Working to make government more effective


Paul Burstow

Paul Burstow was interviewed on 26 October 2015 for the Institute for Government’s Ministers Reflect project.

Paul Burstow
Paul Burstow, former minister of state for health

Paul Burstow was minister of state for care services in the Department of Health (2010–12). He was a Liberal Democrat MP between 1997 and 2015, and served as chief whip and health spokesperson while in opposition.

Nicola Hughes (NH): So if we can start back in 2010, when you first started as a minister, could you talk us through what your experience of coming into government was like?

Paul Burstow (PB): Right. So I received a call from Nick Clegg on the 13th May, my birthday, to offer me the role at the Department of Health. The way it was offered was that I was to become the number two in the department. I’ll come on to that in a moment. It didn’t quite land in that way internally. And shortly after that I was contacted by the Permanent Secretary’s office wanting to start the arrangements of me coming in and meeting people and so on. So I came into the department the following Monday, was met at the front door by the Permanent Secretary, and taken up to my private office and to my ministerial office. I met the private office team, or the private office team that I inherited, in the sense that it was going to go through quite a bit of change over the following 18 months.

Really from that point on, it was pretty much a never-ending cycle of introductory meetings for quite a long time. But at the same time quite a lot of immediate moves around the emerging programme for government and what would go into it from the parties’ manifestos on health. And the beginnings of thinking through where we want to go on things like reform of the distribution of the burden for paying for care, which was one of my main areas of responsibility. And implementing our manifesto commitment about independent review, which was something I’d taken advice on from a number of people, and it was very clear to me we needed to move on it quickly, to have any chance of getting it to some conclusion during the life of a single parliament.

So there was a lot going on in a very short space of time. And an awful lot of personalities I met, many of whom probably if I was asked to recount much of what was said to me by them or me to them, I probably couldn’t recall it.

NH: Did you feel well prepared for the role?

PB: Well, in the sense that I suspect no Liberal Democrat minister would say that they were well prepared, no. I think some of the things that informed my political career probably meant I was as well prepared as any, in that I had had experience in local government not just as a councillor, but as a member of an administration at a relatively senior level. So I had practical experience of engaging with a form of civil service, [local government officers] with a slightly different mandate and accountability. So that had got me somewhat versed in how to deal with and how to set expectations and manage that relationship.

And in the policy area, it had been my area of interest, the whole time I’d been in Parliament. So I came into a policy area I knew a lot about and was already well established with a lot of the stakeholders as someone who was credible.

I was as well prepared as any, in that I had had experience in local government not just as a councillor but as a member of an administration at a relatively senior level

NH: And did anything particularly surprise you in the first weeks or months?

PB: So one thing that I asked to see fairly early on were the Civil Service briefing packs on both Coalition parties in terms of preparation for an incoming Conservative government or an incoming Liberal Democratic government. Didn’t so much surprise me that there was far more detail on one than then other. But actually that was the reflection of the fact that we had a fairly thin manifesto on health anyway. So there was inevitably less. But that was quite useful in terms of getting some sort of sense of what was going to be a balance of policy drivers going forward.

NH: Did you have any kind of support over that period?

PB: No. And one of the things the Institute [for Government] documented I think fairly early on was that deficit in terms of support. I think again, because I started with a fairly deep knowledge of the policy area and a fairly good set of relationships, I was able to compensate for that. But nominally, the responsibility I had in the department was to be across the whole department and therefore to try and have a line of sight on everything. And I got early agreement to contemporaneous access to all submissions.

So I was able to see pretty much everything everyone else was seeing, but with no support to properly process it. So because we didn’t have at that stage, special adviser coverage across the Government in the way that we later had, we had to find workarounds. And in my private office, probably about six months in, we managed to get to a position where one of the APSs [Assistant Private Secretaries] effectively had the role, not in a partisan way, but acting as an aide and facilitator of properly managing that flow. And that helped quite a bit, but the absence of that, I think probably in terms of governance outside of the Coalition, was probably one of the biggest mistakes we made not to have that and not to insist on that. It left ministers disconnected and buried in their departments.

