I’ve told this story before, but when I started working with the NHS, Nick Timmins’ reputation for possessing the remarkable power to explain what was going on in the NHS went before him.
I had started as Alan Milburn’s Special Adviser after the election of 2001. Having immersed myself in the 2000 NHS plan and the Labour Manifesto I had come up with a wide range of practical policy interventions that sprang out of these two documents. These I presented to my new boss, trying to get these different activities to form a coherent (ish) whole programme.
At the end of our meeting Alan told me that as the programme developed and I got into the detail I might lose sight of the way in which each minute part interacted with others in the overall programme. He said that when this happened the loss of coherence would be a problem for us all – “But never mind, all you have to do is ring up Nick Timmins and he will tell you exactly how it fits in with the other parts of the programme and what it means.”
And he was right – Nick always knew how everything fitted together. As a journalist he was interested in the detail and as a writer about the welfare state he was passionate about the very big picture. And he is radical.
That’s why last week when I went to the publication of his latest pamphlet “The World’s Biggest Quango: The First Five Years of NHS England” published by the Kings Fund and the Institute for Government I knew it was an important event. The Secretary of State obviously thought so too since, continuing the tradition of the Department of Health needing to find out from Nick what it was doing, he came along to talk at the launch.
A few years ago Nick wrote ‘Never Again’ his analysis of the passage of Andrew Lansley’s Health and Social Care Act. The current pamphlet is his analysis of what has happened with NHS England since then.
The most important part of the story was the attempt by Andrew Lansley to remove the Secretary of State from responsibility for the NHS. At the time of the passing of the Act it was interesting to see him lose an argument that appeared to have such a popular support at the outset. If you asked people whether it was important to ‘remove politics from the NHS’ – many would agree. However when Lansley tried to remove the Secretary of State, as a politician, from responsibility, he failed completely.
Passing a law that says that the NHS is to be run by an independent quango may seem to settle the argument once and for all, but the cultural and political practice of the relationship between the NHS, the British public, taxation and Parliament has meant that every attempt to remove the Secretary of State from responsibility has failed. So many people know that the NHS is paid for out of general taxation and so many people want to ‘write to their MP’ about the NHS, that in terms of the practice of the activity, politics is in control of the NHS and probably always will be.
David Bennett who at the time was running Monitor (for younger readers Monitor was one of the predecessors of the NHS Improvement Agency) said “If the purpose of setting this all out in legislation, as Andrew has said, was to make it permanent, so that it could not be changed … well, it hasn’t been changed. It’s just been ignored!” This is an object lesson in the limitations of the law. Unless something fits in with the great mass of the people’s wishes it can be ignored – and no-one ends up in court as a consequence.
But there are still different ways of interpreting the role of the Secretary of State,
“If the buck stops with the Health Secretary, then there are still choices to be made by the occupant of that office on how to discharge his or her responsibilities. Nick shows that Jeremy Hunt brought his own distinctive approach to the role, reflected in regular Monday morning meetings with leaders of the various national bodies involved in the NHS. These meetings often focused on detailed aspects of NHS performance underlining the inherent difficulty of separating policy from operations. Hunt also took on the mantle of the patient’s champion, using the report of the inquiry into Mid Staffordshire to shift the focus away from Lansley’s technocratic vision to patient safety and how it could be improved.”*
The reality there of the Secretary of State quite correctly believing that the public wants him to be responsible for the NHS. But this conflicts with a law that signals the independence of a number of Arm’s Length Bodies – including NHS England. If the CEOs of the Arm’s Length Bodies ‘stand on the law’ and say they are independent and therefore won’t work with the Secretary of State – the system falls apart. That does not happen in this script.
Nick has organised this pamphlet as a series of acts and scenes and these go into some detail about how this important relationship works. The contradiction echoes through the Monday meetings between the Secretary of State and the apparently independent arm’s length bodies. Whatever the intention of the Act people work together and work together with the Secretary of State.
I know I am a geek for going into this detail. (But then you are reading it so that makes you a bit of one too). This is a really important story, not just for the NHS but for the way in which we organise important institutions or our society. The humour of the writing helps the reader to engage with the detail.
(Frontispiece image by Jon Twin, Bowyer Press)