The story of NHS England: the world’s biggest quango

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NHS England was established in 2013 as part of the sweeping changes contained in the Health and Social Care Act 2012. Known originally as the NHS Commissioning Board, NHS England is responsible for overseeing the commissioning of NHS services and it operates alongside a number of other national bodies including NHS Improvement, Public Health England, Health Education England, the National Institute for Health and Care Excellence (NICE) and the Care Quality Commission. Former Health Secretary Andrew Lansley intended that NHS England would operate at arm’s length from government under a rolling mandate agreed with ministers. Lansley was so convinced of the merits of his changes that he enshrined them in law.

A new study by Nicholas Timmins, commissioned by the Institute for Government and The King’s Fund, tells the story of NHS England in its first five years. It shows that in many respects the way in which the 2012 Act was implemented was quite different from the intentions of its architects. Drawing on in-depth, and for the most part on-the-record, interviews with the principal protagonists, the study describes how Jeremy Hunt, as Health Secretary, has maintained close involvement in the day-to-day running of the NHS through his Monday morning meetings with the leaders of national bodies and other channels.

The study also demonstrates that, notwithstanding the continuation of the political micromanagement of the NHS that Lansley had sought to end, NHS England asserted its independence from government as financial and operational pressures on the NHS increased. Under the leadership of Simon Stevens, appointed as Chief Executive in 2014, NHS England spoke out privately and publicly on the impact these pressures were having on the NHS. And unusually for a public official, albeit one who was accountable to an independent board and cannot be sacked by ministers, Stevens challenged the government to either increase funding or be honest in recognising the consequences for patient care.

With the 70th anniversary of the NHS approaching, there is no doubt that they are united in their commitment to get the best possible settlement in the face of push back from the Treasury. NHS England’s independence is real even though, paradoxically, politicians remain closely involved in the operation of the NHS.

In Timmins’s account, Stevens took on the mantle of Health Secretary with Hunt acting more like the NHS’s chief operating officer. Hunt and Stevens are now making the case for substantial and sustained increases in NHS funding as the government decides how to fulfil the Prime Minister’s recent commitment to a long-term funding settlement. With the 70th anniversary of the NHS approaching, there is no doubt that they are united in their commitment to get the best possible settlement in the face of push back from the Treasury. NHS England’s independence is real even though, paradoxically, politicians remain closely involved in the operation of the NHS.

How to explain this paradox? Timmins advances several plausible explanations, including the difficulty of separating policy from operations, the way in which behaviour trumps legislation, and the fact that personalities matter. Jeremy Hunt, in his interview which is cited at length, emphasises the importance of two forms of accountability: his own to parliament and the accountability of national bodies to the Health Secretary. Discharging these accountabilities meant that Hunt felt he could not work only through the mandate agreed with NHS England, especially when leadership of the NHS at a national level is fractured between NHS England, NHS Improvement and many others.

According to Hunt’s interpretation, the Health Secretary has a key role in bringing together the leaders of national bodies to recreate the single national view of the NHS that was lost as part of the huge collateral damage caused by the 2012 Act. One of the interviewees puts the point more colloquially in likening the process to putting Humpty Dumpty back together again after his fall, although reconstruction is not proving easy as moves to align NHS England and NHS Improvement show. The continuing close interest of the Prime Minister and the Treasury in the performance of the NHS also helps explain the difficulty, perhaps even impossibility, of the Health Secretary distancing himself from operational matters.

For as long as the NHS accounts for such a large share of public spending, and the public rate the NHS as an issue that matters greatly to them, there will be limits to how far politicians can delegate their responsibilities to others.

If personalities matter as much as this study suggests, then other occupants of the roles of Health Secretary and NHS England Chief Executive might have discharged their responsibilities differently. Time will tell but it seems hard to believe that the fundamental institutional forces at work would not have had a similar effect to the one that became evident in the early years of NHS England. For as long as the NHS accounts for such a large share of public spending, and the public rate the NHS as an issue that matters greatly to them, there will be limits to how far politicians can delegate their responsibilities to others, especially at a time of constant and often intense media scrutiny.

The twist in the tale is that the attempt to do so has had consequences revealed in fascinating detail in The world’s biggest quango. It is a tale that has as yet no clear ending but some of the lessons for students of public service reform are already clear. The most significant in my view is to beware politicians who come bearing solutions that promise permanent change that will resolve the challenges of the NHS once and for all. The case for pragmatic, problem-solving, incremental reform shines through brightly, albeit indirectly, in this story which should be essential reading for anyone responsible for or interested in the stewardship of the NHS. Now more than ever those leading the NHS need more humility and less hubris.

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