I was able to see pretty much everything everyone else was seeing but with no support to properly process it.

NH: So how did you stay in touch with other Lib Dems from across government?

PB: So we’d have regular meetings, but the meetings inevitably were time limited, highly pressured, quite tactical, all focused on understandable preoccupations of people at the centre. And also there was a fair amount of contact with senior colleagues that were involved in the advisory side and the policy side of Number 10, like Polly Mackenzie [then a special adviser] who was very good at being a contact point. But even someone as good as she is, couldn’t really act as a challenge to the process and actually prioritise all of what was coming in, I suspect, from ministers across government. So it did mean that a lot of us were left to make a lot of judgement calls for ourselves.

NH: Could I just come back to the point you mentioned about thinking that you were going in as the number two in the department? How did that pan out?

PB: In a way, it didn’t much matter, but the disposition of roles in terms of portfolio that I had meant that I had, although I had a lot of responsibility for NHS services because since I was responsible for a number of disease groups, I didn’t have any of the structural or financial responsibilities within the portfolio within the NHS. They came to Simon Burns, who was also a minister of state – we were both ministers of state. But I think there was a sort of expectation that he was dealing with the big part of the department’s responsibilities, which subsequently changed when Norman [Lamb, Burstow’s successor] came in; he took over more of that role. So there was a rebalancing at that later stage.

But I think that was something that if I had thought about it more at the time, I would have kicked up more and would have tried to get that changed. But this was the storming and norming stage of forming this relationship, there was a desire to avoid having those sort of rows, I think. So it didn’t really make much difference because I had a view across the whole department anyway, in a way that other junior ministers hierarchically didn’t in the department. So I was sitting outside the normal hierarchy anyway.

NH: Based on your experience, how would you describe the main roles and duties of a minister?

PB: To set policy direction, to hold officials to account for execution of policy, to act as an advocate and representative of government to stakeholders, [and] to help with the overall communication of the department’s position as formed by ministers. I think probably also to be able to give clear steers in an official way on emerging issues. So, to be able to react quickly to things, not just set the direction.

NH: On setting the direction, how did you figure out early on what the key things you wanted to achieve were? And then also how did you communicate those out to the department?

PB: I wrote them down. So I wrote in the summer of 2010, a priorities paper for my portfolio.

NH: And you’d been thinking about it in opposition?

PB: During the pre-election period I was in fact Chief Whip, so I wasn’t the Shadow [Minister]. Norman Lamb was the Shadow. So I didn’t have time to prepare in opposition but having said that, I was still interested in social care – very much engaged with the sector, talking about the issues, thinking about the issues, [and] speaking at conferences. So I had just been churning it over in my head. So that fed into the paper that I wrote. Also some of the introductory meetings I had, I think were very helpful for me in just crystallising some of the things I wanted to particularly focus on.

Jen Gold (JG): Thinking about the day-to-day reality of being in the Department of Health, how was most of your time actually spent?

PB: Well, in the early days an awful lot of my time was spent along an almost factory process of people coming in to see me – both internal-facing meetings, but also making time for a lot of the stakeholders. And quite a bit of the time was also spent on processing the very rapid work of developing a white paper for the health reforms which I was involved in, commenting on successive drafts and a lot of the internal meetings around how that was framed. Similarly, a lot of internal meetings around framing and negotiating and agreeing a terms of reference for the Dilnot Commission, which was fairly time-consuming because the Treasury were none too keen even at that stage. So those were things that were the particular focus up to the summer. And the pattern didn’t change dramatically afterwards. There’d be public-facing things, but they were mostly conferences and visits and so on.

JG: And you obviously had roles and responsibilities not just in the department, but also in Parliament and your constituency. I’m just wondering how you managed to balance those competing priorities and if you found there were particular pressure points on your time?

