Filed Under (Reform of the NHS, Secretary of State) by Paul on 25-10-2011
(Note: There was a comment yesterday from The Jobbing Doctor that I would like to share with everyone. The Jobbing Doctor seemed to think that I was masquerading as being impartial. I apologise if I have ever given that impression. I am partial. I have an argument and I have a position. What I try and do is explain that position, and how that position makes sense of what is going on in the NHS.
He also quite rightly pointed out that I was involved at the heart of Government between the years 2001-2007 when I advised two Secretaries of State and the then Prime Minister. My experience of carrying out those roles deeply informs the position that I have and I am very happy to take responsibility for my part in those reforms.
Without having played that part and without standing up for it, I would have very little to say).
Yesterday’s Guardian had one of those revelation/leak stories that are always fun.
Apparently the new Chair of the National Commissioning Board, in preparing his evidence when appearing before the DH, had a set of written evidence which outlined how the NCB would operate at arm’s length from the Secretary of State and would not be directly accountable to him for their day to day work.
The fact this is a ‘leak’ must puzzle the government quite a bit. In July 2010 this was clearly outlined in the White Paper that was published that month; there were tens of clauses in the Bill published last December about it. It is difficult to see therefore how this is a ‘hidden aspect of policy’ which newspapers can only uncover via a ‘leak’.
But the fact that a reputable journalist can see this as a leak when it has clearly been public policy for 15 months is worthy of comment.
First it is another example of the Government not explaining what it is doing. This idea is a central part of Andrew Lansley’s vision. But he has not gone out and explained why it is so important to him. Therefore so many months on, what is a central public plank appears to be news to a journalist that knows this subject very well. If you don’t tell people why you are doing something, they will think you have a ‘secret plan’. This is another example of the Government’s secret plan that is secret only because no one has explained it!
Second, in the summer when the Government reformed its reforms it apparently went back on its original idea of removing the Secretary of State from responsibility for the NHS. Its reformed reforms appeared to say that the Secretary of State would once more be responsible. Therefore the story is a story because it would appear that the Secretary of State is sticking to some secret plan that he had last year rather than changing his mind in public as he appeared to do in June.
This is another example caused by the muddle of facing both ways.
And it fits in with what this and tomorrow’s blog will be about – which is the centripetal centralising tendencies that have to be a part of any reform of the NHS.
The public may not know much about NHS finance (lucky them) but they do know that the NHS is paid for out of central taxation. “We all pay for it from our taxes”. Once you have that as a major principle then there has to be a strong set of centripetal powers in any NHS reform. The public want this to be centrally funded and since it is, their money flows from individuals to the central Treasury in Whitehall. They then give it to the DH which in turn gives it to the NHS.
More than anything else that creates the N in the NHS and given that N, the public expects some NATIONAL accountability. The Secretary of State failed, between July 2010 and April 2011, to make the case for not being accountable. There is an interesting case to be made for changing that accountability, but you can only do that by accepting that the public are correct to expect an overall accountability.
What there is in the Bill at the moment is a mess. The Lords will amend it, but it will still be a mess.
And curiously – the law does not matter here. The vast majority of the public and the vast majority of MPs feel that the Secretary of State for Health should be responsible for the NHS and therefore whatever the law says – the Secretary of State will be held responsible for some time to come. This is a political, not a legal issue.
The point I am making is that however passionately you believe in localising decision-making in the NHS you have to recognise that at the same time the public will look to the Secretary of State as the accountable person for their NHS.
They will also look to the N in the NHS to provide national standards. Even when the NHS was at its most “command and control” (as I have said before – all command and no control) there were very sharp differences between the standards of services across the country.
When – to reprise Jobbing Doctor’s concerns that I addressed in my opening comment – I was part of a Government that insisted there be maximum waiting times for treatment; we did so because we felt that the public were right to expect similar waiting times wherever they lived. So we took accountability very seriously. We put it into manifestos that were voted upon and then ensured that the system met the national targets.
Interestingly many of the people that are now arguing for strong national Secretary of State accountability were very angry when that accountability was accepted by Secretaries of State and waiting time targets were set and met.
They saw this as political interference, and given that it had appeared in a manifesto on which a Government was elected and had then had a Secretary of State carry it out, it was accountable to politics.
That was central accountability. It was a centripetal force in reform and it’s what happens when a Secretary of State accepts the responsibility that organisations like the BMA are now thrusting at the current incumbent.
Tomorrow I will look at how the National Commissioning Board will work as a centripetal force and next week will look at the centrifugal reforms that are moving power away from the centre.