Steve Richards: If the Health Secretary won't be accountable, then who will?

A policy aimed at cutting bureaucrats looks more like one where no one knows who is in control

In a supposedly non-ideological age the Coalition is coming unstuck through an idea. The two policy areas under intense scrutiny this week, the economy and its NHS reforms, are defined by a wariness of the state, an assumption that all other levers can be pulled, but not those most readily in possession of elected ministers.

In both cases David Cameron and others insist that the Government is acting with expediency, the need to respond to hard times. They make a fair point. No one can accuse the Coalition of arriving in power at a time of hedonistic plenty. Yet its Plan A for the economy and the NHS reforms suggest that something more than pragmatism shapes the hazardous routes ministers choose to navigate. Both are informed by a distinct view of government and its limits.

The House of Lords might have voted for the NHS proposals yesterday afternoon, but the debate that preceded their tame verdict highlighted a single, forensically expressed concern. No one argued that the health service was a perfect model as it currently stood, or that it could not be much more efficient, but former health ministers, surgeons and the rest outlined their alarm that the new lines of accountability were dangerously unclear and that the envisaged responsibilities of the Health Secretary were extremely limited.

In spite of repeated questioning over recent months, Shirley Williams was still not satisfied that the key elected figure in relation to the NHS would be accountable for very much at all. She pointed out that a Health Secretary would intervene only in the event of "significant failure" and went on to argue: "We all know about the danger of reactions to such things as necessary hospital closures, mergers and so on. But if the Secretary of State is unable to take any part in those until the failure becomes significant, heaven help us in making the changes that lie in front of us as effectively, cheaply and sensibly as we can."

The former health minister and surgeon, Lord Darzi, put it more vividly. He was a minister under the previous government and so comes from a distinct perspective, but neither his speech, nor the debate more generally, was marked by partisan glee. The issue at stake is too big. This was his take on the blurred lines of responsibility: "We now have health and well-being boards, clinical commissioning groups, clinical senates, local health watches, the NHS commissioning board, a quality regulator and an economic regulator... At the end of the day, who is responsible for making sure that the NHS saves more lives this year than last? Who is accountable for how its budget is spent? Who will inspire NHS staff to lead the difficult changes?"

He got no clear answers from the relevant ministers because there is no clear answer in the proposals. David Owen raised a specific scenario in which the lack of clear accountability would lead to paralysis: "If a pandemic suddenly grips this country we will not be able to accept that the Health Service is managed by the Chairman of the National Health Service Commissioning Board. We will instinctively come back to the Houses of Parliament".

When we do so the Health Secretary will declare that it is nothing to do with him or her. Indeed that is the objective of the reforms, in theory a noble one, to take power away from the centre and, ultimately, to empower patients. But the theory is tested at every stage by practicalities, so much so that already a policy aimed at reducing the number of bureaucrats looks like increasing the mediating agencies with no one knowing who is in control. This has not happened by chance. No doubt the coalition seeks to save money, but the ideological dimension is absolutely clear, the centre cannot and should not be held responsible for the delivery of local services.

Precisely the same pattern applies to economic policy. The Coalition responds to unquestionably appalling external circumstances, but its distinct response has an ideological edge. It pulls every lever, except the one that would have the most direct impact, government activity. Perhaps the credit easing to be announced next month will lead to more money becoming available for small businesses. Maybe the second round of quantitative easing will have more impact than the first. But it is still not clear where the demand will come from when the spending cuts are inevitably leading to job losses and, equally important, a fear of further losses. The Coalition refuses to revisit its austerity programme, framed in such an intoxicating hurry over the summer of last year and reinforced by the increase in VAT in January. Its theory, that government doing less would lead to the private sector doing more, has been tested to the limits and yet still they make no move.

In the case of both the economy and the NHS David Cameron and his colleagues have set out to address almost impossibly complex problems. The relationship between the state and local providers of publicly funded services is so demanding that no government has managed to achieve the right balance between efficiency, innovation and accountability. Labour remains split over how to do so. How to get an economy growing when there is no demand poses a greater challenge to this Government than its equally ideological predecessors in the 1980s, when the rest of Europe and the US were booming.

But its instinctive resistance to government activity and accountability from the centre leads to even greater storms. Unavoidably when huge sums for the NHS are raised centrally the Health Secretary must be responsible. If he or she is responsible there must be levers for him or her to pull, over and above those available to vaguely accountable, largely anonymous non-elected quangos. In relation to the economy, if the private sector is dormant the Government is powerful enough to generate a degree of demand, if it wants to do so.

In Number 10 some of Cameron's entourage noted the only successful part of Ed Miliband's conference speech, as they saw it, was his attack on their NHS plans, a gift from them to him. The Lords would have done Cameron a big favour if they had delayed or defeated the proposals. Now he will need to find another way to make further changes. On the economy Cameron will not want to arrive at too many more Prime Minister's Questions on the back of grim economic news, as he did yesterday. One way or another, Plan A will become Plan B.

There is much to commend ideology in politics, but only when the ideas are working.

s.richards@independent.co.uk;