1. History and analysis



What is the role of the health secretary? What should it be? How far, in an almost entirely tax-funded NHS, can health ministers be removed from the day-to-day operations of the NHS? How far should they be, if the service is to remain accountable to its patients, to taxpayers and to the public at large?

These are the core questions that lie behind this review. To put them another way, and in rather more detail, how far can the service be turned into a ‘self-improving’ one, to use Labour’s phrase from the mid-2000s? One where ministers, and the health department, really do stand right back from operational matters and let the service itself – clinicians, managers and patients – drive improvement and change. How far can policy, which clearly lies in the purview of ministers, genuinely be separated from strategy, from operations and from management?

Will the demands of patients in their particular case, or indeed the demands of patients and the public collectively expressed through their MPs and the media and on to the secretary of state in parliament – ensure that ultimately ministers cannot escape operational responsibility? Is that the inevitable – and quite correct – price to be paid, at least to some degree, in a tax-funded health system?

Or is it – even if the answer to that last question is ‘yes’ – possible to find a more constructive balance between ministerial responsibility and operational matters? And, if so, where does that balance lie?

To address these issues, 11 former health secretaries kindly agreed to be interviewed about them, starting with the questions ‘What is the role of the health secretary? What should it be? And what was it when you were there?’ The Health Foundation is immensely grateful to them for finding the time so to do.

This study, unsurprisingly, was prompted by the decision of Andrew Lansley, health secretary between May 2010 and September 2012, to create NHS England – a statutorily independent ‘commissioning board’ that has been dubbed ‘the world’s biggest quango’ (an accolade that may not be entirely accurate, although it is certainly England’s biggest).

In 2019/20, NHS England was responsible for some £124bn of the department's £140bn total budget – the money for the ‘front line’ so to speak, with the remainder going on public health, education and training, and assorted responsibilities that remain with the Department of Health and Social Care itself.

This study does not seek to provide a definitive assessment of the success and/or failure of these new arrangements, which, as the analysis here will show, have not turned out in the way their originator expected. It does, however, 7 years in, make a preliminary assessment – preliminary because at the time of writing these were still evolving.

But the very fact that an idea that has knocked around for decades has become a reality – the creation of an arm’s-length body, or a more BBC-like structure, or a governing board separate from ministers, or a Health Service Commission (the idea has taken many forms) – has provided a new focus for these questions.

These questions involve some long-standing tensions. Between localisation and centralisation – in terms of administration and management, but also in terms of how far there should be local or national political accountability. Between the interests of patients and those of taxpayers. And between the interests of the staff and those of the patients and their carers which, inevitably, are not always aligned. Tensions that have existed, not just since the formation of the NHS in 1948, but which were there – and which had to be resolved – in the run-up to its creation. In 1945 and in the run-up to the 1946 Act there were Cabinet battles over whether it should be a national health service, or one run by local government. The arrangements in Manchester, dubbed ‘Devo-Manc’, do give local authorities a larger role and may yet provide a model for some other parts of the country.

Before we get to the health secretaries’ views, however, it is important to note that each of them operated in an environment where the management of the NHS itself changed over the years. So – if readers can bear with it – a decent dose of history is required, even if it is a short and somewhat superficial one, and one which by no means covers all the changes to the NHS superstructure (the various tiers of authority and the various purchasing arrangements) over the years.

It is needed both to paint the backdrop of what each of the health secretaries inherited, and to dispel some myths.

A short history of health secretaries and the NHS


One of the biggest myths about the NHS is that it was deliberately set up in 1948 by Aneurin Bevan as a ‘command and control’ system to be run from Whitehall – or, more accurately from Jermyn Street where the department was then headquartered.

It is a myth that has been reinforced by almost every health secretary since at least the 1980s as, in various ways, they have sought to distinguish what they were up to from the bad old days of ‘Soviet-style command and control’ – to quote just one speech of Virginia Bottomley’s in the 1990s.

