David Oliver: Why would Number 10 propose an NHS power grab?

On 10 July the Guardian’s Denis Campbell headlined with “Boris Johnson plans radical shake-up of NHS in bid to regain more direct control.”1 He reported that the UK prime minister’s “health and social care taskforce” was “drawing up proposals that would restrict NHS England’s operational independence” and curtail the freedom of its chief executive, Simon Stevens, to make key operational and strategic decisions about the health service. The taskforce would set out options for action, with a view to a parliamentary bill in the autumn or, as the HSJ now suggests, in 2021.2

Maybe the noise will amount to nothing. But why do this now, and why do it at all?

For the NHS itself the timing couldn’t seem worse.

The final outcomes of a negotiated Brexit deal, or its implications for the NHS, remain highly uncertain and worrying.3 Brexit will preoccupy large numbers of officials also counted on for the proposed government power grab.45

We are still trying to rebuild normal elective work streams after the first wave of covid-19, while preserving enough spare capacity and ability to respond quickly to a second pandemic wave.67 Shop floor clinicians and managers have their hands full.

The timing could look good only through the lens of party political spin doctors. In mainstream media and opinion polls the prime minister, cabinet, and Boris Johnson’s chief adviser, Dominic Cummings, are being widely blamed for deficiencies in the response to the pandemic in England, and opposition leader Keir Starmer’s star is rising.

Organisations such as Public Health England and NHS England have attracted criticism for their pandemic response in the specialist healthcare press, including The BMJ.8 And Campbell’s Guardian reports suggest that Number 10 does blame them, or wants to, for failings in our pandemic response.9

But NHS England is not responsible for testing and the procurement of personal protective equipment. Public Health England is, but as an executive agency of the Department of Health and Social Care it is already accountable to ministers. The public’s appreciation of the efforts of frontline NHS and social care staff has grown during the pandemic.10 Blaming the NHS might seem a convenient reputation saver for Number 10, but it would be a public relations disaster, as proved by the outrage over Johnson’s recent attempts to blame care home staff for covid-19 outbreaks.11

As to the reasons why, well, there are probably four years until the next election. Even before the pandemic Johnson had made highly contested pledges on NHS capital expenditure, new builds, and nursing numbers.12 The chancellor has since given the NHS several billion pounds more on top of the existing five year funding uplift pledged during the last parliament conditional on NHS England’s 10 year plan.131415

The Treasury and Number 10 will always be frustrated if they find that any additional funding they commit to key public services is contingent on performance improvement and efficiency gains over which they have little control. Before the 2012 Health and Social Care Act the NHS chief executive was a civil servant and so was nominally easier to direct and control.16

Stevens has proved an independent, politically shrewd operator who is unafraid to challenge the government or put his own stamp on services, and ministers are frustrated at having to get any change in the NHS done through him.

But if the government does reverse the current arm’s length status of NHS leadership by legislation, then attempts to blame officials and senior managers will no longer wash. And if career health service professionals can’t deliver change and good news stories at the pace Number 10 would like to see, what price cabinet ministers with no relevant expertise?

This can’t end well.