A brief interlude from exploring future welfare policy that might develop as the virus threat recedes, to examine the politics of the White Paper on structural reform of the NHS.
Last week, when the Secretary of State introduced it in the House of Commons, he was careful to claim that the legislation had been requested by the NHS.
Now there are of course a number of different ways to argue for legislation for reorganising the NHS. The most straightforward would be for the Secretary of State to say, “I am bringing forward this legislation because I’ve given it a lot of thought and concluded that, for these reasons, it’s important for the future of the NHS.” This would be taking ownership of the arguments for the legislation and acknowledging that, for the next few months in Parliament and the next few years in the NHS, you will have to be ready – every day – to counter any opposing arguments. It’s a battle of your arguments versus theirs. It’s down to you.
Or – as has happened here – you can say that this reorganisation is mainly your response to NHS requests. Don’t argue with me – argue with them.
The logic behind this thinking is clear. The claim is that since the NHS asked for these changes, it can’t possibly complain about any disruption they cause.
I think this was a neat way of getting past last week’s debate on the White Paper. But for the future it creates a whole basement full of hostages to fortune.
It will be interesting to see how far this justification works as the White Paper becomes a Bill and goes through the Commons and Lords legislative process.
The first and most obvious point is that the NHS – and the 1.4 million people who work in it – did not ask for this. The ICU nurse rushing from patient to patient is not thinking about the need for urgent reform of the NHS and wondering when the Secretary of State is going to realise the urgency of making changes. Nor is the GP, providing hundreds of vaccinations a week, thinking about the different Boards that will constitute an Integrated Care System. The NHS are not impatiently tapping their feet in anger at the length of time it is taking the Government to pass this legislation.
This may appear to be a cheap point – of course frontline staff aren’t preoccupied with legislation. But the Secretary of State’s problem is his claim that they are asking for legislation. In portraying the NHS as being in need of speed to introduce legislation during a pandemic, he lays himself open to a raft of arguments. Over the next 10 months of legislative grind there will be certainly be weekly opinion polls – from various parts of the NHS – suggesting that nurses and doctors do not want the reorganisation that he claims they do.
‘The NHS’ has not said it wants to be reorganised and we are likely to hear loudly and often that it doesn’t want it to happen – especially when the people in it are so exhausted. As ‘the NHS’ expresses its opinion it will become a part of the politics of this reorganisation just as it did the last.
And the Secretary of State will find himself fighting the very people whom he has claimed are on his side. That will be news of his own making.
The people who asked for some of this legislation are the board of NHSE/I. In their efforts to develop integrated care, they have found the Lansley legislation restricting what they need to do. This is an important issue and the direction of change in structures is correct.
But as the White Paper becomes a Bill it will become clear that most of the people who work for NHSE/I – not those at HQ – but out in the field working for CCGs are likely to be forced by this legislation to move their jobs. If ICSs are to mean anything, they will have to absorb the current role of CCGs. This set of structural changes will mean that commissioning, as a part of the historic purchaser/provider split, will be diminished and with it the number of staff who work for CCGs and the nature of the work they do.
At that moment – as it becomes clear that some staff who currently work for NHSE/I will lose their jobs, the claim that NHSE/I supports this legislation will be contested – and those contesting it will be NHSE/I staff.
And, again, every aggrieved group of staff that want to make the news will be able to do so courtesy of the argument made last week by the Secretary of State. They will all be disproving his claim of their support.
But the biggest problem for his claim that NHSE/I asked for this legislation is that they have not asked for the part that is most important to him.
It has not asked for the Secretary of State to have more power over the NHSE/I. It has not asked for legislation that reduces its own independence. Yet this is clearly what matters to the Secretary of State. He wants more personal control over the NHS.
He believes – yes, think about this for a moment – that he can run the NHS better than Simon Stevens.
And somewhere in his mind is a belief that the last 10 months of Covid has made that case for him.
Much of his argument during the legislative process will revolve around his belief that he that he could have done a better job than Simon Stevens. This argument will be contested.
But he has an even bigger problem than this.
The Lansley legislation he is undoing argued strongly that the Secretary of State should not be in charge of the NHS. Lansley’s reorganisation came from a huge and complex piece of legislation that took a couple of years of sharp conflict to wend its way on to the statute books. Over that time there were countless very sharp debates in Parliament. There was a very fierce contest about removing the Secretary of State from being in charge of the NHS.
Back then (in 2010) there were a number of new, keen Conservative members of Parliament who repeatedly voted to strip the Secretary of State of the very powers that Matt Hancock now wants to give back to his post.
And one of those enthusiastic MPs was Matt Hancock.
Newly arrived in Parliament he voted time and time again for legislation to remove powers from the Secretary of State for Health. He was keen. He really believed in it. and, in part thanks to his efforts, the legislation passed.
Yet now, as the current Secretary of State for Health, he profoundly disagrees with that same legislation for which he once fought so hard. This seems, at best, a tad inconsistent.
I suspect someone may point that out.