PB: I was lucky in that I was a London Member of Parliament, so my constituency – where I lived – was relatively easy to get to and from. I had a well-established constituency office with a good team. The balance of that changed in that more of the correspondence that was coming in was dealt with by the office and less of it was dealt with directly by me. So I did less signing. I signed the more complex and difficult cases. I continued to hold all my surgeries, which I considered very important. But I think if you were to talk to my staff in my constituency office, they definitely felt an absence that was difficult for me to juggle being in the office, being in the constituency and having some family life, as well as doing a ministerial role. And the bit that gave probably most was the direct engagement in the constituency office because there was time I couldn’t spend in the constituency.

JG: What about Parliament? Did you notice a significant change in the amount of time you spent in Parliament?

PB: In some ways I probably spent more, funnily enough, because as a junior health minister you were routinely answering debates. So you’d be in the Chamber responding to end-of-day and Westminster Hall adjournment debates. And that, indeed, in terms of the ministerial calendar, is one of the things that is unplanned for and means that some of the things that you were going to do have to be pulled out to create the space to prepare and take those debates. But that in some ways meant probably more contact time on the floor of the House [of Commons] than I would’ve had before because as a third party; historically, our ability to be in the Chamber and [to] get called when we wanted to be called was very limited. So actually, it was quite a frustrating place to be. As a minister you always knew you were going to be called.

JG: Could you talk us through an occasion where an unexpected event or crisis hit the department, something you might have been involved in, and how you went about dealing with it?

PB: Unexpected event? I don’t know whether you’d say it was unexpected. I think the growing opposition to the Health and Social Care Act Bill would be a model of a crisis in slow motion. Some of the seeds of it were there and visible in the white paper publication in the summer of 2010. But when the legislation itself was published and people began to look at the detail of it, the department was actually very flat-footed about having a communication strategy to explain and defend and justify the legislation.

I think the growing opposition to the Health and Social Care Act Bill would be a model of a crisis in slow motion.

I think the way I would characterise that is the Secretary of State at the time, Andrew Lansley, was technically absolutely across every detail of what he wanted to do with the legislation, really understood it in great detail, but was not a good communicator of it externally. And I think, in a sense, the crisis that engulfed the legislation was a product of that failure to recognise a deficit in the Secretary of State, who in many ways was very competent, but needed really strong support to be an effective communicator of the message.

JG: And did you find yourself being pulled into that, or were you able to focus on bits of your portfolio that you were trying to drive forward?

PB: Inevitably I became quite drawn into it, because I was involved as one of the ministers taking the legislation through the Commons. So I was doing the committee stages and all of that. So, inevitably, I became very closely involved and also very heavily involved in the party management, particularly with colleagues in the Lords, but also in the Commons.

And it was really only at that point that probably the centre on both sides of the Coalition really started to seriously engage with the Department of Health. It probably was one of the things that, in the end, bolstered the case for actually looking at a new set of arrangements around special advisers. Probably for the wrong reason, in the sense that it was about the centre wanting to have a much better line of sight into the departments, rather than the right reason which was actually about perhaps if you support ministers properly, you might avoid some of these problems in the first place.

So I think it doesn’t entirely answer your question because I don’t know that we actually ever did manage to get from under that particular crisis. I just think in the end, we used sheer muscle and a lot of compromise in the Lords to push our way through to a conclusion. But I suppose the most important thing I draw from all of that was the importance of really good relationships. I don’t think in the Lords the legislation would have gone through were it not for the effective work of Freddie Howe, and for the work that I did more behind the scenes with colleagues in the Lords to build their trust that we were trying to do the right thing in difficult circumstances.

NH: What about your relationship with the Secretary of State in general? How did you make that work?

PB: I found that the best way to pursue my agendas and the things I wanted to do, was through my interventions through submissions. So it was less about having a one-to-one conversation, face-to-face with the Secretary of State. It was often more about mounting the argument through the commentary and the submissions and to some extent allowing the private offices to be the facilitator or the negotiator of an agreed position. And in most cases that was perfectly satisfactory. Very rarely did the Secretary of State and I get to the point where the only way to try and resolve things was by us talking to each other about it. It doesn’t mean we didn’t talk about things. But I think his style is a very policy-orientated, more technocratic personality, [which] meant that that way of engaging with him was the best way to engage with his own style of working.

