A letter to the Secretary of State for Health and Social Care


October 2020

Dear Secretary of State

There is no handbook for the job you are doing and, by the almost unanimous testament of your predecessors, it will be the hardest job you have ever done.

However, what follows in this book is a history of the post and the wisdom of 11 former incumbents – their experiences, their trials and what they learned. Hopefully they will give you some insight into the challenges ahead to help prepare you.

Their main messages are as follows:

  • Regardless of where you have come from, the Department of Health and Social Care is different. It has a different culture, different structures and different demands to any other department. From the unusual relationships at the top, with what used to be a trio of permanent secretaries – the NHS Chief Executive, Permanent Secretary and the Chief Medical Officer – to the much more complex existing arrangements that involve a statutorily independent commissioning board along with a set of regulators and other arm’s-length bodies.
  • The NHS is also different to any other part of the public sector: it is at or near number one in the list of public priorities; much of the talent and knowledge about care is on the clinical front line, with the associated political power; and it carries out very high-risk activities. For these reasons, the NHS is never far from the headlines.
  • There is an inescapable overlap between politics and the management of the NHS. Different boards, executives and laws have tried to give a structure to the relationship between the two, but one of the key challenges is recognising and deciding what is in the scope of the politicians and what is in the scope of the service. Different incumbents have taken wildly differing views as to the extent of the overlap, but there is overall consensus that politicians should not try to ‘manage’ the NHS.
  • There are two major but intangible factors that influence this politics/management overlap:
    1. Context will always influence the degree to which the secretary of state will see the need for intervention. Context could come in the form of an emergency event such as a financial crisis in the NHS or a pandemic – or, as William Waldegrave puts it, ‘The job of the Secretary of State for Health depends on whether you think the system, at any given time, is in need of policy reform.’
    2. Your behaviour will tend to trump structures and legislation. When the scandal of quality of care at Mid Staffordshire NHS Foundation Trust came to light, both Alan Johnson and Andy Burnham overruled Monitor to do their job as they saw fit. Similarly, Jeremy Hunt was appreciably more interventionist than was intended by the 2012 Health and Social Care Act introduced by his predecessor.

Finally, we would not presume to offer direct advice as to how you should do your job, but we did ask your predecessors for theirs.

Each was informed by their own tenure and, within this book, you can read their thoughts on a range of issues, from staff pay to service reform. But if one theme was dominant in their advice, it was – in the first few months of the job at least – to give yourself space to think.

‘Buy time,’ says Alan Milburn. ‘The best political trick I ever pulled off was to publish a 10-year plan.’ ‘Have a good think,’ says Frank Dobson. ‘Which is out of fashion really isn’t it, to sit down and have a good think?’ ‘Make no major speeches for at least a month,’ recommends Alan Johnson. ‘Find out exactly what’s going on there.’

Fundamentally, you will have to decide how you want to approach the role – as Virginia Bottomley puts it, ‘Sometimes you want a window breaker and sometimes you want a glazier. Ken was a window breaker and he was brilliant. But after that you get William Waldegrave who was a glazier… And then a new set of problems will arrive and you need a Ken to break the windows again.’

Hope you enjoy the book – it’s a great read.

Best wishes and good luck,

Dr Jennifer Dixon CBE

Chief Executive,

The Health Foundation

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