It’s often said that politics is showbusiness for ugly people, so it should come as no surprise that Keir Starmer loves a bit of street theatre – like robotically announcing the demise of NHS England while visiting a Reckitt Benkiser factory for example. Last week sitting down in the Oval Office, this week a stand-up gig in Hull. Are you not entertained?
Readers unfamiliar with the arcane administrative minutiae of our beloved and world beating NHS may wonder what all the fuss is about – and with good reason. To understand what’s happening, we need to take a trip in the TARDIS (Time and Relative Dimensions in Space), back 25 years to the regime of ‘Call me Tony’ and his Health Minster Alan Milburn, ably assisted by youthful SPAD Simon Stevens.
Things were different then. The management of our revered and precious NHS was centralised within the Department of Health. It was a time of centrally imposed targets for hospitals with financial penalties attached for failure. Tight media management, presentational sleight of hand and gaming of metrics. Some colleagues called it a ‘Stalinist system’. I couldn’t possibly comment.
It was a time of hope and expectation. The eminent surgeon Lord Darzi was brought in to advise the Government on improvement initiatives. Several projects were instigated all guaranteed to improve efficiency and clinical results – for example Diagnostic and Treatment centres (failed), Community Polyclinics (failed), publication of individual surgeon’s outcome measures (failed)… I could go on, but despite the general fabulousness of the glorious NHS, ungrateful patients still seemed dissatisfied and regularly berated politicians in front of TV cameras. Complaints often centred on short-termist politicians interfering with the national treasure that was the NHS.
On the change of Government in 2010, new Health Secretary Andrew Lansley had a big idea. Management of the NHS would be separated from the Department of Health. The NHS would be granted operational autonomy from government – no more political interference in day-to-day affairs. Lansley assumed that the public would then blame NHS management rather than the politicians for any shortcomings. He was wrong.
Lansley set up NHS England in 2012. He overlooked three crucial factors. The first relates to accountability. NHS apparatchiks do not have to stand for election and are effectively immune from being sacked. Politicians are not. Hence, despite NHS England presiding over the consistent inexplicable underperformance of our wunnerful NHS, the public continued to blame elected representatives rather than professional managers.
Second, Lansley forgot the ‘iron law of oligarchy’, a tenet of social science articulated by the German sociologist Robert Michel in the early 20th Century. Simply put, this concept maintains that any organisation evolves to serve the interest of its elite managing cadre rather than the interest of other stakeholders. I could not possibly comment further.
Finally, and most significantly, Lansley underestimated Simon Stevens, who took over as Chief Executive of NHS England in 2014. Stevens was probably the most talented politician of his Oxford cohort (which included Cameron, Johnson and Starmer). He expanded NHS England to 20,000 employees, centralising control of information, finance, regulation and authority across the entire network of the English Health Service. NHS Trusts were subject to tight control and supervision from NHS England in a regime some considered ‘Stalinist’. I could not possibly comment.
Simultaneously, Stevens lobbied for and obtained massive extra funding from central government – its budget currently stands at £200 billion a year. No matter what the problem was, the answer was more taxpayers cash for our chronically underfunded and victimised NHS. Inexplicably, service productivity continued to decline. Fortunately, managers at NHS England were able to retain a semblance of dignity by patronising top class hotels and hospitality on their expense allowances. Stevens was awarded a knighthood in 2020 and a peerage on his retirement from the NHS in 2021. He was succeeded as CEO of NHS England by Amanda Pritchard, a previously popular and effective CEO of Guy’s and St Thomas’s Hospital.
So, to July 2024 and the change of governing regime. The youthful and inexperienced Health Secretary Wes Streeting needed reliable advice. Alan Milburn the former Blairite incumbent seemed a natural fit for a position as the lead non-exec on the board of the Department of Health and Social Care, having pursued a prosperous career in healthcare consultancy via his personal company AM Strategy Ltd.