I found that the best way to pursue my agendas and the things I wanted to do, was through my interventions through submissions.

NH: And what do you think was your greatest achievement in office? Or the thing you’re most proud of perhaps?

PB: So, two things. So the thing I’m most proud of and then my greatest achievement. I think they’re not the same.

The thing I’m most proud of is the decision as part of the mental health strategy that we introduced in 2011, early in 2011, to undertake the implementation of a new improving access to talking therapy policy for children and young people. But we decided not to do it in the same way as the development of the IAPT [Improving Access to Psychological Therapies] programme for adults, which had been a very top-down, national programme. So instead, with the assistance of a fantastic clinical lead called Professor Peter Fonagy, we developed within the space of about three months new national curricula, a service user-led bidding process and engaged with higher education institutes and created a vehicle for effectively rolling out in just over five years a new model of outcomes-based measurement of delivery of talking therapies within children and young people’s mental health services.

So we didn’t create a new service. We redesigned in a voluntary way, the existing services. And that transformation has gone mostly unmarked because it’s happened so quietly and smoothly. And yet it now means that the idea of measuring outcomes in children’s mental health has been established. And there are more places delivering more therapy – still a long way to go. So that’s the thing that I’m most proud of because that will have the most profound effect on the most people.

And the biggest achievement actually was being able to take through the care legislation. I didn’t get the job of actually taking it through Parliament that was passed to Norman [Lamb]. And that’s probably my biggest regret that I didn’t get to take the legislation that I had taken all the decisions on. But the fundamentals of the legislation were all the things that I had spent the previous two years working on and that legislation is such a marked departure from the previous social care legislation, in that it establishes a clear legal purpose for social care, which is more than just a poor law safety net.

JG: You mentioned just at the beginning that you felt that sense of necessity, right at the beginning of entering office that you needed to get moving on the legislation and getting it through Parliament. How much of that was in your first year, in the first few months, how quickly were you moving on that?

PB: So the legislation: I came into office with the advantage of the fact that the Law Commission was doing a piece of work that had been commissioned by the last government reviewing all the fragmentary law around adult social care. I took the decision that the department would draft the legislation rather than the Law Commission, which was intended to speed it up in order that it had the possibility of being introduced in the third session of the Parliament. In the end, it came into the fourth session. And the sort of two years were very much used to frame the white paper that was published in July 2012 and to drive the legislation [The Care and Support Bill 2012].

The bit that I was really referring to in terms of trying to get the pace right was around the Dilnot Commission. As I talked to people who had been involved in the Royal Commission on Long-Term Care and one or two other attempts to try and get to some conclusion on this, one of the things that was very clear from discussing with them was in most cases these processes started too late in the parliamentary cycle to ever have a chance of implementation. Having said that, despite the best endeavours, we’ve still got to a position where although we got it on the statute book and had a nominal commitment in two manifestos to implementing it, it’s still not going to happen. It’s still in a position where it’s postponed from happening.

NH: And it’s quite an interesting issue – social care is one of those long-term ones that needs buy-in from different parties.

PB: Yeah.

NH: How effective did you think the policy process was in the sense of using a commission, outsourcing some of the thinking to Dilnot? Do you think that is a good way of getting agreement on those long-term issues?

PB: So, I think the Law Commission process, which did the lion[‘s] share of heavy lifting around most of the law reform, was very helpful in building a consensus and clearing the ground. And it made therefore a lot of the decision making around the bulk of part one of the Care Act very easy. The only bits that were, if you like, novel were the introduction of a new legal principle which was around the promotion of individual wellbeing and a new duty of prevention. But there was a good deal of consensus around all of that. And it was easy to work with the sector and get their buy-in to all of that.

Dilnot was a different matter in that whilst it was relatively easy in the end because he was a very good advocate and a communicator of the rationale for the policy to get the sector on board, we were never able to get the Treasury to sign up to it, even after it was public and became a government policy. I don’t think the Treasury actually signed up to it, nor for that matter, the Chancellor. I think the problem for it was it was competing with the overall question about the resources for social care and often got misconstrued as being a mechanism for addressing that, which it never was. And it very clearly never was in the terms of reference of the Dilnot Commission.

