Since the first week of June, when the Prime Minister promised that the NHS would get more money, I have been blogging about various aspects of the process of spending it. It won’t surprise anybody that I think it’s important, and it’s not surprising that the NHS thinks it’s important, but it is becoming obvious that it is very important to far more people than us.
Imagine you’re a Government minister for a domestic policy area – any domestic policy area. Imagine also that you did not come into Government to bang on about Europe all the time. Given current events it may be difficult to imagine such a paragon, but I can assure you that there are a lot of them who are pretty fed up with how much oxygen has been sucked out of our politics by Brexit.
You may have entered politics a decade ago because you really wanted to improve an area of policy. You’re passionate about it and one day you experience that “wow” moment when you are appointed to that policy area and told “make it better” by the Prime Minister. I’ve known this happen to a few people and I can tell you it’s a wonderful feeling of the culmination of all your hopes (and OK, some of your fears).
You know this Brexit business is very important, but you get your head down and make some plans for your policy area. You work through this with stakeholder groups and begin to develop your base for action. In spring 2018 you begin making your case for a bit more money in the 2019 spending review to achieve something you consider really important. By chance – wonderful chance – there is also slightly more money from slightly larger tax receipts coming into the Treasury.
Then, in the first week of June, in a break from the Brexit noise – the Prime Minister announces that the Government is going to spend ALL its extra money on the health service. A slightly grumpy Chancellor agrees and it becomes clear in the late October budget that the entire Government financial uplift for domestic policy for the next few years is going into health.
You have a moan and your Secretary of State raises it quietly in Cabinet. They don’t get anywhere but what becomes clear as the autumn continues is that the entire domestic policy for the Government is now going to be about spending that money on the NHS.
The long-term plan stops being an issue for the NHS and becomes one for all those other areas of Government.
Apart from Brexit (pause for laughter at the absurdity of that thought) the NHS is not the biggest game in town it is the ONLY game in town.
Why is this important? Well with a big commitment like this the Treasury usually keeps a tight hold on the accountability strings. They watch closely how you spend the money. This is in fact less burdensome than it sounds because once the money has been promised by the PM the Treasury can’t for example say in a few months’ time, “We’re stopping the money because we don’t like how you’re spending it”. The money was secured by politics and cannot be unsecured by Treasury accountability.
But if domestic government ministers are full of resentment that they can do nothing because the NHS has all the money, they are likely to be looking very closely at outcomes – all the time.
What effect does this have? It means the entire government will be watching the Secretary of State for Health and Social Care to make sure their money is being spent in the way it is meant to be spent. Such a level of scrutiny is likely to lead to a lot of performance management – starting with the Secretary of State who will, in turn, pass this burden onto NHSE and NHSI… and we have considerable experience about where they will take it and how they will do it.
Spending everyone else’s money will come at a price.