Andy Cowper: An Act for NHS reform, but an argument over the bill for social care

In his first column for CSW, health policy expert Andy Cowper reviews Simon Stevens’s Whitehall legacy, and considers the changes being wrought by the new round of health reforms the NHS boss authored
Simon Stevens Photo: Alamy

By Andy Cowper

19 May 2021

It’s a pleasure to start a new regular column on health and care issues for CSW. Health policy is possibly the most high-profile area of government spending, and this isn’t surprising – the NHS is the one public service that we can all imagine ourselves needing to use in the future.

This feels timely, too: the health bill in the Queens’s Speech (the leaked text of which I published back in February) promises some major changes to how the NHS will operate. The biggest of these is that the health secretary will explicitly be “taking back control” of NHS England, with the ability to issue operational directions and intervene earlier in reconfiguration decisions.

There is A Lot Of Change coming in these sectors. This may not feel like reassuring news for a civil service that has only recently emerged from the threat of a “hard rain” from the PM’s former chief adviser Dominic Cummings. A persistent drizzle of change may be the best we can hope for, but worse forecasts are not unrealistic.

This is under a Government which is justly not famous for its command of detail: the reinvention of a prime minister’s delivery unit (to be led by NHS England’s chief commercial officer and vaccination programme leader Emily Lawson, on secondment) may in time help with this.

However, this re-born PMDU’s effectiveness will be governed by the PM of the day. PM Boris Johnson’s capacity and hunger for operational detail are perhaps not the qualities one first notices about him.

Towards social care reform (very, very slowly)

Social care is rising up the reform agenda, albeit with a level of political hesitancy and timidity that makes DHSC feel more like the Department For Health But Social Care.

The prime minister’s promise in his first speech in Downing Street to “fix social care once and for all” has not yet been transferred into legislation, with the Queen’s Speech instead saying that proposals on social care reform “will be brought forward”, although legislation is planned to allow the NHS to “innovate and embrace technology”.

We hear that the PM has become attracted: this time, not to pole-dancing, grant-winning tech entrepreneur Jennifer Arcuri, but rather to the Dilnot Commission’s 2011 proposals for social care reform.

A mere decade in the waiting. Nobody could accuse this government, nor its three predecessors, of rushing social care reform. The PM loves Latin quotes: “festinare lente” (more haste, less speed) must be its social care reform motto.

Senior hands will recall that former Conservative chancellor George Osborne raised Dilnot’s suggested £35,000 “cap” level to £72,000 and deferred implementation until 2016, and then until 2020.

The Treasury is hitting back with the notion that the cap/floor arrangement, if set at around £100,000, will reward high-value house owner-occupiers in the south, while potentially taking the entire estate of less high-value house owner-occupiers in areas such as the “Red Wall” seats that gave the current government its commanding majority.

Which promise to break?

The Treasury are also arguing that if this goes ahead, they will need tax rises to fund its likely £8-10 bn annual costs. This, they further argue, will breach their 2019 manifesto promise not to raise taxes.

Which promise to break? It’s a question with which the prime minister is not unfamiliar.

Enter the new health bill, exit Sir Simon Stevens

The new health bill is about 95% written by the outgoing NHS England boss Sir Simon Stevens, who compiled a list of legislative requests for the government.

Stevens was in large part hired to take health off the government’s agenda after the high-profile political disaster of the Andrew Lansley reforms that became the 2012 Health And Social Care Act. He achieved this largely by ignoring the market mechanisms of choice, competition and clinical commissioning, that the act enshrined in law.

Not only did he do that (largely unnoticed at the time), Stevens also twice won multi-year increases in NHS funding during the period of public sector austerity, in 2014 and 2019. His political acumen and understanding of the workings of Whitehall were central to those achievements.

Sir Simon began his career in NHS management. He moved into politics as a special adviser to Frank Dobson (New Labour’s first health secretary); then to Dobson’s successor Alan Milburn; and finally to Tony Blair in Downing Street. Stevens was significantly influential on New Labour’s health reforms and spending increases, and on the reintroduction of market mechanisms, the national tariff and the creation of semi-autonomous NHS foundation trusts.

The two Stevensisms

The aim of New Labour’s NHS market mechanisms was less ideological, and more about increasing NHS activity and capacity. This wasn’t just about the funding increase, though that was huge: 6% real-terms year-on-year cash growth from 2000 to 2010.

Long waiting lists developed over the 1990s meant that average waits for some operations were 18 months or more when New Labour came to power, and trolley waits in A&E were measured in days.

To achieve their promise of reducing this to 18 weeks, the NHS needed greatly-increased activity from providers. Tariff payments were designed to incentivise this.

