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Pity poor Matt Hancock if he thinks he can take back control of the NHS

Newspaper article

Another decade, another reorganisation of the NHS. Or as the late health economist Professor Alan Maynard put it when describing the most recent set of reforms, another re-disorganisation. A white paper was published last week. After all, ministers and officials at the Department of Health don’t have much else on at the moment.

As with most of these documents it is long and full of platitudes. This particular re-disorganisation will “remove the barriers that stop the system being truly integrated”, “remove transactional bureaucracy” and “ensure the system is more accountable”. It will also apparently help to deliver 50,000 more nurses and 40 new hospitals, and allow the NHS to “use technology in a modern way”.

Quite why these things are made impossible by the status quo is not explained. But “this is a unique moment when we must continue to build on the audacious legacy that makes the NHS the very best of Britain. We must seize it”.

Sorry. It’s easy to scoff. But what does it all mean? It looks as if there are two big changes afoot.

The first is largely to give legislative cover to things which are already largely happening. It’s the one designed to promote integration and remove transactional bureaucracy. For the past several years the NHS has been working around much of the legislation introduced by Andrew Lansley in 2012, legislation designed to increase the forces of competition within the system. After an initial flurry of ministerial enthusiasm, the system rapidly came to the conclusion that the reforms were largely unworkable. It set about creating new structures designed to circumvent and bypass the legislation. New bodies, with no basis in legislation, emerged to facilitate the sort of co-operation and integration that Lansley had wanted to replace with competition. It’s both a tribute to the NHS, and a warning to over-zealous legislators, that such fudging was possible. The white paper proposes to tweak this and put it on a more secure legislative footing. Not the obvious time perhaps, and beware such top down legislation, but fair enough.

The second change is the one supposedly designed to make the system more accountable. What that means in practice is to give the secretary of state more direct control, thereby undoing probably the most successful element of the Lansley reforms which was the statutory independence they granted to NHS England. This has given it a stability and consistency of purpose, as well as an independent capacity to make the case to ministers and public for funding and other priorities.

Exactly how much control Matt Hancock, the secretary of state, is looking for is unclear, but it looks like quite a lot. He’ll be able to change the mandate and objectives of NHS England as he sees fit. He also wants to be able to “intervene in local service reconfiguration changes”. I think that means a general power from Whitehall to determine what happens to any local hospital “informed” by the lobbying of the local MP or the size of their majority.

Quite why this is needed we don’t know. Nor is it clear how the experience of the past year has convinced the secretary of state that Whitehall is so good at running things that it can take on the NHS. In truth, this is just the latest chapter in a never-ending saga of NHS reform and counter reform. Centralisation of power causes too many political problems so power is devolved.

Secretaries of state get itchy and decide, to coin a phrase, they need to take back control, so decision making is recentralised.

That idea of control, though, is largely illusory. Pity the poor secretary of state. A lifetime’s ambition achieved. In charge of one of the great Whitehall departments. A seat around the cabinet table. But what actual power to make things happen? The biggest transformation in the NHS in recent decades happened in the 2000s not because of the actions of any secretary of state but because of the colossal sums of money made available by the Treasury. Even Lansley’s vast legislative programme eventually got swallowed by the system. The levers from Whitehall are mostly rather bendy and extremely floppy. Careful pulling will eventually result in change but only after a long period, and not necessarily the change intended. Ministers require what few of them have: time, patience, and tolerance of uncertainty.

This all seems so disappointing to them, and probably to most of us, because we suffer a national blind spot as to the nature of the NHS. We think of it as a single organisation. That’s what we’re told and retold from cradle to grave. It’s not. It can’t be. It’s too big, too dispersed, too complex. It makes up getting on for a tenth of the economy for goodness sake. You can’t sit in Whitehall or anywhere else and exert real control.

There’s no perfect way to organise a healthcare system. Like most advanced nations — the US is the great exception — we have a system which is taxpayer funded and largely free at the point of use.

And thank goodness for that. Despite the national mythology that isn’t remotely special. And nor, sadly, is the quality of what it provides. What is special is its immensity and the bewitching belief that the whole thing can be controlled from the centre. Hancock is just the latest in a very long line to grasp for that illusion of control. One day, probably in a decade or so, one of his successors will be so burnt by the experience of attempting to achieve the impossible that another re-disorganisation will be visited upon a system still doing its best to deliver that healthcare to us all.

This article was first published in The Times and is reproduced here with kind permission.

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