The Friday Guest Blog with Dan Jones
Get ready for a Downing Street Power Grab
When I saw that the subject for this blog was on what the Government has in store for the rest of 2020 and into 2021, my first thought was obviously to look back to 2010. Why? Well, it is just over ten years since the newly formed Coalition Government produced their White Paper – ‘Liberating the NHS’. The content of that White Paper proved to be quite surprising – whilst the 2010 Conservative Party manifesto had hinted at fundamental reforms to NHS governance, the Coalition Agreement had explicitly stated there would be no ‘top down reorganisation of the NHS’.
What we got was a White Paper that planned to radically overhaul the system, tearing down the existing structures and replacing them with a new, more localised NHS. The new system would create a greater role for front line clinicians in commissioning, on the basis that they were best placed to commission for the needs of their local population. At the same time as giving more power to front line clinicians, the Government created a new, ‘all powerful’ body with responsibility for running the system – NHS England.
Following a long and convoluted legislative process, the Bill became an Act in 2012 and the NHS still works on the model established by Lansley. However, moves to shape a new system have been underway for several years, with a new blueprint expected to be enshrined in legislation this year. For those following the narrative closely, we have effectively been on this path since Sir Simon Stevens published his ‘Five Year Forward View’ in 2014. Sustainability and Transformation Plans became Sustainability and Transformation Partnerships and some of them became Integrated Care Systems (ICSs), with plans for them all to be converted to ICSs in the end.
But then Covid swept in, irrevocably altering the way we work, travel, shop and socialise. The irredeemable wave of change evident across wider society was not going to pass by the question of NHS governance. Plans to reform the NHS into around 45 healthcare systems, which would effectively remove the NHS purchaser/provider split, have been gently moving forward for quite some time. All it required was legislation to give new organisations legal status. The ambition was clear – reduce local variation, remove the internal market and reinsert a layer of regional governance. All simple and straight forward.
The impact of the virus is said to have led to a change of heart at the centre of Government. Ministers, in particular Matt Hancock, are said to be frustrated with their inability to take direct control of NHS activity. Whilst previous Governments got used to working with NHS England and accepted a degree of separation – a relationship they learnt to adhere to if never truly embrace – it appears the current incumbents of Number 10 will not accept anything less than pure political and operational autonomy of the health system.
So, what does this mean for the NHS? It now looks likely that the legislation to reform the NHS and give legal standing to new ICSs will now take on a whole new dimension. The Department of Health and Social Care, working with Number 10, are now looking at how they give themselves more power to take back control of the running of the system. This will mean far greater control from politicians on how the new system should operate, priority setting and delivery.
How this works in practice is yet to be decided. As it stands, we are unaware of which aspects of control the Government chooses to bring back to the Department of Health and Social Care and away from NHS England. However, in the more immediate term, this could have far-reaching implications.
In recent years, my conversations with MPs have been characterised by a dialogue of frustration and repetitive explanations that, despite numerous letters raising issues and complaints, they rarely see any action or a change of policy from their local NHS organisations. Alongside this, NHS England has become less open and less willing to meet with stakeholders and discuss decision-making processes. Responses to Parliamentary Questions and Freedom of Information requests have become more and more evasive over the years.
A system that truly has politicians at its helm will naturally be more susceptible to political pressure. What is more, the current crop of Conservative politicians don’t necessarily work in electoral cycles like previous Governments. This is a Government fighting a perpetual election campaign; every announcement needs to focus on winning votes. As we saw with the plans to build more hospitals, they are not afraid to use the NHS and major announcements to give themselves a timely boost in the polls. I would expect to see plenty more high-profile announcements as the Government takes direct control of the NHS.
The move to bring back power to Number 10 would also align with other Government activity. DExEU did not survive long under the new regime and DFID wasn’t far behind. Special Advisers, historically given quite a lot of freedom, are currently under orders to get everything signed off by Number 10 before going public. Despite Rishi Sunak’s favourable public profile following his eye-catching announcements during Covid, the Treasury is now effectively a branch of Number 10. For Boris Johnson, this could also be an opportunity to put his name on the shape of the new NHS by wrestling control from Sir Simon Stevens. At a point when you are planning to invest more in the system than ever before, that might not be a terrible idea.
The road ahead is long and complex and if I could give one piece of advice for those planning projects that require major infrastructure spending, it is to work to the deadline of early 2024 – an election year that will trigger a new wave of promises and funding to ‘fix’ our wounded health system.
Dan Jones is Managing Director at PB Consulting: a specialist public affairs and consultancy service.