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Good morning. All change at the top of NHS England, and change too in how NHS England operates. The head, Amanda Pritchard, is leaving her post — and the major reason is that Wes Streeting, the health secretary, wants to change what the institution does.
The important prologue to what Streeting is trying to do is what Andrew Lansley did back in 2012. His Health and Social Care Act, which blindsided Downing Street at the time, changed healthcare in England significantly, and every health secretary since has been managing the aftershocks. What is Streeting’s approach and will it work? Some thoughts on that below.
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New lease of life
How do you solve a problem like the Health and Social Care Act? That’s the problem that successive secretaries of state for health have struggled with since Jeremy Hunt was appointed to the post in the autumn of 2012 with, essentially, a brief of ‘don’t open up all that unpleasantness again’, all the way to Wes Streeting taking office in the summer of 2024 with a brief of ‘we aren’t going to get re-elected if we don’t get better outcomes from the NHS’.
The problem — in the eyes of many Conservatives, at least — is that Andrew Lansley ripped up the internal market (which was introduced by Ken Clarke, and scrapped by Alan Milburn when he was a junior minister before New Labour realised it worked quite well and promptly reintroduced it two years later, leaving a mess in its place). Hunt, Matt Hancock and Sajid Javid all tried to work around it in one way or another. (If you want more on this, Hunt’s interview with the Institute for Government about his approach is well worth your time.)
The complaint that successive health secretaries have had is, ironically, the same as the one that frontline NHS workers have: that it created this weird, unhelpful structure called NHS England. Time and time again, I hear from people who work in the health service that much of their job involves providing “fake reassurance” for NHS England. Frustration is common in the centre too. All it has done is create unnecessary layers between the department and the people and organisations that actually provide healthcare in England.
Under Rishi Sunak — and, as I understand it, under Keir Starmer — this was a particular pain for the adoption of machine learning and digitisation in the NHS. i.AI, the government’s attempt to develop in-house competence in artificial intelligence, would struggle to actually talk to people on the frontline or get useful feedback.
One consequence of this has been that ministers have responded to their lack of direct control by increasing the number of targets for the NHS in England, further increasing the amount of “fake reassurance” — and on it goes.
The thing that frustrates health ministers the world over is that once you give people some form of free at the point of use healthcare, voters become really reluctant to change or improve it, and everything has to be done via the structure you’ve inherited. There is not much that most countries envy about the NHS, but one thing that comes up time and again is that its size, and its in some ways overly-centralised nature, mean that it is well-placed to draw investment from and take advantage of changes in pharmaceutical research, uses of big data in healthcare and uses of AI. But that first requires you to do something about NHS England.
The trade-off for ministers is that if you scrap all or part of the Health and Social Care Act, you have to go through a period of lengthy reorganisation without much immediate policy reward. What Streeting is trying to do with NHS England’s new chief, Sir James Mackey, is essentially reform the body into an almost entirely different, much slimmer organisation.
That’s why Mackey has the rather goofy sounding title of “transition CEO”: the plan and hope is that he can create a leaner body that essentially acts as an improvement mechanism for the wider NHS, rather than a body that feels like it micromanages you on the frontline and disempowers you at the department for health.
Streeting will hope to get the benefits of replacing it without losing the momentum and energy needed to hit the NHS improvement targets Labour must deliver on if it wants to have any chance of being re-elected.
No one is ever told what would have happened, and Streeting’s middle way — his third way, perhaps — looks to me worth trying. But he may yet end up, like so many of his Conservative predecessors since 2012, leaving office cursing the name of Andrew Lansley and the Health and Social Care Act.
Now try this
I went to see the Manchester Museum’s new gallery, which was curated in collaboration with the British Museum. It’s an absolutely terrific account of the city’s long relationship with China. The museum as a whole is an absolute jewel since its renovation, and I cannot recommend enough going to the late-night opening on Wednesday, when it closes at 9pm. I was able to read the captions and potter around it to my heart’s content. (I am here to work, honest.)
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