Andrew Lansley wins strong support from NHS managers

In 2005, before he ruled out standing for leader of the Conservative party, Andrew Lansley told his colleagues they had to be less confrontational if they wanted to regain public trust.

To be elected, they had to be "less strident and more interesting", the shadow health secretary said. "A critique of one's opponents can be deployed without descending to abuse, to personal attacks or opposition for its own sake." It was a call, if you like, for Conservative MPs to improve their bedside manner.

Three years on, and with the Conservatives flying high in the polls, Mr Lansley is still attempting to lead by example. Leader David Cameron may have abandoned his pledge to shun "Punch and Judy" politics, but Mr Lansley remains friendly and polite. In our interview, he describes Alan Johnson as a "nice man" and the strongest criticism he levels at the health secretary is of being "probably hyperbolic" in describing rising obesity levels as a threat on the scale of climate change.

Public image

After nearly five years as shadow health secretary, he is still not well known by the general public, but his determined efforts to understand the detail of health policy have made an impact on managers. Despite his previous criticism of the "army of administrators" in the service, an HSJ poll last week revealed he was the health secretary of choice for 22 per cent of readers - second only to Alan Johnson. Considering the likelihood of a Cabinet reshuffle, managers putting Mr Lansley ahead of any of the likely Labour replacements is significant, especially since Mr Cameron has guaranteed he can keep his job if the Conservatives win power.

So it is perhaps not surprising Mr Lansley does not seem bothered that managers cannot, in large part, tell Conservative and Labour health policies apart. Not afraid to use the "sincerest form of flattery" cliche, he says that while journalists and politicos might like to see greater distinction between left and right, "from the public administration point of view, difference for its own sake is pointless".

"My political strategy is that the Conservative party at this coming general election should be in a position where people working in the National Health Service and the public feel confident the Conservative party not only attaches the highest priority to the NHS but is capable of improving delivery of the NHS for the future."

Board games

Both parties have a commitment to a greater focus on outcome measures and to greater local freedom from central control, and also not to implement new targets or unnecessary reorganisation, but Mr Lansley says there are differences in policy and in the method of delivery.

The most obvious of these are the pledge to create an independent NHS board and to replace the Department of Health with a public health department, ringfencing spending on public health and allocating it separately from funds for "NHS services".

In the current economic climate, and with members of the monetary policy committee disagreeing in public, the comparisons between a health service board and the independent Bank of England have been dropped, but Mr Lansley says that without a board "it will not be possible for organisations across the country to feel they are genuinely making decisions close to patients in a way that is more likely to use resources effectively".

Firm ideas

As a former deputy director general of the British Chamber of Commerce, he has firm ideas about what the board should look like: chief executive, finance, medical and nursing directors and, in keeping with "normal corporate governance principles", a lay majority.

"The lay people clearly have to be high quality individuals, probably many of them with experience predominantly outside the NHS, who bring to the board a sufficient set of skills but also an understanding of what it is the NHS is trying to achieve for the public as a whole."

Mr Lansley promises the board won't be "politicians manques". "It's focused on the outcomes, and it's the job of the NHS board then to translate that into progressively more disaggregated measures. So when I say I'm abolishing targets, I'm not abolishing performance management."

In fact, it will be up to strategic health authorities, which Mr Lansley has promised to keep, to performance-manage primary care trusts - and that seems to be their main job, although he adds: "I also think the SHAs and the regional offices of the DH need to work in an extremely close relationship."

Appropriate action

So which role for the public health secretary himself? Mr Lansley blamed the latest rise in C difficile rates on the government, saying it had not taken appropriate action. If the same happened under a Conservative government and the public turned to him and asked him what he was going to do about it, what would be the response?

"Well, I have a set of objectives that I have agreed with the NHS board: I'm going to hold them to account for their delivery on those objectives. My powers are powers of appointment in the first instance, of specifying through those objectives how it works, or agreeing resources and, as a fallback position, of direction," he says.

He insists that although patient safety will be given priority, "frankly, I shouldn't need to specify in detail how it's done because people in the NHS know how to do it".

As SHAs will performance-manage PCTs, so PCTs will be responsible for performance-managing GPs and their contractors, as well as local strategic commissioning and the relationship with local authorities, which under the Conservatives' plans, will play a much greater role in commissioning. PCTs will not provide services, and GPs and GP consortiums will be given a more central role in primary care commissioning, through enhanced practice-based commissioning.

Responsive development

"As a consequence of that, we will have far less top-down reconfigurations and far more development of services in a way that is clearly responding to the observed commissioning decisions of primary care commissioners and the decisions made by patients through patient choice," Mr Lansley says.

What will life be like for PCT chief executives? "Firstly, it should be much more focused upon identifying what are the objectives locally and being clear about the nature of the purchasing and commissioning decisions that need to be made locally. If PCTs are trying to commission services in a detailed fashion, then they are doing the wrong thing," he says. "For a PCT chief executive, that relationship with GPs, like the relationship that hospitals and providers will have with GPs, is going to be a critical relationship. And they are going to feel that that relationship is not a top-down 'I tell them what to do and they go away and do it' relationship... but the PCT should be listening to the primary care commissioners and saying 'What is it that through our commissioning process and our contracting process you need? What services do you need locally?'"

World class commissioning

Mr Lansley will not, however, scrap world class commissioning. "Under the structure that I'm describing, an NHS board through SHAs will be performance-managing PCTs and the objectives and criteria of world class commissioning are entirely relevant to that purpose."

The plan to ringfence public health funds is a recognition that those services do not receive enough money, he says. But he insists this will not be at the expense of spending on acute services.

"It doesn't mean less, it may mean differential rates of growth between public health budgets and NHS budgets."

The National Institute for Health and Clinical Excellence will evaluate public health interventions as well as drugs and other treatments and the NHS board will make clear "to what extent these commissioning guidelines are mandatory and to what extent they are discretionary". Mr Lansley will not eradicate the postcode lottery, saying "it doesn't work like that". Clinicians will be able to make some decisions about what care should be provided locally: "Differences drive improvement as well as expose inequalities," he argues.

The man who knew too much

He will try to eradicate those inequalities by giving more money to areas with the greatest demand for NHS services. But he says this does not mean taking money from poorer areas and redistributing it to places with a higher proportion of older people, as many have interpreted. "That would only be if one imagined that the money I was taking for public health purposes wasn't spent in poorer areas, but the point is, it is."

In his five years as shadow health secretary, Mr Lansley has hung on to his job while several of his opposite numbers have come and gone. Could the mastery he has acquired of the intricacies of health policy, in fact, be "dangerous" (his word) for a secretary of state? He laughs. He does "know a lot", he says, but he promises he would not "try to run" the NHS, instead leaving it to "people out there whose expertise we can exploit far better than we are doing at the moment".

"The solution to this is not for me to go into Richmond House and say I now know all the answers."