The Guardian July 10 report suggesting Boris Johnson is planning a “radical shake-up of NHS in a bid to regain more direct control” has understandably triggered alarm in many campaigners, but also confusion on a number of levels.

A subsequent HSJ report largely contradicts the Guardian account, suggesting that the proposal for legislation originates not from Downing Street but from Health Secretary Matt Hancock – and that Downing Street has halted moves to push through legislation this summer and pushed it back to 2021, fearing the imminent possibility of a second peak of Covid-19 infection and a grim winter ahead.

The alarm at the Guardian version of events centres on the likely consequences of an  intervention by a government that is clearly led by Dominic Cummings, Johnson’s principal advisor, especially when the task force that the Guardian reports has been established to draw up proposals for legislation includes Cummings’ and Johnson’s controversial health adviser William Warr.

Warr is an avid proponent of apps and digital solutions, an opponent of extra funding for the NHS, and an advocate of focusing “public health” initiatives towards younger people – as long as these do not include “sin taxes” on sugar, alcohol etc. – while dismissing the increasing numbers and health needs of older people as a major pressure on the NHS.

The Johnson government’s response to the coronavirus and Covid-19 has been a refusal to engage with existing public sector expertise or resource public sector providers, coupled with a turn to private sector consultancies and contractors including hundreds of millions of pounds awarded in no-bid contracts for supplies of PPE to small and completely inappropriate companies.

Private sector

Many campaigners fear that the same government gaining increased direct control over the NHS will lead to further rapid increases in the share of NHS spending flowing out to private companies.

The Guardian report does not mention more privatisation, but focuses on the arm’s length separation between the government (Department of Health and Social Care) and NHS England, whose chief executive Sir Simon Stevens is not directly accountable to Matt Hancock. This separation was established in law by the controversial 2012 Health and Social Care Act driven through by David Cameron’s government with key support from its Liberal Democrat coalition partners.

Now the Guardian suggests the task force is aiming to reverse this legislation, and “drawing up proposals that would restrict NHS England’s operational independence and the freedom Stevens has to run the service.”

However no tangible reason is given for this power-grab from the centre. The Guardian article quotes “a source with knowledge of the plans” as saying “[The health secretary] Matt Hancock is frustrated [by] how limited his powers are and wants to get some of that back.”

However there seems to be no rational explanation for this sudden change of line, or what powers Hancock/Johnson/Cummings are seeking to reclaim.

Under-funding

The issues that appear to be frustrating ministers and the Treasury (“The Treasury in particular is irritated that NHS treatment waiting times continue to worsen, and many hospitals remain unable to balance their budgets, despite the service receiving record funding”) are the result of a decade of deliberate under-funding and under-resourcing that had left the NHS short of beds and up to 100,000 staff, and almost doubled the size of the waiting list from 2.5 million in 2010 to 4.4 million at the end of 2019.

Other problems – the chaotic, largely privatised, test and trace system and shortages of PPE – are a consequence of the Johnson government’s own political intervention. Indeed as ministers have brought in consultants from McKinsey to try to sort out the shambolic test and trace system, the HSJ  points out that it is not run by NHS England, but by Matt Hancock’s own DHSC:

“McKinsey has been asked to explore the status and future shape of the organisation, potentially considering whether it should remain as a directly controlled DHSC agency; be given greater operational independence; or be merged into another DHSC arms-length body, such as Public Health England.”

In other words the government is already in charge – and to blame for the shambles – now.

Other changes which the Guardian cites as reasons for the Johnson power-grab are already being eagerly promoted by NHS England – and central to last year’s Long Term Plan.

Changes

These include  minsters’ “desire to make permanent some recent changes in NHS working, such as different NHS bodies working closely together, and the huge increase in patients seeing their GP or hospital specialist by video or telephone”, and turning “integrated care systems, which are currently voluntary groupings of NHS organisations within an area of England, into legal entities with annual budgets of billions of pounds and responsibility for tackling staff shortages and ensuring that the finances of its care providers do not go into the red.”

The reported Tory determination to “clip the wings” of Simon Stevens also lacks any obvious explanation. Stevens, not least because of his past record as an advisor of marketising reforms to Tony Blair in the early 2000s and subsequently an Executive Vice President of US health giant UnitedHealth, is seen by many on the left as a leading force driving privatisation.

For that reason the same campaigners have criticised almost any proposal Stevens has made, including last year when he and NHS England pushed for legislative changes that would unpick some of the 2012 Act, most notably removing the requirement to open increasing numbers of services up to competitive tender, and clearing the obstacles to integrated care systems that bring together commissioners and providers.