It is a view reinforced by the famous Bevan quote that when a bedpan was dropped in Tredegar the sound would echo in the corridors of Whitehall – although I’ve never actually been able to find a reliable original source for this famous dictum, or the many variations of it that have been used.

It is a view reinforced by the almost equally famous 1937 observation of Douglas Jay that ‘the gentlemen in Whitehall really do know best’ – in fact, itself, a paraphrase. What he actually said was ‘in the case of nutrition and health, just as in the case of education, the gentlemen in Whitehall really do know better what is good for the people than the people themselves’.

The Bevan aphorism is usually quoted as though it was something he profoundly desired; that he positively wanted the bedpans to echo in Whitehall. There is in fact a strong case that his words should be viewed the other way round. That what he was describing was something that he recognised to be an unwanted by-product of the system he had created. The case for this alternative view is there in what he said. And in what he did.

On 2 June 1948, a month before the launch of the NHS, he made a speech to the Royal College of Nursing. According to the report in Nursing Times, he declared that after 5 July, there would be many complaints. The order paper of the House of Commons would be covered in questions. ‘Every mistake which you make, I will bleed for,’ he said. ‘I shall be going about like St Sebastian, bleeding from a thousand javelins, so many people will be complaining.’ They were complaining at the time, he said. But they weren’t being heard. The arrival of the service would place ‘a megaphone’ in the hands of those who complained, although he predicted that the number would ‘dwindle and dwindle… because you will be attending to them. All I shall be is a central receiver of complaints.’

The italics there are my emphasis. But these hardly sound like the words of a man who saw the echoing of dropped bedpans to be something entirely desirable, or of someone who wanted to run the service by command and control. And certainly he did not set it up that way.

Hospitals were to be run by regional hospital boards, not from Whitehall and not as outposts of the Department of Health. The teaching hospitals retained an additional special status with their own boards of governors continuing to exist. It was Bevan himself who insisted that GPs should be independent contractors, not state or local government employees, and he did so in part because he wanted to ensure that patients had a choice of GP.

And when in 1950 Bevan appointed a senior civil servant, Sir Cyril Jones, to study the financial workings of the NHS as expenditure appeared to be running out of control, Bevan rejected Sir Cyril’s recommendations. These included turning the regional hospital boards into purely planning bodies while the individual hospital management committees beneath them should become ‘subject to direct control by the ministry’ with civil servants posted out to them in order to ensure that.

Bevan’s response was that ‘there would have been no theoretical difficulty – there is none now – in having from the outset a tightly administered centralised service with all that would mean in the way of rigid uniformity, bureaucratic machinery and ‘red tape’. But that was not the policy which we adopted when framing our legislation.

‘While we are now – and rightly, I think – tightening up some of the elements of our financial control, we must remember that in framing the whole service we did deliberately come down in favour of maximum decentralisation to local bodies, a minimum of itemised central approval, and the exercise of financial control through global budgets.’

As Rudolf Klein, the distinguished analyst of the NHS’s history, has put it, the 1940s and 1950s were characterised ‘by a philosophy of administration which saw policy as the product of interaction rather than as the imposition of national plans’.

‘The centre provided the financial framework and advice about desirable objectives. It left the periphery free to work out the details… The centre, quite simply, did not know best and indeed could not know best.’ Even when it had a clear view about what was desirable ‘it did not perceive itself to be in a position to command. It could educate, it could inspire, it could stimulate. To have done more would have run counter to the values of localism… and challenged the right of [clinical] professionals to decide on the content of their work.’ It was, Klein says, a case of ‘policymaking through exhortation’. As one civil servant put it in evidence to a parliamentary committee ‘the minister seeks always to act by moral suasion’.

The NHS was, of course, a national organisation in that it had, and still largely has, national terms and conditions. The department issued many circulars on that and on many other matters, including broader policy aims. Roughly one every 3 days throughout the 1950s. But how far the thousands – literally in those days thousands – of individual hospitals acted on them was a matter for them and for the regional hospital boards which retained a distinct, decidedly local, independence from the centre. And that remained pretty much the case through the 1960s.

