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What is his least worst option and will he pick it?

The Conservatives entered the 2010 election campaign with ambitious plans to make significant reforms to the NHS, education provision and welfare and benefits – three of the biggest spending departments of government – on top of tackling the deficit and re-establishing economic stability after the biggest boom and bust since the War. It would have been an ambitious agenda for a single-party government with a majority. In retrospect, attempting to do it all despite the constraints of coalition was asking too much.

That the one to have run into trouble is healthcare is unsurprising: it’s the most complex, the rationale for undertaking it wasn’t well-made and it touches on an area many political activists feel strongly about as a matter of principle. In a good summary, antifrank posted yesterday that the government has three options: to withdraw the Bill, to plough on regardless, or to make further major changes but pretend that they’re carrying on. None of the options will be appealing.

If the government withdraws the Bill, it takes a huge political hit. The short-term damage would be bad enough, where the government’s plans would look (and be) in disarray, where Labour would claim a major victory and where Lansley’s position would at best be under severe pressure. The long-term damage would be even worse. Losing the reforms outright would enable Labour to scaremonger very effectively on what they would claim would have happened and the Tories (and Lib Dems) would have no adequate response.

Consequently, the government has no real option but to plough on, making concessions as necessary. It has now got to the stage where for the government, it is more important politically that the Bill is passed than that the Bill does anything.

Because few people understand what the reforms are about, even fewer understand what each concession or amendment means. There’s therefore little damage sustained when they are made. With no realistic prospect of radical reform, the next best option for the government and particularly the Tories, given that a Tory is Health Secretary, is to be able to go into the next election saying “we’ve run the NHS for five years, enacted reform, and the service has improved”. Labour will of course dispute that last point but if it comes down to a media numbers game, the debate becomes background noise.

Where the Lib Dems fit into the equation is not easily answered but very important. The whole reform started to go wrong for the government following a revolt at last year’s Lib Dem Spring Conference. That disquiet has not gone away and the government should be keen to get the Bill enacted within the month if possible to prevent a repetition.

Were the Conference to bounce the parliamentary party and leadership into opposing the Bill, it would place tremendous tensions within both the Lib Dems and the Coalition, and it’s difficult to see how anyone on the government benches comes out ahead in that scenario. To what extent the activists, caught in their own bubble as activists in all conferences are, will appreciate that is a moot point.

That Cameron is committed to Lansley – and implicitly to the Bill – was clear at PMQ’s this week. He can’t afford to be anything other. Whether he remains committed to Lansley once the reform – in what ever shape it eventually ends up – is on the statue book is an entirely different question. I wouldn’t bet on it.

David Herdson