Why Andrew Lansley should stay - and why he might go

For all the missteps, misunderstandings and mishaps Mr Lansley is still best qualified for the job of health secretary among those available for the position within the current government. Those who wish him gone would do well to consider the alternatives. Mr Lansley’s knowledge of and commitment to the NHS gives him the ability to fight off the far more radical and damaging alternative remedies for reforming the service which always bubble under the surface of the Conservative party.

The health secretary is, partly, a victim of his own good intentions. He gave instructions to those drafting the Health Bill to write it in a permissive manner so as to give local decision-makers maximum flexibility.

He now privately admits that this permissiveness went too far, allowing critics to paint all kinds of possible damaging scenarios which Mr Lansley claims, with some justification, were never the point of the reforms.

That is how he is justifying the month-long “pause” in the legislative process. It is a chance to expose the scare mongers for what they are and to work out the tweaks that will clarify those intentions. He is genuinely relaxed about most proposed clarifications (commissioning accountability, safeguards over private sector involvement).

In the meantime, Mr Lansley has said there should be no “pause” in the reform process as it effects the restructuring of the NHS.

He has done so in the knowledge that this is no longer his call. The £20bn Quality, Innovation, Productivity and Prevention challenge is the priority on the ground – and that is firmly in control of NHS chief executive Sir David “fireproof” Nicholson. Primary care trust clustering is continuing apace and the QIPP mission is being rapidly transferred to emerging commissioning consortia.

HSJ readers will know that calls for the structural changes to be slowed to reflect concerns around GP readiness have already been addressed by Sir David in HSJ. He has made it very clear they will get “hard” commissioning budgets when he thinks they are ready – whether that is before April 2013 or after it. “Centralise before localising” is his current modus operandi.  

Mr Lansley’s job is to stay out of Sir David’s way. Not defaulting to manager bashing as the health secretary did in the House of Commons debate on Tuesday might help the NHS chief executive rally his increasingly disillusioned troops from whom every day brings another leaving do.

Staying out of Sir David’s way will allow Mr Lansley to spend more time supporting the prime minister and his deputy as they begin their explaining and listening campaign.

This may be essentially a PR exercise (with the possibility of a few tweaks on the rudder) for Mr Cameron and Mr Lansley, but the stakes could not be higher.

Fail to convince the doubters and the substantive changes demanded by doubters, which clearly include Nick Clegg, will be hard to resist. Post the 5 May AV referendum, these demands may be being made by a Liberal Democrat party which feels it has nothing to lose from all out resistance to the reforms.

It will also be the case that, if the health reforms are still a hot issue in the summer, it will be Mr Cameron, rather than his health secretary, who is accused of not listening.

These would effectively re-toxify the NHS as an issue for the Conservative party. Faced with that potential outcome, the prime minister will know even substantive policy changes will not suffice and that he needs to make a big political gesture.

He may even reluctantly conclude that: Andrew Lansley must go.