The Cabinet Office categorises NHS England as an “Executive Non-departmental Public Body”. In other words, it is not part of the Department of Health and Social Care (DHSC) but it is part of government. It is independent and not independent at the same time: it is a quango. But it gets better. The IT, legal and HR functions, which all other CEOs of large organisations would expect to be under their control, are separate executive agencies of the DHSC. NHS Improvement is tasked with running the NHS alongside the Board of the NHS. In April 2019, they were brought under one roof but still with one Board each. The foundation of the country’s health care, the GPs, are contractors to, not employed by, the NHS.
The CEO of NHS England has probably the toughest job in the country. NHS England, with more than ten times the number of employees it started with, or employed by any other UK organisation, is simply too big. The NHS is the fifth biggest employer in the world. This CEO, Sir Simon Stevens, is beset by 2,163 politicians and civil servants in the DHSC, its arm’s length bodies and every member of the House of Commons. And that is not counting all the local politicians and bureaucrats on hospital trust committees, “integrated care systems” and “primary care networks” (PCNs). The BMA, being itself a bureaucracy, is keen on these things but a survey it published earlier this year showed that about half the GPs reported that sitting on PCN committees reduced their ability to provide primary care. Now there’s a surprise.
The oddly named Norfolk and Norwich University Hospitals (NNUH) Trust has 10 governance boards and an untold number of committees. There is no Norfolk, or Norfolk and Norwich, University; the only Norwich University is an arts college. When I was in the NNUH for two weeks, with nothing much to do except watch the nurses, they seemed to spend more time tending their computer terminals than their patients. I asked why and was told (a) it was none of my business and (b) they were too busy with their computers to talk with me. The then Trust CEO was a friend of mine so I asked her what they were doing. She said she had no idea; she was too busy with committees to know things like that, still less walk round her hospital and to see it through the eyes of patients.
Some politically inspired NHS initiatives have been helpful, but the number of such re-organisations has not. The Health Secretary may or may not be in charge of NHS England but is a professional politician, with little if any managerial or health provision experience, more suited to running the largest employer in the land than a seasoned executive with long experience in both? On March 16, Matt Hancock announced that 30,000 patients were to be immediately discharged from hospital beds. The extent to which Sir Simon Stevens was involved in that decision is not known, but what is certain is that the care home sector was not consulted. This exodus was largely responsible for taking Covid 19 into care homes.
Confusion over, and excessive, governance lies at the heart of the long-term under-performance of the NHS. Its response to Covid this year, however, has been brilliant. Many have noted that this was due to the dedication of the front line and their just doing things that would usually have taken months for approval.
The confusion comes ultimately from classifying the NHS as a quango, neither run by politicians nor run by those qualified to do so. It should be one or the other, an executive agency or a public corporation, not supposedly independent with politicians and bureaucrats meddling. Thank God the GPs are independent; the rest of the front line are professionals and they too should be as independent as possible, with the senior ranks providing the resources and light touch leadership. A hospital should have one management board, not ten. Healthcare in Britain in the 1930s worked quite well apart from most of the population not being able to afford it. Aneurin Bevan cured that but he saw his NHS as a public service, not an instrument of government.
The NHS, like the Bank of England, should be a public corporation, not a quango. Of course the government must agree the long term plan and annual budgets. Of course, it should set the key objectives, i.e. what NHS should achieve, and of course it should top the funds up in times of crisis. But that does not mean that politicians and bureaucrats, national or local, should interfere. Define the “what” by all means but not the “how”. And that should allow the staff numbers in the DHSC to halve, releasing funds for the health and social care front line.
Politicians will be reluctant to agree to this because they like playing Santa Claus. Party political game-playing requires headlines announcing dollops of cash for this or that praiseworthy purpose. October 9th saw three such announcements: “Over £400 million pledged to remove dormitories from mental health facilities”, “How GP practices in England can access the extra stock of flu vaccines this winter that the government has secured”, and, in case we missed the point, “Guidance has been issued to GPs in England setting out how they can order more flu vaccines to ensure 30 million people can receive the jab this flu season.” According to the last of those press releases, over half the population of England are “65s and over, pregnant women and those with pre-existing conditions, as well as frontline health and social care workers”. The administration of the jab I was given last week looked nothing like the photo on the press release but then, this is the world of make-believe.
All these releases come from the DHSC, not the NHS, because Santa Claus would have us believe that every day is Christmas.