Even Enoch Powell’s mighty 1962 Hospital Plan, which promised 90 new hospitals and the remodelling, on various degrees of scale, of some 490 more, became, in Rudolf Klein’s words, a ‘negotiated order’. Not only that, but, as it turned out, a much delayed one. As civil servants told a parliamentary inquiry, the department could ‘advise’ the regional hospital boards, it could ‘discuss’ the plan and seek to ‘persuade’, but it would not dictate. Not least because ‘it is not easy for us centrally… to form a judgement of the precise needs of each regional board’. The same applied to Powell’s other great initiative, the ‘setting of the torch to the funeral pyre’ of the great Victorian lunatic asylums, announced in his famous ‘water towers’ speech. It was to take 30 years for the last of them to close.

Indeed at the end of the 1960s, Richard Crossman, Labour’s health secretary (strictly speaking the first secretary of state for social services), described the relationship with the service as follows. ‘You don’t have in the regional hospital boards a number of obedient civil servants carrying out central orders… You have a number of powerful, semi-autonomous boards whose relation to me was much more like the relations of a Persian satrap to a weak Persian emperor. If the emperor tried to enforce his authority too far he lost his throne, or at least lost his resources, or something broke down.’

The department was perfectly capable of putting out detailed circulars on precise requirements for building specifications which were expected to be followed. So the distinction should not be pushed too far. But, certainly up to the mid-1970s, and on most measures until the mid-1980s, the NHS was essentially an administered service rather than a managed one. One where policy, in so far as it could be enforced, was enforced by persuasion, discussion and advice. Not by central planning, and most certainly not by command and control.

One should not underestimate the power of a phone call from one of the department’s senior civil servants. But health ministers up to the 1980s and indeed beyond, and doubtless even today, would say that in practice there was damn all command available, and, for much of the time, more or less bugger all control.


This, in time, led to frustration. Ministers were indeed accountable for the NHS and had to answer many gruesomely detailed questions about it in parliament. But the sense steadily grew, not just in the ministry but in the Treasury and elsewhere, that there were too few levers that could be pulled at the centre with any sense of certainty that anything would change on the ground. For example, by the 1970s there had been, for many years, a developing policy for ‘care in the community’, not least for people with mental health disorders, learning difficulties, as well as for others in the so-called ‘Cinderella services’. Progress, while real, was snail-like. Ministers could exhort. They could not execute.

The mighty 1974 reorganisation of the NHS was in part an answer to that. It was also many others things – not least an attempt (which partially failed) to unify the service.

Bevan’s original dispensation had left much with local government – for example district nursing and health visiting, midwifery, the ambulance and the schools service, along with public health, with the best (though not the worst) of the local authority medical officers of health being powerful and effective figures. 1974 brought all of this together. Health authorities replaced purely hospital boards, acquiring a broader population remit. The reorganisation, however, failed also to unify what we would now call social care with health. Social care remained with the councils. Nor did the reorganisation bring GPs under more direct management, although both ideas were extensively trailed and debated.

The mid-1970s was, of course, the apogee of faith in planning in the UK. The near absolute belief that the state could plan and run services better, and, indeed could do so in parts of the private as well as the public sector. This vision was held by both the main political parties at the time, even if to varying degrees. It was a faith that was to fall, rapidly and spectacularly, out of favour, at least among the Conservatives.

So the 1974 reorganisation, the product of Sir Keith Joseph as the social services secretary, did indeed introduce a planning system into the NHS for the first time, even if it proved initially to be highly tortuous, and eventually rather weak.

It was introduced with two slogans. The first was ‘maximum delegation downwards, but maximum accountability upwards’ – the very phrase capturing the tension between localism and centralism. The second was ‘consensus management’. This saw finance officers and senior clinical staff – chiefly, but not exclusively, doctors and nurses – brought onto health authority boards and onto district management teams as nominally equal partners to sit alongside administrators. And, at this stage, hospital and health authority managers were still very much administrators, if often powerful ones, and were named as such.

