he health service was founded in 1948, and at every election since Labour has hoped to harvest votes by accusing the Tories of plotting to abolish the NHS. Labour leaders as very different as Tony Blair and Jeremy Corbyn have sought to rouse people with the battlecries “NHS up for sale”, “not safe in Tory hands” and “24 hours to save the NHS”. The public usually tends to share the suspicion that the Conservatives are not to be trusted with the health service, and yet that hasn’t stopped Britain electing a lot more Tory prime ministers than it has Labour ones. Voters perhaps intuit that no Tory government, however dastardly its soul or sinister its motives, would be so politically suicidal as to try to raze Britain’s best loved state organisation. Nigel Lawson, one of Margaret Thatcher’s chancellors, once expressed his frustration that the public would never accept an insurance-based alternative by sighing that “the NHS is the closest thing the English people have now to a religion”. It was with deep cynicism, great mendacity and also considerable impact that the Brexit campaign promised a stupendous cash windfall for the health service if Britons chose to quit the EU. We know that Boris Johnson understands how Britons feel about the NHS, because we have seen how he sought to exploit that national sentiment when the coronavirus put him in hospital. He emerged from his treatment to express his gratitude to the UK’s “greatest national asset” and “the beating heart of this country”, hoping by doing so to establish an enduring association in the public’s mind between himself and this most sacred national institution. The real sin of Conservative governments has not been to conspire to demolish the health service. The acuter criticism, one made more piercing by the pandemic, is that the Tories are guilty of inconsistent and habitually inadequate funding combined with haphazard and often contradictory fiddling with the organisation of the NHS. Restructurings of the health service come around about once a decade and are often driven by secretaries of state ambitious to make names for themselves as “Tory radicals”. The typical pattern is for the author to hail “a landmark reform” before it then turns into a millstone. No one now has a good word for the “Lansley reforms” launched 10 years ago. Truth be told, few had a good word for them at the time. They were put through parliament by a Tory-Lib Dem coalition government whose senior members were pretty clueless about what the health secretary was really proposing. Nick Clegg once sought an explanatory meeting with Andrew Lansley only to emerge from it complaining that he might as well have been speaking “nanu-nanu” for all the sense the plan made to him. David Cameron waited until he was writing his memoirs to admit that he paid far too little attention to what his health secretary was concocting until it was too late. The Tories had two animating ideas at that time. One was that more choice and competition was the way to bring about higher quality services and better value for money. The other notion was that it would be helpful to “take the politics out of the NHS” by making it quasi-independent and putting its operations at an arm’s length from the health secretary. I recall a member of the Cameron cabinet telling me that “the health secretary will no longer be racked on the Today programme every time a hospital fails.” It did not work out that way. Politicians still take the heat when things go wrong. And rightly so. Democratic accountability demands that the buck stops with a cabinet minister, not with unelected officials. A decade on, we have a different Old Etonian as Tory prime minister and another Tory health secretary eager to leave an imprint on history. Matt Hancock has just produced a blueprint for the NHS in England which directly contradicts the philosophy of his predecessor. This involves making a significant-looking ideological concession by the Tories. It accepts that competition, the lodestar of their thinking about almost every other aspect of human activity, is generally not appropriate for a national health service. Where Mr Lansley wanted to extend pseudo-market mechanisms in the NHS, Mr Hancock promises legislation “to clarify the central role of collaboration in driving performance and quality in the system, rather than competition”. “Transactional bureaucracies” and “compulsory competitive tendering” are out. In comes the much nicer sounding “collaborative relationships” and “working together flexibly”. Organisations representing health professionals have been broadly supportive, but wary of the most significant thing that Mr Hancock wants. This is more power for himself and his successors as health secretary, all in the name of “unified national leadership of the NHS” and ensuring the accountability of ministers to parliament. This power-lunge is being justified by the experience of the coronavirus crisis. Time and again, so it is whinged from within government, things have gone badly because a fragmented service with semi-autonomous agencies has not been sufficiently responsive to ministerial interventions. There is reason to be sceptical about the contention that Britain would have endured a less fraught crisis if only ministers had possessed more dictatorial powers. Things for which the NHS has responsibility have generally gone very well, a notable example being the smooth implementation of the vaccination programme. Things over which politicians have direct control – such as test and trace, the provision of protective equipment, the timing of lockdowns, the enforcement of quarantining measures and border controls – have not been glittering testimonials to the speed and quality of ministerial decision-making. It is not self-evident that the best answer to the health service’s many challenges is more Matt Hancock. There is a hole in his plan so big that it can be seen by a moon-based astronaut with a foggy visor. It has little of substance to say about the crisis in adult social care. The pandemic has taken more than 25,000 lives in care homes and pitilessly underlined the myriad problems in the sector. On the day that he first stood outside Number 10, Boris Johnson declared that he was determined to “fix the crisis in social care once and for all, with a clear plan we have prepared to give every older person the dignity and security they deserve”. Since when, no plan has materialised. If he ever really possessed one, he appears to have mislaid it. Or perhaps Dilyn the Downing Street dog has eaten it. Or, most likely, there is some kind of plan, but the Treasury is balking at the cost. The health secretary expresses an ambition to integrate care for the elderly, but that cannot be fulfilled without a system of financing solid enough to ensure it is a success. One group of critics, which includes the Labour party, asks the question: why now? Is this a sensible time to embark on another reorganisation of the NHS? Covid-19 has placed the service and its staff under the most intense strain. The pressure will continue for long after the epidemic subsides because the health service will then have to cope with a huge overhang of postponed operations. There are now nearly a quarter of a million people who have been waiting for treatment for more than 12 months. Things have become so desperate in some hospitals that they have been repeatedly compelled to cancel potentially life-saving operations, the very last choice anyone would want to make. Remodelling large institutions invariably causes turbulence and costs money. That’s not an argument for never contemplating reform, but it is a caution to be very sure that it is worth it and very careful about the timing. Changes that sound brilliant when discussed in a thinktank seminar can be extraordinarily destabilising and demoralising for staff on the frontline. If Mr Hancock proves typical of other politicians who have held his post, he will be overestimating the benefits of his plans and underestimating the disruption they will cause. He makes a case for urgency on the grounds that we need to get on with implementing the lessons from the coronavirus. That sounds reasonable until you remember that the government of which Mr Hancock is a member is led by Boris Johnson. The prime minister keeps resisting demands for a public inquiry on the grounds that we can’t “learn the lessons” until the crisis is over. Embarking on another round of NHS “reform” does not make much sense until we have a complete understanding of what worked and what didn’t during the gravest public health emergency in a century. You can’t put things right until you know precisely what went wrong. • Andrew Rawnsley is Chief Political Commentator of the Observer