The other problem with it was that because there was a heated row in 2010 between the Conservatives and the Labour Party over approaches to this question, there was a high level of distrust between the two sides. So trying to secure a political consensus when the Treasury didn’t really agree with it, and therefore didn’t really want much, even private, discussion with the Labour Party, meant that it was very hard to have an honest and open conversation with Labour spokespeople. And I suspect if you spoke to Liz Kendall she would say when she and Andy Burnham met with myself and Andrew Lansley, we were very cagey. We were very cagey because we weren’t allowed to say more.

…we were never able to get the Treasury to sign up to [the Dilnot social care reforms], even after it was public and became a government policy

JG: That brings me onto our next question which is what did you find most frustrating about your time as a minister?

PB: Well, I found that most frustrating. I now know what Sisyphus felt like, because it was the one thing where it felt constantly [like] you just get to the point where the boulder is at the top of the hill and then someone else would come up with another alternative route.

So, during the debates internally about Dilnot, there was a lot of talk about why don’t we instead make a big offer on integration of health and social care. As if that were an alternative to addressing the issue of people’s liability for care costs. So there were lots of attempts to try and change the question and move the answer to the new question into some other completely different space that, in truth, didn’t cost anything. I think that’s the big issue in social care because it is below the radar most of the time. It doesn’t generate much political tension of the sort that actually leads to any real decisions about changing the resource allocation to it, and that was at the heart of trying to get any money to implement Dilnot.

NH: And what about your relationships across government? Do you have any reflections on how government as a whole could be made more effective? I mean you’ve mentioned the Treasury.

PB: I found ministerial, inter-ministerial meetings, generally pretty pointless because every minister was so busy and came with the brief they’d been given by their officials. And occasionally we would have a conversation where it was clear other ministers had a genuine interest in the subject and were able to step away from their brief. And then you’d have a good conversation and sometimes you might even get to somewhere different to the seemingly pre-determined, pre-discussed outcome for the meeting. So I think as a piece of process they’re not very good other than rubber stamping the internal processes of cross-government negotiation between officials.

I found ministerial, inter-ministerial meetings, generally pretty pointless because every minister was so busy and came with the brief they’d been given by their officials.

And to the extent to which those cross-government discussions between officials reflect the steers and decisions of ministers that’s fine, but sometimes these things feel as though that’s not quite what they’re doing. So that I think is frustrating. How do you fix that? I think if you are going to have those sorts of inter-ministerial groups then you’ve got to be quite clear about whether there is a minister with the seniority who is able to cut through and either drive a decision across the departments that are party to it or have a very clear escalation mechanism that does mean it gets to a point where there are people who can actually make that decision and cut through. I think there were things that some of the mechanisms, like the meeting between the Deputy Prime Minister and Prime Minister and so on, [that] did that to some degree.

NH: The Quad.

PB: Yes, the Quad. Inevitably and rightly they were only going to be dealing with the top 2% or 3% of matters that needed to be dealt with. They certainly wouldn’t want to bother with the stuff that inter-ministerial groups were dealing with. But I did think there was a lack, if you like, [of] an investment of authority to be able to make decisions. There was too much just rubber stamping.

NH: And how did you work with Nick Clegg and with the centre?

PB: Again, I think this absence of having a special adviser made that harder because in a sense there wasn’t someone to act as an intermediary with colleagues in Nick’s office. And just the sheer volume of stuff that was going on in this government I guess, there was the same issue of the capacity to process that within his office.

My sense is, and I have not talked to Norman in detail about this, is that there was much more engagement by Nick’s office with the Department of Health and particularly with Norman’s office, than there was with my office. The only engagement we had, and it was pretty intense, was around trying to navigate a route out of the crisis around the health and social care legislation. So it was a reactive engagement, albeit trying to solve the problem, rather than a proactive one which I regret. I think it would have been good if there had been that dialogue earlier on. Maybe some of the warning signs around the health and social care legislation could have been taken up at the centre earlier if they had engaged in that way.