In administrative terms, this was part of the weakening of the autonomy of the medical profession. One of the first major dilutions of the unwritten compact at the beginning of the NHS. Namely, that the taxpayer would fund the NHS but the medical professionals would largely be trusted, individually as well as collectively, to decide what should be provided. The retreat of the profession’s ability to influence policy over how the NHS was run is a huge subject in its own right, though one that is largely, but not entirely, outside the scope of this study.

In so far as there is any truth in the NHS having ever been in practice a ‘command and control’ system, the 1974 reorganisation was an attempt to introduce at least an element of both. The search for a set of policy levers that would indeed give ministers, as representatives of the taxpayer, more power to implement the policies they set out. An ability to plan, linked to a mechanism to deliver.

In the words of Sir Patrick Nairne, the Permanent Secretary who inherited the results of this mighty reorganisation, 1974 became a case of ‘tears about tiers’. The new structure of regional, area and district health authorities proved mightily bureaucratic. The teaching hospitals lost their independent boards of governors and were placed under the area health authorities – a melancholy little plaque in the boardroom at Guy’s recording the final meeting of its governors in their 248th year. That plaque, a dozen years later, was to catch the eye of a Downing Street adviser, leading first to the creation of NHS trusts and, many more years on, to their offspring: NHS foundation trusts.

If 1974 saw the NHS become much more bureaucratic and, to a very limited degree, more of a command and control system, it also became much more politicised through the introduction of local authority members on to the boards of health authorities.

Councillors had indeed been on regional hospital boards. But they had been there as individuals, not as nominees or formal representatives. The reorganisation coincided with a tough time for the economy, and thus health spending. And an additional voice had been added to the formal mechanisms of the NHS in the shape of community health councils (CHCs) who were there, for the first time, to represent patients. As the money tightened, however, both the councillors and the CHCs voted themselves the role of critics – a stance that was enhanced by the tendency of medical and nursing members of the authorities to act as though they were representatives of their professions, rather than what they were formally appointed to be – informed individuals. As the unions and governments of both colours clashed repeatedly in the 1970s over pay and much else, the net result was that the level of political debate about the NHS escalated, with many on the health authorities publicly blaming any and every problem on a lack of resources from central government rather than anything else.

Enoch Powell – who, in my view, despite the ‘rivers of blood’, must rate as one of the half-dozen great health ministers – once observed of a tax-funded NHS that it endowed ‘everyone providing as well as using it with a vested interest in denigrating it’ – in the hope that the result would be more money. The 1974 reorganisation handed them all a bullhorn. Thus the level of accountability demanded from health ministers – if not necessarily their sense of what they could practically be held accountable for – rose.

Initially the reorganisation did little to make administrators feel they were any more directly accountable to the ministry than in the past. It is at this time your author started reporting on the NHS, and back then many administrators saw themselves as public guardians of the NHS locally – frequently speaking out individually and publicly against assorted bits of government policy, with little sense that they feared dismissal from above; something that is seen somewhat less often these days, save where they are speaking on behalf of at least some sort of NHS collective body.

Glacially, however, that began to change. In 1975 the department added to the planning system a programme budget. That allowed it to work out broadly where the NHS was spending its cash – showing for example that a falling birth rate had not been matched by a reduction in maternity services, thus allowing money to be diverted from that to community care for the geriatric and people with mental health disorders, and for growth in acute services to be restrained to achieve the same thing. Broad targets for changed priorities could now not only be set, but monitored.

Equally, again slowly but again surely, the regional chairs of the health authorities became increasingly powerful figures. In time, as we shall see, some became despotic. These were people who, when they took on board what the minister wanted, began to demand action from their own regional administrators and staff, and so on down the line. How far that applied varied distinctly across the country. But all this – a planning system – did indeed begin to introduce a little more command and a little more control, and somewhat less freedom for administration locally to decide whether or not to comply with the wishes of the centre.