Streeting’s first act as Minster was to invite the eminent surgeon Lord Darzi to conduct a comprehensive review of the ‘broken’ NHS. It is a matter of record that NHS England has presided over a steady decline in NHS productivity. Despite a 17% increase in the NHS‘s workforce over three years, productivity has fallen year on year. The influential House of Commons Public Accounts Committee reported in January on the state of NHS finances, commenting: “The scale of Government’s ambitions is great, but senior officials do not seem to have ideas, or the drive, to match the level of change required, despite this being precisely the moment where such thinking is vital.” Some readers might consider that to be a political pitch roll for a pre-determined plan to abolish NHS England. I could not possibly comment.
The recent extra £20 billion generously granted from taxpayer’s funds by the former highly experienced Bank of England economist Ms Reeves is unlikely to shift the stubborn productivity dial – the money has already been absorbed by pay increases and rising inflation. Therefore, the decision has been made to bring NHS management back under the direct ‘democratic’ control of the Department of Health. Some colleagues fear the regime will be ‘Stalinist’. I could not possibly comment.
So, what can readers expect from the abolition of NHS England? Well in the short term, absolutely nothing – by that I really do mean nothing. Many of the soon to be former employees of NHS England will spend the next three months working out their notices, looking for other jobs and planning where to invest their redundancy payments – the cost of which is estimated at between £800 million and £1 billion.
In the meantime, hospital trusts will be in limbo, waiting to be told how the new regime will operate, how funding mechanisms will work and how services will be commissioned. Senior management will probably be distracted by process adjustments and recalibrating to the new reality, rather than focusing on the important task of waiting list reduction and operational efficiency. The new Integrated Care Boards (ICBs) are similarly still bedding in having been the subject of a recent review by another former Blairite Health Minister with a lucrative second career in healthcare consultancy, Dame Patricia Hewitt.
The scrapping of NHS England is all about efficiency and avoiding duplication of bureaucracy. Or so they say. Feel free to call me sceptical, but my suspicion is that many of the former employees of NHS England will soon find themselves assigned new jobs within the Department of Health or the new ICBs doing much the same as before.
We find ourselves going ‘back to the future’ on health policy even to the extent of resurrecting the same cast members from 20 years ago. Consider the set design of Starmer’s open mic slot in Hull. Prime Minister in tieless, shirt sleeve order, cuffs turned back, delivering ‘man of the people’ faux frank oratory. Curiously reminiscent of the current occupant of an anonymous looking office building on Great Portland Street – home to the ‘Institute for Global Change’? (Google it). Same band, different front man. Readers may also like to consider the counterfactual – if the evil Tories had abolished NHS England, how might Labour in opposition have responded? So, the carnival continues – round and round the same maypole, going nowhere. The difference between our trip in the TARDIS and the current position is that now there really is no money left.
The latest political performance is therefore like Samuel Becketts play Waiting for Godot. Takes up a lot of time, is hard to understand and the end turns out to be much the same as the beginning. Yawn. Could someone please wake me when it’s over?
The author, the Daily Sceptic’s in-house doctor, is a former NHS consultant, now retired.
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Some people may be going round and round the maypole but I feel like I’m stuck in the spin cycle of a washing machine [a slow one].
I never did.
On another point….I hear they want to ‘force’ Smart Meters on people, that’s my conversation!
One recent claim has baffled me, that is the fantastic number of appointments delivered by the NHS since the election. With little change in the fundamentals of the health service, how has this amazing figure been achieved. Was it perhaps that under the previous Government, there was inefficiency or were doctors’ strikes the reason. Maybe under the new Government the doctors have got off their arses and are now doing what they are paid for. But no, none of these, as my wife and I have recently discovered. She received a text message to say her medication has been reviewed without reference to her and they were happy with what she was taking. Strange we thought, who originated this review? An hour later, she received another text advising her of an appointment to review her medication in ten minutes. We urgently contacted the surgery to say she would not be able to get to the surgery in ten minutes, but that she had already had a text saying the review had taken place. No problem say the surgery, we’ll just check the box that the review took place. So a fake appointment for a fake review. How many more of these have happened to allow the Government to brag about the number of appointments?
