Reform is the watchword, right across the political spectrum. But what does it mean?

From Education to the NHS, the debate is framed in terms that are far too simplistic

When asked about reform in general, David Cameron insists that he is about “giving power away from the centre to the users of public services” (PA) (PA)

In a crowded field of evasive, misleading, and destructive political terms there is one in particular that stands out. The wretched term “reform” is thrown around indiscriminately. There are associated terms that are almost as deadly. They include “caution”, “bold” and “modernise”. Debates within parties and between them are billed as clashes involving modernisers and conservatives, or as contests between pro-reformers and those who are anti-reform, when the divisions are far more complex. Count the number of times these terms are deployed in the current election campaign. They never shed any light.

David Cameron’s speech on education is a good example of his confused thinking in relation to "reform". When asked about reform in general, Cameron insists that he is about “giving power away from the centre to the users of public services”. There is a lot of evidence to suggest that this is indeed what Cameron believes. He is more Thatcherite than Margaret Thatcher in his wariness of the state, almost as if he believes that if the state withdraws, a thousand flowers will bloom.

The qualification is important. He almost believes it. When faced with specific problems Cameron becomes a fleeting statist. Yesterday he insisted that he would impose new forms of leadership on schools with poor Ofsted ratings. Struggling academies would be switched to other academy sponsors.

These proposals are sensible and yet they have nothing to do with reducing the role of the state. Ofsted is accountable to the Department of Education. The Department of Education would act to improve failing schools based on Ofsted reports. Pupils would be empowered to fulfil their potential because the state would take responsibility for the standards of schools. The lines of accountability are clear. There is no hiding place for weak of complacent leadership in schools. High performance levels will be demanded from the centre.

But this is not usually what Cameron means by “reform”, which in its theoretical application applies more to markets or individuals seizing responsibilities, however ill-defined they are. Precisely the same contradiction applies to the Prime Minister’s view of the NHS. When his former Health Secretary Andrew Lansley proposed that the state should have no direct responsibility for standards in the NHS, Cameron regarded the reforms as emblematic. His big idea was that power and responsibility must be transferred away from elected ministers. Yet when the care scandal at Mid-Staffs erupted Cameron set out sweeping reforms from the centre, accepting that the Government must take responsibility for ensuring that improvements were made.

In an excellent Commons statement he proposed immediate moves to improve standards. These included the idea that hospital boards be suspended for care failures; an element of performance-related pay for nurses; a new chief inspector of hospitals; and an inquiry into hospitals with the highest mortality rates. Since the introduction of inspections for hospitals, the Health Secretary, Jeremy Hunt, has rightly argued that they represent a new form of accountability for NHS managers.

None of these changes are related to the market or to so-called competition. They are important innovations from the centre, but are rarely regarded as “reform” when the term is bandied about. In the narrowest of stifling debates, “reform” can only mean market-based changes combined with simplistic views on competition and choice.

The former Health Secretary Alan Milburn launched his “reform” attack on Ed Miliband and his Shadow Health Secretary, Andy Burnham, last week, arguing that the current Labour leadership was too conservative in relation to the NHS. Milburn was supported by those who say that “what matters is what works” but he was referring to a specific version of reform - market-based change. If his ideas had worked successfully when he was in office, they would no doubt be hailed more widely as the only acceptable reform. There is quite a lot of evidence that coordinated collaboration between hospitals - and the establishment of clear lines of accountability, as outlined by Cameron after Mid Staffs - are essential reforms that work too.

Those who question Milburn’s “reforms” are not necessarily anti-reform or defending outdated rights and pay of NHS workers and GPs. Indeed it was a succession of Blairite Health Secretaries who negotiated the extremely generous GPs’ contracts a decade ago. In this Alice In Wonderland world it was the then Chancellor Gordon Brown who was consistently tough in relation to public-sector pay, while at the same time was accused of being “anti-reform” in order to woo his party’s public-sector activists.

While Milburn and others were attacking the Labour leadership for failing to focus on reform, Andy Burnham was proposing an historic reform - the integration of health and social care. This is a change of daunting ambition and one that will meet some resistance from within the NHS and social services. You can agree with Milburn’s idea of change, and oppose the even more radical vision of an integrated service, but it is utterly misleading to imply that there is only one possible “reform”.

The framing of this debate originated with Tony Blair, who set out a simplistic divide – reform vs anti-reform, boldness vs caution. Blair also argued that what mattered was what worked, as if he faced a formidable array of foes insisting that what did not work was what mattered. For the current Labour party, Blair’s legacy is as problematic as the Thatcher one is for the Conservative leadership.

All reformers strive to discover “what works” but disagree over how to innovate while securing value for money. Looking at the UK’s fractured, poorly funded public services, they will be striving for some time yet.