NH: And I don’t think you have mentioned it, but what did you think of the quality of the Civil Service and your departmental staff?

PB: I had three private secretaries [PSs], which sounds like a lot in two years. My first had been through a pretty intense period in the preceding two or three years with the previous minister. So I think [it] was pretty much at the point where they were all worn out by the role. So I appointed two PSs who were really mine. Both of whom are fantastic and both of whom came from within the private office as APSs [Assistant Private Secretaries]. I really felt that the private office went above and beyond to support. And were very genuinely watching my back, and also were very good at working the corridor on the fourth floor on my behalf to make sure that the agenda that I was trying to promote was being guarded and promoted. So no, I thought that was good.

I really felt that the private office went above and beyond to support.

And certainly in terms of the DGs [Director Generals] that I dealt with, it is primarily David Behan, who was there at that time and his team. I thought there were some very able people who helped a lot with moving both the Dilnot stuff forward.
We did have another crisis. I think probably it’s an example of a crisis that was so well managed, I don’t almost regard it as a crisis now. I am referring to the collapse of the case company, Southern Cross. This was a company that had thousands and thousands of people within its care. And the department had no levers to intervene to deal with this. Indeed, intervening would simply have meant picking up a very large bill. So intervening in that direct sense was just not on the table. And David Behan in particular, along with myself, played a key role in leveraging the sector’s anxiety about its own long-term reputation to get people to engage and have conversations that resulted in Southern Cross being broken up but every part of the business being taken on. And as a result of that, almost no one experienced a discontinuity of care and almost none of the staff lost their jobs.

But that was a huge crisis and led me to have to go to the House [of Commons] a couple of times and answer questions, and be really very closely grilled. And being forced to try and do far more than actually the department had in its gift to do. So trying to explain that. That informed some of the stuff that in the end found its way into the Care Act, a failure regime to try and have a better line of sight into the sector, and we’ll see whether that works potentially within the next 12 months, because there’s one business that is very near the edge.

JG: Can you give a sense, from your experience, of how you’d define an effective minister?

PB: I wish I knew. I still to this day don’t really understand why I lost the role. I say that, [but] I don’t think I lost the role on the basis of merit. I think I lost the role on the basis of needing to create spaces for others to be promoted. And that I think, in the environment in which particularly a coalition is working, where the flexibility around numbers of posts that are at a Deputy Prime Minister’s disposal, limits their ability to both prefer but also to reflect effectiveness. So I wouldn’t honestly say I could give you a good answer to that question.

I think I lost the role on the basis of needing to create spaces for others to be promoted.

I think it’s a mixture of being a good external communicator, a good creator of relationships with stakeholders to the point where, even when the stakeholder is actually very unhappy with the policy you’re pursuing, they still seriously engage with you and the department, so you maintain respect. And I think that it is the ability to carry your policy. And to the extent to which the things I’ve talked about happened, I suppose I look back on the time with some pleasure.

JG: And what advice would you offer to a minister coming into office for the first time, someone in a similar position to you?

PB: So, we’re talking in a scenario where no party has a majority and there is a coalition? Or are you talking a majority government because the advice would be different?

JG: If you sat down with someone in this Parliament who was coming into the office, where there is a slim majority.

PB: Right. See, I think the fundamental difference is that if you’re coming in at my level as a minister of state into a majority government, you’re coming into a fixed hierarchy and that’s the difference. And the disruption that the Coalition caused, the hierarchy was fractured because suddenly you had ministers with a separate power within the department. I think that created some opportunities for more engagement and involvement of the Civil Service in the policy process. I think that was a very healthy thing. So I think my advice would be to find ways to still have that sort of disruptive approach within the department, because it’s good for policy development and policy formulation uses the skills and engages the commitment of your officials, more if you do that.

Political party
House of Commons
Public figures
Paul Burstow
Institute for Government

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