impossible to construct.

As New Labour found, anything understandable to those outside the health policy and management world becomes overly simplistic, hence the polarised debate we have suffered for more than a decade.

With the bill likely to crawl through Parliament for most of 2011 there will be plenty of chance to close the knowledge gap – and for future explosions of frustration from the health secretary.

Let us hope the former predominates, because the detail of the bill needs close study.

A crucial area of examination will be how the bill constrains and/or allows the centre to direct the service. The scepticism felt over the government’s claims that a new era of freedom is just around the corner was reflected in last week’s HSJ coverage.

As with other alleged “myths”, the government is keen to change this widely held impression. It points in particular to the loss of the health secretary’s power to direct individual health organisations and how his steering of the service will be limited to an annual “mandate”.

Many of the safeguards against central interference rely on legal interpretation of the bill’s measures. The government insists it has selected the toughest parliamentary and legal barriers against health secretaries reverting to type.

Its belief is that any government wanting to directly intervene in the NHS (outside the annual mandate) would be dissuaded from doing so by a toxic combination of political embarrassment and potential legal challenge. The in-year adjustments that will, no doubt, serve to smooth out the financial problems emerging among a fifth of primary care trusts, or the pleas for commissioners to take pity on providers hit by winter pressures will be a thing of the past.

Much depends on how governments construct the annual mandate, which will replace the operating framework. Even if we assume the bill’s measures have the intended effect, the mandate could still be a powerful lever.

The government will be required to go through a consultation exercise each year (effectively echoing last year’s white paper procedure) before issuing its instructions in time for plans to be made for the coming financial year.

Might this annual exercise be the answer to building the desired informed public narrative over health reform? Like so many aspects of the government’s plans, the jury remains firmly locked in its deliberations.