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Ten former health secretaries reveal insights into running the NHS Ten former health secretaries reveal insights into running the NHS
(about 1 hour later)
“Is it possible,” asks William Waldegrave, “in any business or in any organisation, truly to separate policy from execution?” This quotation comes from one of 10 interviews with former UK health secretaries published by the Health Foundation last week, aimed at better defining that relationship between the secretary and the NHS.“Is it possible,” asks William Waldegrave, “in any business or in any organisation, truly to separate policy from execution?” This quotation comes from one of 10 interviews with former UK health secretaries published by the Health Foundation last week, aimed at better defining that relationship between the secretary and the NHS.
Related: Eight things the new government should prioritise for the NHS
It is a long-held truism in health that Aneurin Bevan established the NHS in 1948 as a centralised command and control structure. But this is not the case. In reality, says the book that I co-wrote with Nick Timmins, Glaziers & window breakers, the words were quite possibly born of despair – Bevan was the first health secretary to find that there is an impossible tension to navigate a service that is politically accountable to parliament and run day-to-day by its staff.It is a long-held truism in health that Aneurin Bevan established the NHS in 1948 as a centralised command and control structure. But this is not the case. In reality, says the book that I co-wrote with Nick Timmins, Glaziers & window breakers, the words were quite possibly born of despair – Bevan was the first health secretary to find that there is an impossible tension to navigate a service that is politically accountable to parliament and run day-to-day by its staff.
Our book charts how 10 recent health secretaries have coped with that tension and, importantly, how the incumbent can better do so.Our book charts how 10 recent health secretaries have coped with that tension and, importantly, how the incumbent can better do so.
It was prompted by Andrew Lansley’s most recent attempts to remove politicians from the daily running of the NHS. What emerges is that even the weight of the Health and Social Care Act 2012 can’t formalise the relationship between secretary and service because of one crucial factor – people. It would seem that throughout the history of the NHS, health secretaries have been consistent in one way: their behaviour trumps legislation.It was prompted by Andrew Lansley’s most recent attempts to remove politicians from the daily running of the NHS. What emerges is that even the weight of the Health and Social Care Act 2012 can’t formalise the relationship between secretary and service because of one crucial factor – people. It would seem that throughout the history of the NHS, health secretaries have been consistent in one way: their behaviour trumps legislation.
Perhaps the book’s clearest example of this comes from Alan Johnson’s time at the helm and the emergence of problems at Mid Staffs. He says: “When Mid Stafford broke, Bill Moyes [the chairman and chief executive of Monitor] was trying to tell me that it was his responsibility and not mine [to remove the chair and chief executive of Mid Staffordshire NHS foundation trust] because it was a foundation trust. Now, politically, it would be very nice if you could get away with it and say, ‘That’s yours. That’s your can of worms.’ But I told him, you know, ‘Piss off. I’m dealing with this.’Perhaps the book’s clearest example of this comes from Alan Johnson’s time at the helm and the emergence of problems at Mid Staffs. He says: “When Mid Stafford broke, Bill Moyes [the chairman and chief executive of Monitor] was trying to tell me that it was his responsibility and not mine [to remove the chair and chief executive of Mid Staffordshire NHS foundation trust] because it was a foundation trust. Now, politically, it would be very nice if you could get away with it and say, ‘That’s yours. That’s your can of worms.’ But I told him, you know, ‘Piss off. I’m dealing with this.’
“Bill was probably right that the legislation said he was responsible … [But] you’re the secretary of state. There is public money going in there. You are responsible.”“Bill was probably right that the legislation said he was responsible … [But] you’re the secretary of state. There is public money going in there. You are responsible.”
Lansley’s legislation sought to break this cycle and, in his own words, “to hamstring the politicians a bit”. But in his interview – in which he enters a fierce defence of his reforms - he concedes that ministers are still intervening on operational issues, whatever the legislation says.Lansley’s legislation sought to break this cycle and, in his own words, “to hamstring the politicians a bit”. But in his interview – in which he enters a fierce defence of his reforms - he concedes that ministers are still intervening on operational issues, whatever the legislation says.
“I [do] think they’re still intervening – of course they are – but it will get harder and harder over time.” Of Jeremy Hunt’s actions on interventions on hospital parking or food, he says, “he knows he shouldn’t”. But Lansley argues that some of these apparent interventions are “stuff which NHS England has in practice decided and ministers are badging for political reasons” – a theory which in itself serves only to further blur that line between policy and management.“I [do] think they’re still intervening – of course they are – but it will get harder and harder over time.” Of Jeremy Hunt’s actions on interventions on hospital parking or food, he says, “he knows he shouldn’t”. But Lansley argues that some of these apparent interventions are “stuff which NHS England has in practice decided and ministers are badging for political reasons” – a theory which in itself serves only to further blur that line between policy and management.
Indeed the whole dilemma is neatly summed up by Stephen Dorrell in just a few words: “You can’t legislate away responsibility.”Indeed the whole dilemma is neatly summed up by Stephen Dorrell in just a few words: “You can’t legislate away responsibility.”
Related: My plea to the next health secretary: don't restructure the NHS again
Each interview ends with some direct advice for the current and any future health secretary and one theme is clear – give yourself some space to reflect on what your job is and how your behaviour will affect that. Those that have done the job do not necessarily agree on what it is, but they do agree that the attitude of the incumbent is the deciding factor.Each interview ends with some direct advice for the current and any future health secretary and one theme is clear – give yourself some space to reflect on what your job is and how your behaviour will affect that. Those that have done the job do not necessarily agree on what it is, but they do agree that the attitude of the incumbent is the deciding factor.
Virginia Bottomley’s interview ends with a thoughtful reflection on this, which ultimately gives the book its name: “There are different times in politics, and it does go in cycles. Sometimes you want a window breaker and sometimes you want a glazier. Ken (Kenneth Clarke) was a window breaker and he was brilliant. But after that you get William Waldegrave who was a glazier. And my job, after the election [in 1992], was that we’d got some trusts and fundholders up and running and my task was to get all of that beyond a tipping point. Quieten it all down. Show them you care. And then a new set of problems will arrive and you need a Ken to break the windows again.”Virginia Bottomley’s interview ends with a thoughtful reflection on this, which ultimately gives the book its name: “There are different times in politics, and it does go in cycles. Sometimes you want a window breaker and sometimes you want a glazier. Ken (Kenneth Clarke) was a window breaker and he was brilliant. But after that you get William Waldegrave who was a glazier. And my job, after the election [in 1992], was that we’d got some trusts and fundholders up and running and my task was to get all of that beyond a tipping point. Quieten it all down. Show them you care. And then a new set of problems will arrive and you need a Ken to break the windows again.”