At the end of May, NHS England announced that dentists could re-open as of the start of next week. The decision was not made by Ministers. It was not even cleared by them. Almost immediately, dentists themselves began to protest that they didn’t have the personal protective equipment necessary in the time of Coronavirus.
But NHS England didn’t get the consequent kick in the teeth. Ministers did, because they’re held responsible for what happens to health services, regardless of whether or not they have decision making-powers. And Boris Johnson, Matt Hancock and Dominic Cummings have had enough of it.
Stand ready for the most remarkable change in NHS policy for over 30 years – and a U-turn on what has been the trend in healthcare policy-making during that period. Its core principle has been to stress competition rather than co-operation.
Enter the first of the three main actors: Ken Clarke. In 1988, with the health service’s finances, as so often, in deep trouble, the then new Health Secretary came up with the idea of dividing the two, and putting purchasing power in the hands of doctors themselves. He drove GP fundholding through his party and Parliament.
Travel on to the New Labour era, and meet our second player: Alan Milburn. A Blairite reformer, he adapted the concept of foundation hospitals from Spain, envisaging NHS trusts with managerial and financial freedoms. The Coalition abolished their private patients income cap, but they must do most of their wok for the NHS.
That era brings us to our third figure: Andrew Lansley. David Cameron thought that his first Health Secretary would deliver evolutionary change. Instead, he aimed for radical reform: “a reorganisation so big you can see it from outer space,” as David Nicholson, then NHS Chief Executive, put it.
Despite a Liberal Democrat revolt and a humiliating “pause” to his legislation, Lansley got much of what he wanted – including the elements that now so frustrate Johnson and Hancock. The former Health Secretary envisaged politicians removed from the day-to-day management of the NHS.
Hence NHS England, its powerful Chief Executive, Simon Stevens – and the dentists’ episode that we report above: only one instance of many in which Ministers feel they have been let down by NHS institutions during the Covid-19 outbreak, especially over a quick national roll-out of testing.
But it’s important to grasp that the frustration of Ministers with the system hasn’t simply been sparked by the Coronavirus. Jeremy Hunt presaged their discontent – operating with an A1 piece of paper pinned to his office wall detailing that week’s NHS “never events”: serious mistakes with patients that should never have been made.
Hunt had an activist view of the Health Secretary’s role, writing on this site three years ago about how he introduced a programme of “Ofsted-Style ratings and special measures into the NHS”. But he was forced to operate within the framework that Lansley had established.
Then came Hancock. His period at the Department of Health has been so consumed by the virus that it’s easy to forget he was there before it came – indeed, that he was in place before last December’s election. Which is when he took up the Health Select Committee’s cry of “collaboration not competition”.
Hancock threw his support “behind an integrated commissioning framework which prioritises collaboration rather than choice and competition”, according to one report last October. “We have to make it easier for people to work together across the siloes,” he said.
So there is a bit of recent history to reports that the Prime Minister wants Ministers to “regain much of the direct control over the NHS they lost in 2012” – in other words, as a consequence of the Lansley reform. A taskforce is meeting. A Bill is planned. Even foundation status may go.
We doubt that last will happen – but Johnson, Hancock and Cummings will want to get a move on. The fear in Number Ten is that the Coronavirus will ebb during the summer, but return during the winter – and that the Government will once more get it in the neck, as they see it, for mistakes not of their making.
“Bevan said that ‘the sound of a dropped bedpan in Tredegar should reverberate around the Palace of Westminster’. But the problem is that when NHS England drops it, Ministers get the blame,” one source told ConservativeHome.
That suggests legislation fast. This site is all for public service reform – a theme absent, on a large scale at least, from Michael Gove’s recent speech about change among civil servants and Ministers. But it would come in this case with at least two consequences.
First, Labour will attack any significant change as “Tory privatisation of the NHS”. Never mind that Milburn’s changes were written up at the time as “a sort of halfway house between the public and private sectors”. Or that the reforms the Government wants sounds suspiciously like…Jeremy Corbyn’s manifesto.
“We will repeal the Health and Social Care Act and reinstate the responsibilities of the Secretary of State to provide a comprehensive and universal healthcare system,” it declared. But what Johnson actually does will make next to no difference. A Bill will also risk hostility from the doctors’ trade union, the British Medical Association.
Second, major structural reform of the system, entirely absent from last year’s Conservative Manifesto, will also come under fire from the Prime Minister’s right – at least if it is structured in the way that the leaks and briefings from government suggest.
Central control of the system is the problem, not the solution, the right-wing thinks will queue up to argue. And they will have a point. If we want a more responsive healthcare system, don’t we need a more mixed, better funded, locally-led one – like Germany’s, Andrew Gimson has argued on ConservativeHome.
Back in Downing Street, Johnson and Cummings won’t mind at all if free marketeers, libertarians and classical liberals line up to roast their ideas. For if the Government becomes seen as the champion of the NHS, they will think, so much the better for its electoral prospects.
More money for the health service, an Australian-style immigration points system, and tax cuts for lower paid workers have long been a Cummings triple theme, together with more funding for the police. Not to mention a curb on abuses of security and control claimed in the name of human rights and delivered by judicial review.
Johnson’s own recent health history, suffering with Covid-19 in an intensive care ward, sets him up credibly as a defender of the Bevan’s creation. The claim that the Conservatives are reinventing themselves a populist, Brexity Hezza-type, Red Wall-friendly party needs no introduction. Here is the latest manifestation of taking back control.