06 July 2015

Last week The Institute for Government and the Health Foundation brought Jeremy Hunt, the Secretary of State for Health, together with three of his predecessors to discuss the “toughest job in government”. IfG Senior Fellow Nicholas Timmins asked the questions, drawing on his new book Glaziers & Window Breakers: the role of the Secretary of State for Health published by the Health Foundation.

The book contains insights from ten former health secretaries. Three of these – Stephen Dorrell (1995-97), Alan Milburn (1999-03), and Patricia Hewitt (2005-07) – joined Hunt to discuss how to be effective in the job. The panel emphasised the unique qualities of the health portfolio, but also highlighted the common challenges faced in any ministerial brief.

“You should be learning every single day” – Alan Milburn

A quirk of our democratic system is the lack of specific qualifications for the ministerial job. Hunt described how he knew nothing about the workings of the NHS on his first day in September 2012, something shared by many ministers both inside and outside the Department of Health. There is value in taking time to learn, hear from experts, and think about what you want to do, something the Institute has also found in its work supporting politicians to lead in government.

“There is nothing new under the sun” – Stephen Dorrell

The panel emphasised the consistency in the challenges faced by health secretaries, whether that is unpopular hospital reconfigurations, or striking the right balance between policy and management. As Dorrell pointed out, the debate over central and local powers has been going on since Bevan and Morrison.

“There are very few problems that someone hasn’t come across before” Jeremy Hunt

There is room to learn from the experience of predecessors. This could include reading Glaziers and Window Breakers, as Jeremy Hunt did on the first day of his second term, or organising a handover meeting, something Timmins questioned the panel on. In most cases the former health secretaries had neither received nor given a briefing – though Dorrell had had a long conversation with his Labour successor Frank Dobson.

“Stuff happens” Patricia Hewitt

The position of health secretary is a unique role mixing public policy and management while theoretically remaining outside of day to day operations. The panel debated the extent to which health secretaries could or should “get involved in pulling levers.” Milburn argued that legislation and regulation are always trumped by behaviour in the end. Dorrell felt a core responsibility of the secretary of state is to develop a policy context that allows the best of professional culture to operate. Despite these differences, the panel agreed that the health secretary would rightly always be held accountable for the health service and its £100bn budget.

“Changes come from politics. . . not from bureaucracy” – Alan Milburn

There was disagreement on the extent to which the health secretary is a driver or a facilitator of change in the system. Hewitt and Milburn, described politicians as the ‘change-makers’. Dorrell on the other hand focused on enabling change by opening the door to anyone with ideas.

But they also recognised that what might be good policy could be terrible politics, as Milburn discovered over the Kidderminster hospital reorganisation, where badly communicated decisions cost a Cabinet colleague his seat. Milburn emphasised his communication rather than the decision as the key factor in this “it’s not that you can’t win an argument but how you conduct it that really counts”. Hewitt noted how she had found the Independent Reconfiguration Panel helped by confirming a need for clinical change but also listening to local communities and building support. However, the health secretary may still need to provide political cover or help oil the machine behind the scenes.

“Most of those delivering care decided to do this from their early teens” – Stephen Dorrell

Every member of the panel recognised the professionalism of those working in the health system and the need, as health secretary, to act with humility and respect towards practitioners who have often dedicated their lives to delivering care. Ministers cannot simply tell clinicians what to do, particularly as the credibility of clinicians always trumps that of a politician – the reason why Milburn had a rule “never to appear on television next to a white coat”. Dorrell thought politicians needed to unleash “the divine discontent” of professional self-improvement to drive up standards and challenge each other. Hewitt noted that Andrew Lansley’s reforms – “a shambles” – had had the consequence of giving the NHS a voice independent of government that is able to challenge decisions made by the secretary of state.

“There is nothing more important to anyone” Patricia Hewitt

The role of health secretary may be the toughest job in government, but there was one thing on which all our panellists agreed: its challenges and importance also make it the most “intoxicating”.