Where next for the Lib Dems on NHS reform?

It is becoming a fixture on the political calendar, that as spring approaches so too does another Liberal Democrat conference debate on health. Cue headaches for Liberal Democrat party managers and nervousness among Conservatives. What will the Liberal Democrat grassroots demand? How much will Cameron and Lansley be prepared to concede in response?

The procedural steps are fairly straight-forward. The Liberal Democrat spring conference meets from 9 to 11 March in Gateshead (or, as the tourist authorities would prefer us to say Newcastle Gateshead). The NHS is not on the conference agenda, but there is an early Sunday morning slot for one emergency or topical motion, to be chosen by ballot among conference representatives. The winning motion then gets debated and voted on.

At each step, every conference representative has one vote. No block votes for trade union chiefs, MPs or even (shockingly) for bloggers. Everyone has one vote – from Nick Clegg to myself to the newest member attending conference as a voting representative for the first time. That equality of voting power, combined with the presence of substantive policy debates at the conference, gives the Liberal Democrat grassroots meaningful power of the sort only rarely and fleetingly spotted at Conservative or Labour conferences – and it can make the outcomes of votes more unpredictable.

The most likely outcome is that a motion critical of the current state of the NHS Bill gets submitted, is ruled in order, goes into the ballot and then wins the ballot. Unlike the autumn 2011 Liberal Democrat conference, the development of events in Parliament means submitting a motion that gets ruled in order should be straight-forward.

Up against a health motion in the ballot are likely to be motions on other high profile and contentious subjects, such as welfare reform. My money is firmly on the NHS motion winning in any ballot, both because it is very likely to have by the far the most organised campaign behind it, and also because the sense of a direct link between passing a motion and as a result potentially changing what the Government does will be weaker for rival motions.

But what will any motion that gets passed say?

At the moment, there are three different options for changes to the NHS Bill which different Liberal Democrats are pushing (I’ve yet to encountered anyone in the party who says, “No more changes, leave it as it is”).

There are those who want the Bill to be dropped, grouped around Winchester Liberal Democrats and their petition. Then there is Shirley Williams, who wants all of Part Three (on competition) of the Health and Social Care Bill to go, a view closely if not exactly mirrored by the influential Social Liberal Forum. And then there are those who are pushing for further amendments, to significantly alter the Bill but short of the sort of dramatic and symbolic act of dropping Part Three in its entirety.

This is the view taken by many of the Liberal Democrat peers most involved in the Bill and many of those around the party’s leadership. Intensive discussions have been going on to come up with a list of further changes that can both deliver the substance (making the Bill workable and successful) and deliver the politics (making it clear that the Liberal Democrats have blocked key Conservative plans for the NHS).

That has caused a lot of head scratching. What is causing rather less pause for thought, perhaps surprisingly, is the question of what the Conservatives will stomach. In chatting to several of the key people involved, I’ve barely heard this issue come up – because in many ways the Health and Social Care Bill is the mirror image of the welfare changes.

On the latter, the Conservatives are almost desperate for a public row with the Liberal Democrats, judging that with public opinion generally behind their party any rows can only do the Conservatives good. By contrast, on the NHS public opinion weighs in on the side of Liberal Democrats pushing for changes. Short of demanding that the Bill be dropped, Lansley be sacked and Cameron run naked down Whitehall, almost anything the Liberal Democrats decide to push for could happen.

Despite the wishes of some members, unless something goes completely wrong in the next couple of weeks the party overall is unlikely to push for the withdrawal of the Bill. That is because it contains many policies the Liberal Democrats have long-called for, such as the better integration of health and social care and the shift of powers to local councils – and complete withdrawal would raise more awkward questions about why the leadership had backed the reforms in the first place.

However, anything short of a dramatic measure (such as Part Three of the Bill completely), brings with it a big political risk for the party, which has already seen the impact of its post-pause ‘wins’ dissipated by further opposition to the Bill. A host of technical changes to the legislation will get politically lost in the simple, top-level picture that most members of the public do not trust the Tories on the NHS and most health professional bodies do not trust Andrew Lansley.

Pushing for concessions that make sense for the NHS, are politically wise for the Liberal Democrats and are politically palatable for the Conservatives will make for a difficult balancing act. All the more so as this is not simply a decision under the control of Paul Burstow and Nick Clegg. They will be but two votes amongst hundreds on the Sunday morning of party conference.

UPDATE: