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Leaked NHS reforms would take us back to the wrong sort of future

The leaked draft of the government’s NHS reform white paper sets out a weak case for returning ‘command and control’ over to ministers

Nicholas Timmins says the leaked draft of the government’s NHS reform white paper sets out a weak case for returning ‘command and control’ over the health service to ministers

A draft of the government’s white paper on planned NHS legislative changes has been comprehensively leaked.[1] One can only hope that it is a draft.

For as it stands, it threatens to take the NHS back to the wrong sort of future. It largely removes the one bit of Andrew Lansley’s Health and Social Care Act 2012 that has worked, namely the statutory independence of NHS England. It reverts, instead, to a model where ministers exercise command and control over the running of the health service, an approach that many a past health secretary has acknowledged is far from ideal.

And, most importantly, it does not remotely make the case for doing that. Indeed, recent events during the pandemic – the initial trials over personal protective equipment and the tribulations of the £22bn Test and Trace programme, both programmes over which ministers already have direct control – make the case the other way. Among the things that have worked are the way the NHS adapted fast, and locally, to handle the huge surge in patients that Covid-19 produced, and the impressive local organisations of vaccine hubs and much else to deliver, to date, 12 million jabs into the arms of its patients.

Centralisation of power in the NHS also produces centralisation of blame

What the draft proposes is extensive new powers for the secretary of state for health to issue directions to NHS England; to intervene at other levels of the health service; and to have an ability to abolish arms-length bodies in health purely through secondary legislation (which could, of course, include NHS England itself).

Precisely who wants these Henry VIII-like powers – King ‘Henry’ Hancock, or World King ‘Henry’ Johnson – is not clear. But both should think again. First in the interests of a well-run health service, and second in their own political interest. For, in Rudolf Klein’s great phrase, and as Labour ministers would attest from the early days of Tony Blair’s administration, centralisation of power in the NHS also produces centralisation of blame when things go awry.

NHS England independence has enabled Sir Simon Stevens to apply public pressure

There is a strong case that the statutory independence of NHS England has been the one success of the current legislation, even if that has happened in a very different way to the one originally envisaged.

It has produced a consistency of purpose – the drive towards better integrated health and social care over the better part of a decade rather than a constant chopping and changing of goals. It has led to ministers imposing fewer unfunded initiatives on the NHS than was too often the case in the past. It has allowed the service itself to make a public case for what can and cannot be done within the money available and, while ministers may not like this, it has enabled Sir Simon Stevens, the NHS chief executive, to apply public pressure for action over both social care and public health – issues that themselves deeply affect the performance of the NHS – in a way that was quite simply not possible for previous chief executives of the NHS working inside the department of health and social care.

But ministers now want to change the way the NHS is given its marching orders through the so-called mandate, in ways that may weaken the service’s ability to argue that new funds will be needed ‘for this new initiative’. And they want new powers of direction too.

The case for ministerial command and control over the NHS looks weak

The draft white paper, however, offers no justification for this other than the frankly spurious one that the pandemic has shown the need. Before parliament even begins to think of granting such powers, it must require ministers to spell out precisely what it is that they have not been able to get the NHS to do in the absence of such powers. Nothing, right now, springs to mind. If good answers are not forthcoming, the power should be refused. It is also worth noting that Jeremy Hunt, now chair of the Health and Social Care Select Committee but previously the longest-serving health secretary, has said he never felt the lack of such powers during his near six-year tenure in the job. And that the one bit of the 2012 Act that he regarded as a success was the independence of NHS England.

One of the many histories of the NHS has been the endless tension between central command and control and local discretion and innovation.[2] That has played out at many levels – between ministers and the service, and between the various incarnations of an NHS executive and the service, for example. In recent years, certainly in terms of the relations between ministers and the service, the seesaw has been well balanced. It would be foolish to disturb it and head back to the wrong sort of future.

  1. Health Policy Insight, 'Editorial Friday 5 February 2021: Exclusive - Government's new Health White Paper draft text', 5 February 2021
  2. Klein R, The National Health Service (NHS) at 70: Bevan’s double-edged legacy, Research Gate, January 2018
NHS Health
Johnson government
Institute for Government

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