Architect of the coalition-era NHS reforms Lord Andrew Lansley has spoken of his regret at the loss of civil service policymaking expertise that occured between his time as a departmental offficial in the 1980s and when he became health secretary.
Lansley also said he believed the creation of NHS England and the establishment of 10-year plans for the health service would be the lasting legacy of his controversial Health and Social Care Act 2012. But he acknowledged he had tried to achieve “too much, too fast” and that the reforms were only fully understood by him and one other member of the government.
In a just-released interview for the Institute for Government’s Ministers Reflect series, Lansley said he had seen significant changes between his time as a civil servant at the Department for Trade and Industry – where he was a private secretary to Norman Tebbit – and as a top minister.
He lamented the loss of institutional knowledge and sharp-thinking generalists in departments that he said had disappeared by the time he entered the Department of Health as its secretary of state in spring 2010.
“In my day, which is of course 20 years prior to this, the strength and depth in the civil service was such that in most key policy areas, it was possible to have both a senior civil servant who knew that policy and had worked in that policy area for much of their career alongside fast streamers coming in to do policy reviews, so the two could work in harmony,” he said.
“By the time I came into government, there were a diminishingly small number of really bright people who had been moved around from problem to problem and were seeing it for the first time. In the old days, the combination of somebody who really understood the policy and the practicalities with somebody who was a really good policy analyst seeing it for the first time was absolutely the right combination. But I don’t think the civil service has that anymore.”
Lansley acknowledged that his experiences were based on his time at the DTI, where there were a range of people with strong industry knowledge and who had worked in the sectors they were advising on.
“I had people alongside me who really understood this stuff, and that isn’t how it seems to work now any more,” he said.
Civil service ‘obsessed with control’
Lansley said the creation of NHS England was the main legacy of his coalition-era health reforms, but he complained that the reforms themselves had to be carefully piloted past an “enemy within” of NHS managers at the Department of Health. He said many of those staff are now part of NHS England and appear to want to run the department.
“NHS England has become so obsessed with its own powers that it’s decided the only way to manage anything is to acquire control of everything,” Lansley said.
“Because the civil service, and indeed public servants generally, are obsessed with control, they are not obsessed with outcomes. And what I wanted them to do was to focus on outcomes, which would mean they would hold people to account for the outcomes but not necessarily make themselves the owners of all of these providers. That’s, of course, what they wanted to do.”
Lansley said that during his time at the helm of DH, from June 2010 to September 2012, many senior positions were occupied by NHS managers, who were not supportive of the government’s health proposals.
“They hated it all. They hated the reforms; they were the enemy within,” he said. “They saw the reforms as handing power to clinicians, and by extension removing jobs and control from the hands of the NHS management.
“I had to negotiate aspects of the reforms with [then-NHS chief executive] David Nicholson in order to keep him on board, and to keep the NHS managers on board, in order to keep the programme for implementation on track.”
Lansley said the continuation of commissioning support units and the form that commissioning support units took had been a direct response to “Nicholson protecting his own people in the NHS and in strategic health authorities”.
The former health secretary said his principal takeaway from that situation was that the civil service should not allow other professions to come in and run policy.
“Civil servants should run the policy,” he said. “I say that as a former civil servant, but I think there is a professional discipline to which civil servants adhere which appears not to be recognised or understood sufficiently by other professions.”
Too much, too fast
In his IfG interview, Lansley acknowledged the confusion that surrounded his reform programme, because of its complicated nature. He said that with the exception of himself and junior health minister Lord Frederick Howe, “nobody else much understood it”.
“On reflection, I tried to do too much, too fast,” Lansley said. “I was trying to shift the whole focus of the department from the management of the NHS into becoming a department for public health. Which, actually, when you look back at it now, was the right thing to do.
“I was about the only secretary of state who’s ever tried to do it, and in large measure I failed because all my successors have so far been obsessed with the management of the NHS.”
Lansley said that from the government’s perspective, NHS England has been “an enormously successful” innovation.
“It has taken control of the NHS, albeit it now wants to be a monopoly operation, it actually is the commissioning side, and it does hold providers to account now in ways that the Department for Health was never capable of doing, where the providers were always playing political games,” Lansley said.
“They can’t play political games with NHS England because, unlike ministers, they don’t come and go. They can set a 10-year strategy. In 2019, they published a 10-year plan. The NHS has never had such a thing before. NHS requires NHS workforce plans, and they’ve never had one before, and NHS Education, and now NHS England working with NHS Education, will develop that. A 10-year plan for the NHS will be a striking long-term change for the NHS, and that will be the principal legacy from the 2012 act.”
Lansley suggested that future health secretaries will be grateful to be relieved of the day-to-day responsibility for operations that the establishment of NHS England represented.