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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