Further evidence that it is a myth that the NHS was created as a ‘command and control’ system comes in the voluminous report of the Royal Commission on the NHS in 1979. It reviewed the 1974 reorganisation. But nowhere does it contain the phrase ‘command and control’. It does reflect the many bitter complaints about the bureaucracy created by the new tiers and matching advisory machinery. But one of its key observations is that ‘in principle health ministers… are expected to have detailed knowledge of and influence over the NHS. In practice, however, this is neither possible nor desirable and detailed ministerial accountability for the NHS is largely a constitutional fiction. That is not to say that it is without virtues.’ It quoted approvingly a memorandum from the department that its ‘oversight of, and assistance to authorities is generally more by administrative guidance than by legislation’.

The full scale of the bureaucracy of the 1974 reorganisation was unpacked by Patrick Jenkin [Baron Jenkin of Roding] in the 1982 reorganisation. Area health authorities were abolished and there was a marked reduction of some of the highly convoluted advisory machinery that had accompanied the 1974 restructure.

‘Consensus management’, however, remained. At its best it worked well. But the demand for ‘consensus’ on local decisions meant that anyone and everyone from the doctor to the nurse to the finance officer to the administrator had, at least potentially, a veto. Too often the result was lowest common denominator decisions on any change that was proposed, not highest common factor ones, and sometimes no decision at all. As Norman Fowler, Secretary of State for Social Services between 1981 and 1987, has put it, ‘consensus management was basically a way of avoiding decisions’.

Jenkin recalls of his time between 1979 and 1981 ‘you issued circulars and you didn’t know what the effect was going to be’. But he had meetings ‘from time to time’ with the regional chairmen and they were ‘the levers I could pull to make sure something happened’.

It is now that we enter the territory of the health secretaries interviewed here.

The 1980s

Ken Clarke arrived as a health minister – not yet secretary of state – in 1982 when proper cash limits for the NHS were biting for the first time. There was little real terms growth after NHS pay and price rises had been allowed for. The public discourse was dominated by ‘cuts’. And the longest industrial dispute in 50 years, and the NHS’s longest ever, was just kicking off.

‘The problem is that there wasn’t a management system worth the name,’ Clarke says. ‘There was next to no management information of any kind, no one knew what the devil we were spending the money on, and the whole thing was dominated by political campaigning. It wasn’t command and control… though I was supposed to command and control.’

To get any growth in services, costs had to be constrained without damaging the service itself. The result was a vast plethora of initiatives that included some rather arbitrary manpower targets – instituted because staff numbers were exploding and some authorities were literally unable to state how many people they employed. There was pressure to sell off nurses’ homes, to rationalise job advertising and much else, plus a hotly contested requirement to put cleaning, catering and laundry out to competitive tender. ‘So I did do some command and control,’ Clarke says, although history shows that administrators and health authority members became increasingly resentful of these centrally dictated efficiency drives.

Clarke and Norman Fowler, as his boss, also ramped up the influence of the politically appointed health authority chairs, at both regional and district level. They refused to reappoint those who refused to deliver on the compulsory competitive tendering of support services, or who sided in public with the staff in the 9-month pay dispute. Refusing to reappoint them was ‘the only lever I had, and the one I continued to pull all the time,’ Clarke says. ‘I gradually got rid of the ones [the chairs] who used to go on strike with the staff and stand on the picket lines, and got in people who were good, local businessmen – not very political, most of them. That was regarded as a real novelty. I used to describe them as my “health cabinet”.’

He and Fowler, with the chairs, also instituted formal annual reviews of each of the 14 regions. Reviews of their performance against agreed targets, and therefore reviews of the performance of the regional administrators, which were then replicated down the line to each region’s districts – but not to the units that were directly responsible for the management of hospitals. This was the very beginnings of performance management in the NHS.

