On the two year anniversary of the Health and Social Care White Paper, the Institute for Government and The King’s Fund have published ‘Never Again? – The story of the Health and Social Care Act’, written by Nicholas Timmins. It tells the story of how and why the Health and Social Care Act 2012 – by far the most controversial piece of NHS legislation in more than two decades – became law.
It relates the story of a political thriller – from the legislation’s origins 20 years ago, through the development of the 2010 White Paper “Liberating the NHS” and the resultant bill. It tells the story from the view point of opponents and critics, but also from the point of view of the man with whom this legislation is uniquely identified – Andrew Lansley. On the way, it explains just what it was that the Health Secretary was trying to do and why the bill was so vast and controversial.
It details the events that shaped it – most notably the Coalition’s now partly forgotten “programme for government”. That document, pulled together by the politicians in Downing Street over 12 days immediately after the election in May 2010, radically reshaped the Health Secretary’s plans.
‘Never Again?’ also seeks to draw some early lessons from what has been described as a “car crash” of both politics and policy making. The Institute for Government (IfG) has today published ‘Learning the Lessons from ‘Never Again?’ by IfG Programme Director, Jill Rutter. The lessons for government in this story include:
Policy making in opposition matters – The Conservatives put in place specific mechanisms to help shadow ministers come into government with implementable plans. Yet engagement with the Implementation Unit was at the discretion of the shadow minister concerned. Some ministers chose to engage – but there was no penalty for failure to do so. Plans could go unchallenged, as was the case with the health reforms.
As Nicholas Timmins points out, these plans were developed when the opposition was committed to matching the government’s rising spending. They were not revisited when the scale of the financial crisis emerged in 2008 and the opposition moved position on the pace of deficit reduction.
Have a “story to tell” or narrative - One interesting consequence of the financial crisis was the effective silence on health in the 2010 election campaign. It was in no party’s particular interest to stir up a debate on what would happen to health over the next five years. That silence meant people were taken by surprise and felt misled by the scale of the changes after what appeared to be a promise to end reorganisations. And that meant the Government was open throughout to the accusation that it did not have a mandate.
Ensure the ministers have all the skills required: Being able to give a strategic lead, set vision and direction, and take decisions are characteristics of an effective minister, as our report on Effective Ministers demonstrated. Andrew Lansley could expect to score highly on all of these criteria. However, communication is also a key component of an effective minister, but here it was lacking.
Strengthen support at the Centre. The Institute for Government argued last year in our report Supporting the Centre that prime ministers make a false economy when they skimp on the support they need within No 10. They need support not just on the detail and the merits of a policy but also on its political handling and saleability. However, increasing the capacity of the Centre to act as an effective backstop is not a substitute for making sure that the policies emerging from departments can be implemented and are politically saleable.
Beware a lack of challenge by the Civil Service. It is clear from the ‘Never Again?’ story that there were many civil servants within the health department who had reservations, if not about the direction of travel, about the tactics being adopted. But it is very difficult, in our current system, for the Civil Service to do more than warn ministers and then accept ministers’ judgement if those warnings are not accepted. As Nick Timmins notes, the Civil Service can be at its weakest in the months after a change of government. Relationships are not yet established and there may be a lingering suspicion that civil servants are still loyal to the previous government. What is notable in the health case study is the extent to which policy making was the unchallenged province of the secretary of state.
Better policy making has been a big theme of Institute for Government work over the past year. “It is too early to say whether the political trauma of the Health and Social Care Act will turn into a successful policy or not”, ‘Learning the Lessons’ says, but the Health and Social Care Act exemplifies many of the problems reported in policy making in the preceding government, in particular:
- the lack of locus for the Civil Service to challenge legitimately;
- the closed nature of the policy process; and
- the unsystematic use of evidence and evaluation of earlier policies.
In our report, Making Policy Better we set out seven “policy fundamentals”. We also proposed that senior civil servants should sign off a public “policy assessment” to state how the policy meets the criteria, as a discipline to make sure poorly-thought-out proposals do not make it out of the department. If they think that there is not a robust enough case for going ahead, a minister should have to give a “policy direction”.
Speed is not everything - The Programme for Government was itself one of the most important factors in determining the fate of the NHS plans and was put together in 12 days without a health expert. The Institute’s ‘Learning the Lessons’ report says:
“....These long-standing issues were compounded by the fact that the UK was getting to grip with its first coalition since the war. That meant the programme for government was agreed too quickly and without sufficient consideration of whether what was being agreed was workable. There was no expertise in the negotiating team – and the health secretary’s comments were ignored.
Nick Timmins’s own synopsis says:
“Sorting out the “disaster” in the “programme for government” turned what would have been merely a large shift of power and accountability within the NHS into a huge structural upheaval: one that allowed the reforms to be written up as the biggest reorganisation in the 63-year history of the NHS; and one that could become this Government’s “poll tax”.
Would the 2012 Civil Service Reform Plan have made a difference?
The Civil Service Reform Plan sets a priority of “improving policy making capability” and it has recommendations that would be relevant to this story.
The most crucial change, according to ‘Learning the Lessons from Never Again?’ is the acknowledgement that “permanent secretaries must be accountable for the quality of the policy advice in their department, and be prepared to challenge policies which do not have a sound base in evidence or practice. They must also ensure they are content that the implementation of any policy is in line with their responsibility for managing their departments and public money in an effective and efficient way”.
This is a very important recommendation – but needs to be backed up with specific proposals and clear support from both the civil service leadership and the political centre so that permanent secretaries and senior officials know they will be supported if they challenge their minister in this way. These changes are very much in line with the recommendations we made in the Institute for Government report Making Policy Better.
Jill Rutter, author of ‘Learning the Lessons from ‘Never Again?’ said in her new blog today:
“There are many sources of failure: a relatively closed process of policy making in opposition – and a decision to go quiet on the reforms before the election; the lack of health expertise in the negotiation of the Programme for Government; a lack of subsequent effective challenge, especially from a denuded centre, to a ‘man in a hurry’ determined to produce a white paper within 60 days and get a bill onto the statute book early.
“These are all themes that the Institute for Government has studied before but which are brought into sharp focus in the case of the health reforms. Our commentary, ‘Learning the lessons from Never Again?’ sets out what needs to change to reduce the likelihood of a repeat.”