Foundation trusts were allowed to keep their financial surpluses, and to borrow to expand over a balanced multi-year period. The national tariff was introduced to prevent competition on price negatively affecting quality and safety. Additional private sector capacity for procedures of limited complexity was commissioned from overseas firms in the Independent Sector Treatment Centre programme (anecdotally, the ‘threat’ of a new ISTC was sometimes enough to get local trusts to up their activity).

Measurement of performance and waiting times was taken seriously by the PM’s Delivery Unit, and the NHS Modernisation Agency was created to stop the sharing of best practice from being optional; also, to support the spread of good and effective ideas.

Combined with a new publication of explicit performance ‘league tables’ by the Care Quality Commission’s forerunner bodies the Commission for Healthcare Audit and Inspection and then the Healthcare Commission), and some elements of patient choice, this amounted to Stevensism Mark One. It achieved many of its aims, as independent evaluation by the Kings Fund think-tank showed.

Stevensism Mark Two was born into a very different public sector. Although he won the NHS slightly preferential financial treatment, the period from 2010 to 2019 was the slowest sustained period of financial growth in the NHS’s history.

Returning in 2014 from running United HealthCare in the USA, having been invited to apply for the job by PM David Cameron, Sir Simon saw the writing on the wall: that the market mechanisms, which the 2012 Lansley reforms proposed turbo-charging, did not stand a chance of working. This was due to a lack of funding, capacity and critically, workforce training (initially cut following the 2006 overspending crisis that did for then-NHS CE Sir Nigel Crisp, and then cut further under the £20 billion ‘Nicholson Challenge’ foisted on Crisp’s successor and NHS England’s debut CE, Sir David Nicholson).

A change of approach was needed: Stevensism Mark Two was born.

Sir Simon accordingly preached the virtue of greater co-operation and integration between the sectors of the NHS, and between the NHS and social care.

The aim to make all NHS trusts into foundation trusts was dropped. Commissioning was quietly sidelined. The purchaser-provider split of ‘commissioning’ was essentially redundant. Local ‘integrated care systems’ were invented (with no statutory basis whatsoever). Planning of the NHS system was very definitely back: RIP the market.

Waiting lists would quietly be allowed to grow and grow: a problem for a later date. Likewise funding, with an underlying deficit concealed as best as possible. His 2014 Five-Year Forward View and 2019 NHS Long-Term Plan painted these approaches in a logical long-term strategy which avoided frightening the political horses of government by not really mentioning it in excessively clear terms.

By 2019, the outsourcing of health policymaking to Stevens was so complete that the government asked him to come up with proposals for legislation. He obliged. Integrated care systems were to become real by legislation. Compulsory tendering of NHS contracts was to be dropped.

His seven years in charge have been remarkable. Stevens’s political skills and peerless command of his brief, combined with strong media presentational ability, left him seemingly above the fray.

His tenure has not been without turbulence or criticism. The highly Stevens-centric control-freakery and focus of NHS England prompted accusations that he is not a team player. The lost Brexit referendum removed the Blairite-loving Cameron and Osborne, who valued him highly.

Mrs May’s arrival as PM brought us an austerity believer who knew very little about the NHS, whose advisors Nick Timothy and Fiona Hill sought fights with Stevens about his being ‘insufficiently attentive and responsive’. Stevens won those fights without getting out of second gear.

Sir Simon’s unabashed use of the 2012 act’s legal independence for NHS England also annoyed both current health secretary Matt Hancock and the prime minister, Boris Johnson, at various points. (Both had, of course, voted for it at every reading). Thus we can understand the new health bill’s plans for the secretary of state to “take back control”.

Explicitly ‘taking back control’ is not without major risks. To name a few:

  • The NHS has an underlying deficit.
  • There is still a workforce crisis in many areas.
  • The current estates backlog maintenance bill runs to £9 billion.
  • Social care is in a mess, which causes delayed discharges of frail older people from NHS hospitals, reducing their possible rate of activity.
  • The current NHS waiting list is at its longest since records began: nearly 388,000 people have waited more than a year to start treatment, and about 4.7 million people are now waiting for hospital treatment, the highest number since at least August 2007.

All were huge problems before the Covid19 pandemic: it has made them worse, and also exhausted and potentially traumatised many NHS staff.

Fixing these problems will cost serious money, and it will take years.

And we do not live in patient times.

In the language of Jay and Lynn’s classic comedy ‘Yes, Minister’, it will be a “courageous” move for our current crop of ministers – Health, Treasury and Prime – explicitly to take away ‘the buck stops here’ sign from the executive offices of NHS England.

In the words of the infamous Chinese curse, ‘may you live in interesting times’.

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