Intended for healthcare professionals

Observations Health Policy

Musical chairs in the NHS leadership waltz

BMJ 2019; 364 doi: (Published 13 March 2019) Cite this as: BMJ 2019;364:l1093
  1. Andy Cowper, editor, Health Policy Insight
  1. London, UK
  1. andycowper{at}

Do the latest changes signify the end of internal competition in the NHS?

Plans for NHS England and NHS Improvement to work more closely together are worth taking some time to understand.

The NHS Commissioning Board, which likes to call itself NHS England, represents NHS commissioning, planning, and provision. Monitor and the Trust Development Authority, which call themselves NHS Improvement, represent the NHS provider sector.

The intention to draw NHS England and NHS Improvement into far closer cooperation was first formally announced in March 2018.1 Last week a joint meeting of the two national arm’s length bodies announced their requests for parliament to make a range of changes to remove a range of competition aspects from the parliamentary legislation affecting the NHS.2

Change of strategic direction

This move follows the decision of NHS England’s chief executive, Simon Stevens, to change the strategic direction of NHS policy. Stevens used his 2014 Five Year Forward View to move NHS policy away from competition and choice mechanisms.3 These mechanisms were embedded in the reforms of the 2012 Health and Social Care Act. That act created the NHS Commissioning Board and the Trust Development Authority, and it significantly expanded Monitor’s role.

Readers interested in NHS politics and policy may already have spotted an irony in the fact that Stevens’s previous work as an NHS special adviser to Labour in the early 2000s involved using choice and competition methods to help drive down waiting lists. Asked about this irony at last week’s Nuffield Trust summit,4 he answered with the economist John Maynard Keynes’s classic line that “when the facts change I change my mind.”

Stevens suggested that the NHS’s problems of the early 2000s had called for more activity and more staff, in an environment of a strongly growing UK economy funding an increase in public spending. Today the NHS needs to work in a better integrated way to improve care for people with multimorbidity and frailty, to tackle inexorable demand growth and demographic pressure.

He now regards the 2012 act’s reforms as having greatly overemphasised competitive tendering for changes as minor as getting an extra 90 minutes of GP service in one city—an example he cited of a change that had triggered a full competitive procurement.

Stevens is now leader of NHS England and NHS Improvement.5 NHS Improvement will carry on legally existing for the time being, but its chief executive will become its chief operating officer and will report to Stevens.

This is largely a human resources statement of the obvious. Stevens has dominated NHS politics and policy since his appointment, partly because of the political trauma caused by the tortuous passage of the 2012 act. A bigger part has been played by his shrewdness and effectiveness as a political operator and mobiliser of key opinion leaders. This shrewdness helped to get the government to agree a significant, if not sufficient, increase in the NHS budget for the next five years.6

He now takes on responsibility for solving the considerable deficit problem in the NHS provider sector, which is running at almost £4bn a year.7 And the National Audit Office’s latest report on NHS finances8 found that the path to sustainability won’t be clear until we know about this year’s government spending review.9

Harding v Prior

A fascinating subplot concerns which of the two current chairs will emerge victorious: NHS England’s David Prior or NHS Improvement’s Dido Harding. Both are Conservative peers, although Prior agreed to resign the Conservative whip in the Lords, whereas Harding refused to do so.

Prior has chaired an NHS hospital trust and the Care Quality Commission, giving him long experience in NHS issues and politics. He has a longstanding reputation for moments of being highly outspoken on NHS issues and reforms.10

Harding has a management consultancy and business background, having been chief executive of TalkTalk.11 A contemporary of David Cameron’s at Oxford, she is friendly with the former health secretary Jeremy Hunt and goes riding with the current health secretary, Matt Hancock.

She is also leading a review into NHS workforce issues,12 due to report this month, and has recently criticised NHS regulators for encouraging the wrong sort of behaviour.13 It’s all quite activist and operational stuff for a chair, which makes one wonder whether Harding would be interested in Stevens’s job if a vacancy arises.

Successful joint chairing between Harding and Prior seems unlikely, meaning that the “blue on blue” attacks we may soon start seeing—overly or covertly—could make for high scoring waltzes in the NHS leadership game of musical chairs.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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