For Stevens now to become a target of hostility from the right wing Johnson government conflicts with this view, and the only explanation for the current stand-off between him and Matt Hancock seems to be Stevens’ willingness in the past to speak out, notably to the Commons Health Committee, against under-funding of the NHS.

Loggerheads

Early in 2017, for example he was reportedly at loggerheads with Theresa May for sounding the alarm over health funding and over his handling of the A&E winter crisis.

Also linked to waiting times, Stevens and NHS England appear to have clashed more recently with the Treasury – over their proposal to block book thousands of private hospital beds through to next spring at a cost of £5 billion, as a means to reduce the growing waiting list while not fully reopening thousands of NHS beds.

So with or without the involvement of Stevens, are some campaigners right to believe that the Johnson government’s proposed changes are in fact aimed at securing changes similar to the ones people fighting to reverse the 2012 Act seek to achieve?

Curbing the powers of NHS England and increasing the health secretary’s ‘powers of direction’ over it, “so that [Hancock] doesn’t have to try to persuade Simon Stevens to do something,” may seem similar to the demand of proponents of the NHS Reinstatement Bill to re-establish government accountability for the NHS by putting the Secretary of State back in charge.

Without seeing any of the task force’s proposals we can’t be sure what will be said or what it means in practice. But in 2020 Britain it’s arguable that the real power does not flow through parliament and is not held by the secretary of state, an elected MP, but is in the hands of the unelected Dominic Cummings.

Silencing critical voices

Only the terminally naïve can really believe it likely that the current centralising government so ruthlessly attempting to silence critical voices would combine the restoration of the powers of the secretary of state with extending local accountability of services that campaigners have been demanding.

The Guardian also suggests the government might bring forward legislation to abolish the foundation trust status introduced by Tony Blair in 2004, and a central plank of the 2012 Act “as part of a drive to give the DHSC more control over the day-to-day running of the health service.”

Campaigners fought a long campaign attempting to block the establishment of foundation hospitals, arguing that they would be even less accountable than NHS trusts to local people.

However foundation trust status and “freedoms” have now become largely academic in a hugely under-funded NHS burdened with hefty deficits: NHS England’s edicts and plans for integrated care systems largely ignore any distinction between NHS and foundation trusts.

More top-down DHSC control over foundation trusts would not satisfy the demands of campaigners: but it would put the government fairly and squarely in the firing line and visibly carrying the can for any failures and gaps in services. The 2012 Act gave ministers a way to duck responsibility, and blame local commissioners of providers – and NHS England – when things go wrong.

The King’s Fund and others have warned that for Cummings and Johnson to reverse that separation now, at a time of unparalleled crisis, with no sign that Chancellor Rishi Sunak is willing to give the NHS the extra funding it will need to go forward and restore elective and emergency services while retaining capacity to cope with continued Covid-19 cases, would be a massive own goal.

Hunt response

Former Health Secretary Jeremy Hunt has already urged Johnson to drop plans for a major reorganisation of the NHS, which suggests the proposals could face a rough ride even amongst the Tory ranks. Hunt told the Independent he believed the 2012 Act was one of David Cameron’s “biggest regrets”:

“I would be astonished if Boris wanted to do the same. If you want to improve care for patients, then looking at the quality and safety of care is going to have far more impact than another big reorganisation,” he said.

At the last election just 8 months ago , the Labour Party and Green Party both pledged to repeal the 2012 H&SC Act and so end competitive tendering and privatisation across the NHS, and Labour promised that all integration of care will be delivered via public bodies. The Conservative manifesto pledged to continue with the restructuring set out in the Long-Term Plan: and the Notes to the new government’s Queen’s Speech stated that:

“The Government is considering the NHS’s recommendations thoroughly and will bring forward detailed proposals shortly.

“This will include measures to tackle barriers the NHS has told Government it faces. This will lead to draft legislation that will accelerate the Long Term Plan for the NHS, transforming patient care and future-proofing our NHS.”

Nobody would be surprised to see the Johnson government, with its 79-MP majority, discard such recent promises and seek to clip the wings of Stevens: but it should be obvious that opposition parties have nothing to gain from endorsing their approach.

We should also be aware it’s more than possible that the whole idea of a vague and inexplicable major restructuring of the NHS could be little more than a Cummings-style “dead cat” thrown onto the table in an effort to distract attention from the government’s chaotic performance on test and trace, the hundreds of millions wasted in ridiculous PPE contracts, and the massive, rising toll of excess deaths since the Covid pandemic first struck.

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John Lister
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