Westminster blog

Buried away in the sweeping proposals from the government commissioned review of how sickness absence from work should be handled is a small bombshell.

Alongside a new independent assessment service to which patients would be sent after 4 weeks on the sick, plus a new brokering service to help people swap a job they can’t do for one they can, is a proposal for tax relief on private medical insurance and private medical treatment aimed at getting people back to work.

This is a highly sensitive issue. In his determination to seal the NHS off as an electoral issue for the Conservatives, David Cameron, in one of his earliest acts as party leader ruled out tax relief for private medical care – declaring that “we should not use taxpayer’s money to encourage the better off to opt out”.

Andrew Lansley is to prevent primary care trusts from arbitrarily setting minimum waiting times and caps on the number of NHS treatments. In principle quite right too.

But the NHS also still has maximum waiting times – despite the health secretary’s initial attempt to scrap them as a Labour “top down” target.

So cash pressured primary care trusts, and their successors the clinical commissioning groups, will not be allowed to set minimum waits but will still have to attempt to honour maximum ones when longer waits have always been the way the service copes when spending is tight.

Over the next four years it is set to get very tight indeed as demand rises but the money remains flat in real terms.

So how can it cope? The good ways include redesigning service to deliver high quality at lower cost – in effect increasing efficiency – although the service’s ability to do that on the scale needed is in question. The bad ones are likely to include raising the threshold for

It is party conference time. And the old convention that each party let is opponents have their week in the sun is dead.

Gordon Brown is partly responsible for that. His decision to go to Iraq to be televised supporting our boys in the middle of the Conservative party conference in 2007 – just head of the general election he was minded to call but bottled – left the Tories spitting teeth.

Today was part of their revenge. Andrew Lansley declares that some 20-odd NHS hospitals may not be financially and clinically viable because of the scale of their PFI debts – their payments are too high a chunk of their turnover – and that is all Labour’s fault. As indeed is the separate build up of debt which some carry and which, as things stand, will prevent them becoming free standing NHS foundation trusts.

Amid all the confusion about what is to happen to the coalition’s controversial NHS bill, maybe the one person who actually knows is Eric Pickles.

Right now David Cameron is talking to his bunch of NHS worthies, Nick Clegg to his, Andrew Lansley to his own kitchen cabinet, while Paul Bate, Cameron’s new health adviser has his own separate set of consultees as each tries to decide what can be salvaged from the bill … not that these groups do not overlap more than somewhat. 

But Eric, it appears, knows the answer. My sharp-eyed colleague Sally Gainsbury has just noticed that the local government secretary  has published a draft list of bodies that will have a duty to cooperate with councils under the localism bill. The only NHS bodies listed are primary care trusts – which, under Lansley’s plans, get abolished in 2013 – and not “GP consortia”. 

There are already strong rumours that “clusters” of PCTs will live to fight another day, particularly if the wish of some Liberal Democrats is granted and GP commissioning becomes voluntary. Eric seems to know they will. 

A departmental spokesman hurriedly explains that the list is “just a draft” and the actual bodies when the statutory instrument comes out “will reflect the health bodies at the time”. Meanwhile, after the roasting that Ken Clarke got over rape sentencing after appearing on her show, Andrew Lansley has pulled out of an interview with Radio 5’s Victoria Derbyshire. Poor boy is in enough trouble already.

The Liberal Democrats in their election manifesto wanted local authorities to do the purchasing of NHS care. Even now, during Cameron, Clegg and Lansley’s “pause” in their NHS reforms, their activists are pushing hard for councillors to be given a much bigger role in commissioning.

This is a really bad idea. And Enfield council, in the first test of what the Liberal Democrats would like to be the new regime, have just demonstrated why.

The reason council commissioning of care is a not a good idea is that it mixes representation without taxation. Councillors have democratic legitimacy. But they don’t raise the money for the NHS.

So over the long term, giving them responsibility for commissioning is simply a recipe for councils to say there is not enough money in the system and to blame central government for the NHS’s deficiencies, rather than take hard decisions – hard in the sense that they are always locally unpopular – over how services need to be reshaped as medicine changes.

That was what almost invariably happened when councillors sat on health authorities back in the seventies and eighties. Today, Enfield has just made the point again.

Chase Farm Hospital in the borough has both accident and emergency, and maternity and paediatric services, that hospital clinicians locally believe are no longer safe. Indeed, it is 17 years since the closure of Chase Farm’s “blue light” A&E was first proposed and 15 years since the same case was made – again on clinical grounds – over the maternity care.

Enfield is bitterly opposed to the plans to transfer both these services to the nearby North Middlesex Hospital – a proposal that would leave Chase Farm doing more non-emergency surgery than at present, and still with an urgent care centre.

Despite endless rounds of consultation which have shown clear majority support among hospital clinicians and GPs across Barnet, Enfield and Haringey – all three boroughs and parts of Hertfordshire are affected by this change – Andrew Lansley, the health secretary, recently gave the council a chance to come up with an alternative strategy.

Today it has done so. Boiled down, its conclusion is “give us more money and keep everything open”. Point made.

“We the willing, led by the unknowing, are doing the impossible for the ungrateful.” Well, not quite.

But the quote attributed to Mother Teresa might be the new slogan for Whitehall civil servants, where, the Institute for Government has just noted, there has been a spectacular turnover at the top.

Jill Rutter, herself a former senior mandarin, notes that since the general election there has been an ”unprecedented level of churn” amongst permanent secretaries.

Of the 16 major departments, just six now have the same permanent secretary that they did when the coalition took office. And of the nine new appointments made so far, just two have immediate prior experience of their department. Five have never worked in the department to which they have been appointed.

This means that in the department’s affected “ministers, all of whom have under a year’s experience, will all have someone with less experience at the top”.

The new perm secs will be playing catch up with their ministers, she notes. And “at a time when unprecedented cuts are being implemented, it might help to know where the bodies are buried and where the landmines are.” Quite.

And not only that. In some areas – health and DWP for example – policies are being tried that have failed, or far from suceeded, before. Having old hands around who know why things went awry last time – and therefore how to stop them going awry this time – might also, one would have thought, be useful.

Civil service morale has – perhaps unsurprisingly – taken a distinct knock in the face of the spending cuts.

But the staff’s increased scepticism that the top of the office knows what it is doing is most marked with Andrew Lansley’s NHS reforms, Eric Pickles major deconstruction of the local government department, and in Vince Cable’s business department.

Staff are also appreciably less convinced that the department’s board is clear about what it is up to at Michael Gove’s education department and in the Home Office, headed by Teresa May.

Each of these departments has seen an 11 to 13 percentage point dip in the proportion of civil servants who believe that the department’s board “has a clear vision for the future of my organisation”.

The results come from Whitehall’s massive annual survey of morale to which more than 300,000 civil servants responded.