Working to make government more effective


The prime minister’s plan for a radical shake-up of the NHS is not the right prescription

There is no case for restricting the operational independence of NHS England and giving ministers new powers of direction over the health service

Nicholas Timmins says there is no case for restricting the operational independence of NHS England and giving ministers new powers of direction over the health service

Two years ago, at the invitation of Theresa May, NHS England began drawing up proposals for changes to the widely derided Health and Social Care Act 2012.

The package it came up with in September last year – with backing from the Commons Health and Social Care committee – was deliberately minimalist. Its two central proposals seek to excise the worst aspects of the 2012 Act without launching yet another major NHS reorganisation.

First, the market regulation part of NHS Improvement – a key part of former health secretary Andrew Lansley’s plan to make choice and competition the way, ideally the only way, to run the NHS – would be abolished. The existing legal obligations to put clinical services out to tender would go, though a “best value” test would remain to leave the service free to seek alternative suppliers when existing services are not up to scratch. The remainder of NHS Improvement, the bit that oversees NHS Trusts and Foundation Trusts, would be merged into NHS England, producing a single headquarters for the NHS.

The overall aim is to reduce a good chunk of the fragmentation that the 2012 Act caused, making much easier the drive for better integrated care.

The NHS does not want another might upheaval – but ministers might disagree

The package deliberately did not go further – changing the status of NHS Foundation Trusts, for example, or seeking to turn the emerging Integrated Care Systems into statutory bodies. Even ahead of Covid-19, the last thing the service wanted, after the searing experience of 2012, and the repeated reorganisations of the 1990s and 2000s, was yet another mighty upheaval.

Matt Hancock, the health secretary, appeared happy to go along with this, although there have been rumours for months that he would like greater powers of direction over the revamped NHS England.

It is now reported that Boris Johnson wants the same, and plans to “clip the wings” of Sir Simon Stevens, the internationally regarded boss of NHS England, which operates as a statutorily independent board. Ministers no longer wish to negotiate over what can be achieved with the money available, they wish simply to issue orders. This is utterly, utterly, remarkable.

The health secretary already has powers of direction – and a poor record of using them

If these reports are correct, then ministers from the prime minister down will need to explain – in detail, not in generalities – precisely what it is that they have not been able to get the NHS to do without formal powers of direction. Because there is absolutely nothing that meets the eye so far. What on earth is it that they cannot get done, which a quick order or two would sort out?

Furthermore, if powers of direction are the answer, the evidence from this administration in its response to Covid-19 is hardly encouraging. Take test and trace, a core responsibility of Public Health England. Public Health England is an executive agency of the Department of Health. In other words, the health secretary can issue it with orders in a way that he or she cannot do with the statutorily independent NHS England. Yet, despite the health secretary’s powers of direction, test and trace, while improving, is still not what it should be.

Or, even worse, take the experience with personal protective equipment. PPE arrives via NHS Supply Chain, a company wholly owned by the secretary of state for health and overseen by his department. In other words, in terms of command and control, wholly under the minister’s thumb. And, in terms of success, wholly underwhelming.  

The independence of NHS England has ended ministerial cases of announcementitis

Finally, painful though they may find it, ministers should listen to Jeremy Hunt. Hancock’s predecessor as health secretary spent more than six years trying to make Andrew Lansley’s Act work, while in practice spending much of his time finding ever more ingenious ways of working around it.

Hunt is pretty scathing about the Act. Some of the fragmentation it caused was, he says, “frankly completely ridiculous.” His judgement, however, is that “the independence of NHS England is the one bit of the Act that has worked best.” It has allowed the move towards Integrated Care Systems – of which Hunt thoroughly approves – to be something that the NHS has set up itself and owns, rather than it being seen as a politically imposed initiative. It has meant that ministers cannot impose new priorities on the NHS – and ministers are entitled to set the priorities for the NHS – without being challenged by NHS England to provide the resources needed to achieve them. And it has pretty much stopped the announcementitis that has so plagued the NHS over the years – ministers wanting to announce £50m for this or £25m for that to achieve some short-lived headline over a new initiative on dementia or cancer or whatever.

As Hunt puts it in a forthcoming interview with the Health Foundation on the role of the secretary of state, “I didn’t particularly find that the NHS was going off doing stuff that I didn’t want, or not doing what I wanted it to. When you’ve got 1.4 million people working for you, the issue is not the ability to give directions. The skill is to find a way where people listen to what you’re saying, and respond to it.”

Wise words. We can only hope that new powers of direction turn out to be a summer whimsy that evaporates by the autumn.


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