The descent into what Guy Debord called the society of spectacle is complete. Real bottom of the barrel crap. A ruling class with that has always had a sociopathic disregard for the comon weal is now no holds barred psychopathically and openly destroying the weak and pretending to be aligned with populist interests. You can perhaps see it best as an end of empire tendency where the tyranny and nastiness that was shown to the natives of the colonies comes home. This tendency has been written about for 2500 years. It is reflected perfectly in the economic system as it stands.
These people really are beneath contempt.
A reasonable analysis. No doubt they will be able to say “something has been done”, but as an experienced patient, I’m sure you will remember that quite a few people of your calibre do a but of work next door, as it were, for other firms. A while back, I had private cover with another firm, paid for by my employer, and it was normal to be able to see the same consultant a lot earlier that way than being on an NHS waiting list, with the private place being within walking distance of the other. I expect that will grow in the medium term.
I like NHS workers in the same way that I like the armed forces. They are like what the English were like fifty years ago before they got all messed up. You feel with an NHS worker that you’re talking to an actual Englishman regardless of where he hails from. The politeness, the urbanity and civility. It is reassuring in the same way that a trip to the countryside is reassuring. The NHS and the army are all that is left of the old beautiful England.
The administrators of the administrators merging back with the administrators to administrate the administrated. What used to be quaintly called clerks, secretaries and adminstrative assistants.
Core task logistics – at the founding of the NHS, used to be overseen by medical staff from the Chief Medical Officer downwards.
Again hold accountable Education, Education, Education. More non-jobs for graduates with non-degrees – Compliance, Care Quality, DIE, etc, etc, etc.
Meanwhile, Sir Two-Tier proclaims AI will be the answer to NHS prayers. Be careful what you wish for.
When I started my hose jobs, my big DGH had ONE administrator and one assistant. Neither was that effective.
Those NHS England staff not needed to cope with the increased workload of the DHS, all too lacking in NHS experience, will be needed as private consultants to the local hospitals and trusts to whom new responsibilities will devolve (as per Starmer’s “back to the frontline, where they belong,” which, being interpreted, means “back to managers who will recruit more to spend any extra resources”).
And of course, as with every money-saving NHS reorganisation since before I qualified and after I retired, new offices with new furniture, new stationary, new IT systems and newly-minted non-jobs will be indispensible.
And they might turn out to be useful as private consultants to do those tasks, off the payroll etc. Ask the Chancellor.
All criticisms of the structure are true but that shouldn’t blind you to the nature of the attack. When I worked in the NHS we had people from overseas working within it and the most striking thing for them was the military structure. Not a bad thing but if you reflect upon it is essentially a military structure, But it got the job done well when it was well-funded. And the NHS is easily the most efficient organisation in the world when it comes to the procurement of drugs because of the arrangement. It is easy to slag it off but in the times we live in it is an easy target. It is certainly the best thing that is left about England. The workers are a cut above.
You had people comng back from Iraq and Afghanistan with their legs blown off and these were obviously very young men and they got well looked after by the NHS and not just fixing them up but also providing a reason for living. The structure itself relies upon a degree of internal cohesion. This is becoming increasingly difficult to maintain. Just look at how recruitment for the armed forces has fallen in the last few years. All of these are signs you can’t just pretend that they aren’t happening.
If we grasp that we are now a disability based country and economy then at least there is an honest acknowledgment. We need to move quickly towards a geriatric and disability based economy. Difficult without immigrants though. Just find your local invalid and wheel him out for a walk. The acolytes of Rudolf Steiner asked, how do we attain knowledge of higher worlds? He said visit the local old people’s home and take a few of the residents out for a walk.
Don’t let this slimy little tosser get his grubby paws on anything. I have no ideological commitment to the NHS but can say that it is worth saving and full of the finest people that we have. It tends to be a bit naive when it comes to attacks. Don’t be naive about this nasty little twat.
The theory: politicians, elected by the population, make policy and the bureaucracy execute the policy.
The reality: the bureaucracy make and execute policy and the politicians sell it to the public. So the public elect the politicians who are going to sell them predetermined policies.
The theory: the bureaucracy serves the public. We pay them, they work for us.
The reality: the bureaucracy rules the public. The money they confiscate from us is the source of their power.