On Monday I explored the disagreement between London Councils and London’s NHS leadership about whether the recent NHS Command and Control of the capital’s hospitals had been a good or bad management experience. NHS leaders thought it was important and that it worked, London Councils experienced the same technique as having excluded them – and everyone else.
Last weekend it became clear that there are still others, jealous of the NHS leadership’s recent power to command and control, who felt that they should be the people in charge. They being the Johnson Cabinet.
A number 10 working party is now looking at potential changes to the Lansley legislation that created the current governance of the NHS. To be fair to everyone involved, the possibility of legislation has existed for some years – but now the rationale has changed. In 2018 the then Prime Minister, Theresa May, recognising her non-majority, asked the NHS to come up with legislative ideas for itself. The changes looked likely to be about empowering Integrated Care Systems alongside the current power of trusts – not a wholesale reorganisation.
The current government’s large majority changed the parameters of what was possible in parliament, and the experience of the Covid crisis has changed everything (in this as in all things).
As far as ‘the Number 10 source’ is concerned some of this will be about their experience of Simon Stevens. I suppose that if, over the last three months, you’ve been the Secretary of State thrashing around for some competent traction on this crisis and been bashed around by the media every other day for talking about protective rings around care homes, it must have been tooth-grindingly annoying to see Simon Stevens, dipping in and out of the media with such calm assurance. And being congratulated.
Sunday 5 July even saw the Secretary of State being foolish enough to go on the same Andrew Marr programme as Simon and give the public the opportunity to make a simple judgment between the two.
Given that experience, it is inevitable that the Number 10 working party will now be looking how the Secretary of State can have more direct control over the NHS.
“Matt Hancock is frustrated by how limited his powers are and wants to get some of them back’, said the source.
If legislation comes before the Houses of Parliament, the party politics will be lots of fun. The current Secretary of State was a new MP in 2010 and will therefore have been loyally voting for the Government’s flagship legislation. And nothing was ‘flagshippier’ than the Lansley reforms of the NHS – the bill started its passage in the same year. The current Secretary of State for Health and Social care will have voted many times to take powers away from his future self. The White Paper that led to the Act was called ‘Liberating the NHS’. The liberation in question was to remove from the NHS the shackles of the Secretary of State (that he was to become). Until then he was happy to vote to remove powers from the post.
If they could fly the skies would now be darkening with the wings of chickens coming home to roost.
But the party political amusements won’t stop there. On the other side of the house the Labour Party very strongly opposed the Lansley Act. At the time many of them saw the very idea of moving the Secretary of State out of direct control of the NHS as a threat to its future. The same was true of unions like the BMA and most of the Royal Colleges.
At the time the arguments were very strong. Keep the Secretary of State in direct control!
It will be interesting to see how the current Labour opposition will respond to a new Bill arguing that the current Secretary of State (or anyone else that the current Prime Minister wanted in the future) be in direct control of the NHS. Do the Labour Party really think that is a good thing?
Because this is the real problem with centralising power and enjoying the power to command as well as control. The reason the Secretary of State dreams of being Simon Stevens is that Simon is the CEO of NHS England. He has a direct relationship with the NHS and the Secretary of State wants that power.
When the Covid crisis hit Simon was able, in just a few weeks, to repurpose beds and quickly reorganise thousands of staff to meet the crisis. Now the Secretary of State wants that power. And it looks likely that he will bring in legislation to take it.
But there is a problem here. I have often commented on the reality that the NHS thinks of itself as run by command and control, when in fact what it has is command – but with very little control. That’s the normal experience of ‘running’ the NHS. Even without powerful NHS foundation trusts with powers over themselves, there are hundreds of thousands of professional staff who do not take at all kindly to being controlled – whether by Simon Stevens or the Secretary of State.
Over the last few months of the Covid crisis what we have seen is a very different experience of command and control in the NHS – operating under very different legislation. In an emergency the NHS leadership can gain control of all the resources at hand. It was this that led to the repurposing of beds and staff.
So when the Secretary of State wants to “take back control” to the situation that existed before 2010, he won’t in fact be gaining the control that Simon Stevens has had during the Covid crisis. To do that he will have to give himself, as an everyday part of the legislation, the much greater powers that Simon has had.
Without that the Government is going through this exercise to give itself the opportunity to command…. but not control.