The health department and the NHS: time to separate?BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4881 (Published 19 November 2009) Cite this as: BMJ 2009;339:b4881
All rapid responses
I welcome Nigel Crisp’s personal view and it was most refreshing that
it was based on firsthand experience of actually running the service (1).
What he describes is separating the running of the NHS from what he calls
‘the wider political issues’, which are really the wider public health. I
have been arguing for years that it was time to separate the NHS from
direct government involvement (2). I stressed the word direct for all the
reasons that Nigel Crisp describes as the difficulties of total separation
from politics. Hence the model I suggested and continue to campaign for
is that politicians should share it with each other and with the main
stakeholders in a truly democratic representation of our society (3).
What it means for example is that if the political commentators are right
and we have a conservative government next year and they decide to adopt
the model, they will have to elect two senior MPs with the best experience
in health matters; one to be a member of the new NHS National Board and
one who will be responsible for public health in charge of the Department
of Health dealing with the wider health issues Nigel Crisp described in
I argued for an elected MP from the main political parties to sit
alongside elected representatives from NHS staff and patients’
representative on the NHS Board. In my view, this will be the only
insurance against instabilities, vacuum around elections and jolts of
direction change with change of governments without totally losing the
political angle. The Board will continue to function effectively at all
times and the direction will only change if the majority votes for it.
Nigel Crisp rightly suggests that the department and ministers will have
difficulty in distancing themselves from the NHS, but in the model I am
suggesting they are actually partners with other legitimate stakeholders
but are in total charge of what impact the health of our people. Hung
Parliament leading to coalition between political parties has occurred in
the past and in recent history so sharing government is not a new idea.
What is new in this model is an altruistic vision and an acceptance with
humbleness of the reality that government cannot run the NHS by itself and
it needs the legitimate others.
What remains is for policy makers, senior researchers and academics to
seize the opportunity to argue and campaign for this change because the
time is ripe. The Conservative Party is for the first time arguing for
an independent NHS board although I have strong misgivings about the other
parts of their manifesto which is unfortunately similar to Labour’s in
England and that is the competition mantra. Competition means winners and
loser and we cannot allow losers in the NHS if we are truly pursuing the
equality in health agenda because they are usually serving the most
deprived areas of our society and even though competition may lead to some
improvements it usually plateaus and is never the answer.
So finally, my advice to the Conservative Party is to campaign for this
model because I believe that it is a great vote winner.
(1) Crisp Nigel. The health department and the NHS: time to break
free? Personal View. BMJ 2009;339.1203.
(2) Jader Layla. It is time to separate the NHS from direct
government involvement. Personal View. BMJ 2006;332:1518.
(3) Jader Layla. Is there any altruistic political leader who will
take us to the 21st Century? Rapid Response. BMJ.Com 19 November 2009.
Competing interests: No competing interests
As a doctor I welcome Crisp's proposal (1) and would suggest he might
draw the distinction he suggests even more sharply. The NHS has long been
misnamed being really an illness treatment service rather than a health
service. None of the NHS, the profession or the government has ever
committed itself to a coherent view of health (2) or its achievement. We
currently have a UK health discourse that focuses on costs, risk, stress,
pathology and treatment, and which regards absence of disease as a
sufficiently good health outcome.
We have little discourse about what a healthy life is, or how to
cheerfully boost resilience (3), rather than dutifully putting up with
stress. We have little idea of what a good death (4) might be, and how it
fits in as a necessary part of life. We have not yet made the full use of
the concept of salutogenesis. (health generation) (5)
Perhaps the separation we need to make is between remedial medical
work which treats disease, and salutogenesis (health generation) which
tries to nudge (6) people towards greater health.
The remedial task is important task for reasons of basic humanity- we
need to relieve each other’s suffering. Medicine is actually focused on
this task, and it is what medicine is really about. There is no shortage
of work under this rubric. An illness treatment service of some sort will
always be necessary.
Perhaps what we need is a Department of Illness that deals
specifically with pathology working alongside a Department of
Salutogenesis that deals with health generation and aiming towards health
individuals in healthy life contexts. I am not sure that the two functions
sit well under one department as they try to do currently in the DH.
As individuals and as a society we would need different inputs from
each department over our life course, and both departments would have much
useful work to do.
1. Crisp, N (2009) BMJ 2009; 339:b4881 The health department and the
NHS: time to separate?
2. Davies, P (2007) Between health and Illness Perspectives in Biology and
Medicine, volume 50, number 3 (summer 2007):444–52
3. Siebert, A. 2005. The resiliency advantage. San Fransisco: Berrett-
4. Smith, R (2000) A good death BMJ ;320:129-130 ( 15 January )
5. Antonovsky, A. 1987. Unravelling the mystery of health: How people
manage stress and stay well. San Francisco: Jossey-Bass.
6. Thaler, R. H. and Sunstein, C. R. (2008) Nudge:Improving Decisions
About Health, Wealth, and Happiness
Competing interests: No competing interests