Secretary of state for health UP 9

No health secretary has ever been more knowledgeable about the NHS than Andrew Lansley. So it is ironic that his first six months in post have also been unparalleled for controversy.

This dichotomy is partly a product of the time spent as shadow health secretary. Mr Lansley’s views - and more importantly the strength with which he holds them - have been built up over seven long, sometimes hard, years. A refusal to listen to criticism is a common allegation but the health secretary’s stubbornness emerges more from a firm belief that no one has looked deeper into the NHS’s problems or examined the solutions in more detail.

Mr Lansley’s reform programme was trailed heavily in 2007’s NHS Autonomy and Accountability but then downplayed as he got on with convincing the electorate the NHS was safe in Tory hands - a job he performed brilliantly.

However, the success of that strategy, including the “no more top-down reorganisations” pledge, meant that when Autonomy and Accountability was cut and pasted into the white paper, those that had not been paying attention were shocked by the scale of the proposals. Unfortunately for Mr Lansley, this included a significant number of Conservative politicians - some very senior.

The health secretary was more than a little hurt by the negative reaction to many of his reforms. After all, he had spent seven years listening to the frustrations of those working in the NHS - especially clinicians - and had produced a plan to answer their concerns.

Mr Lansley believes the strength of his reforms are that he has set a clear destination, something he claims that Labour - for all the programmes it started running during the last decade - was never able to explain clearly. The lack of detail about how the NHS will arrive at that destination is, in Mr Lansley’s view, also a strength; time for the service to work out the answers rather than looking to the centre.    

There is a second dichotomy. Mr Lansley is both very powerful - he is the first health secretary to top the HSJ power list in its five year history - and isolated. His power stems from defusing the NHS as an issue, his knowledge of health and the loyalty demonstrated by former employee David Cameron (which echoes that between Tony Blair and his old boss Derry Irvine).

Mr Lansley’s isolation results from his lack of close political allies and, largely, from the surprise felt in senior party circles over his proposals and, more particularly, the reaction to them. 

It is this situation that is largely responsible for Tory policy kingpin Oliver Letwin occupying second position in the HSJ100 and Commons health committee chair Stephen Dorrell placing fifth. The scrutiny is stepping up, although Mr Lansley’s savoir faire suggests someone who is sure he will have the political support from both the leadership and coalition backbenchers when needed.

There are internal pressures too. Mr Lansley’s relationship with NHS chief executive Sir David Nicholson is delicate: the health secretary joked in a recent meeting that he “almost got a smile” from the service’s most senior mandarin.

Even Mr Lansley’s friends acknowledge his limits as a politician, while his enemies admit he is a master of his brief. His future will be determined by which skill set proves most valuable as the reforms bite.