One aspect of the relationship of ministers to the service is neatly captured in one of Clarke’s stories. ‘One of my first introductions to the service was that I had to go to close a maternity hospital in Clement Freud’s constituency [the Isle of Ely]… A great demonstration took place, and they were moving the babies inside to try to give me the impression there were more than there were. I met the local grand consultants, the obstetricians, who told me ferociously – addressing a minister of state in an absolutely James Robertson Justice way – that I had got to close this place. And they had all agreed that they were not going to accept any more referrals to it. “It was dangerous!” – and they had a better facility in some local East Anglian town.’

‘So I said: “Come out with me and say that to all these women and these television cameras outside who are waving babies at me.” And they refused. Absolutely refused. And it turned out they had not shared this opinion with anybody but me and the doctors from whom they were refusing to accept referrals. One of them said, “That is your job, we are not prepared to do that.” That is a silly story, but it is a true story. It was my first introduction to the fact that some of the medical profession had no time at all for those who did manage the service, but were not prepared to accept the slightest responsibility for managing any change.

‘In fact I closed more hospitals than most people had hot dinners – old Victorian workhouses which were called “geriatric hospitals” but which suddenly became centres of clinical excellence when their closure was proposed.’

If Clarke and Fowler were worried about the management of the service, so was Margaret Thatcher, the Prime Minister. Largely at her instigation, Roy Griffiths, the Managing Director of Sainsbury’s – at the time by far the most successful supermarket in Britain – was brought in, initially to do an inquiry into manpower that soon became one into the management of the NHS. Clarke bristled. ‘There I was clattering about, contracting out this and manpowering that in an attempt to get some management into the service, and here’s this bloke they want to bring in to spend 12 months doing a study… in fact Roy produced a very good report. My reluctance about it turned out to be a terrible mistake.’

In the entire history of the NHS, in my view the Griffiths report is one of its three most important documents – alongside the Guillebaud report of 1956 which rescued the service financially and Ken Clarke’s later white paper Working for Patients which introduced the purchaser/provider split with which we still live. The Griffiths report was easily the most idiosyncratic of the three.

Griffiths produced a mere 14-page ‘letter’ in February 1983, not a formal report. It was, so to speak, written backwards. It began with seven pages of recommendations, followed by seven of diagnosis, while being entirely shorn of the formal evidence beloved of official inquiries.

Its essential message was encapsulated in one ringing phrase. That ‘if Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge’.

The recommendation from Griffiths and his team of three other business people was, in essence, that ‘consensus management’ with its ‘lowest common denominator decisions’ should go. General managers – regardless of discipline – should be appointed at every level of the NHS. The review process – the setting of budgets and objectives and the monitoring of performance and outputs in so far as they were measurable – that Fowler and Clarke had instituted should be strengthened, and extended down to the hospital level. Doctors should not just be eligible to be general managers. They should take responsibility for their own budgets at hospital level because ‘their decisions largely dictate the use of all resources, and they must accept the management responsibility which goes with clinical freedom’. And the centre should be revamped.

‘A small, strong general management body is necessary at the centre (and that is almost all that is necessary at the centre for the management of the NHS).’ This NHS Management Board, with its chair acting as a general manager or chief executive for the NHS, should be answerable to an NHS Supervisory Board, chaired by the secretary of state, with the Permanent Secretary, the Chief Medical Officer, and the management board chair on it, along with two or three non-executives.

And it really was, in many ways, that simple. The goal was genuine devolution of responsibility down the line ‘to the point where action can effectively be taken’, with accountability going back up it. An attempt, in a sense, to make a reality of the slogan that had accompanied the 1974 reorganisation. The department, the inquiry said, should ‘rigorously prune many of its existing activities… the centre is still too much involved in too many of the wrong things and too little involved in some that really matter… units and authorities are being swamped with directives, without being given direction’.

The word ‘command’ does not appear anywhere in the Griffiths report. But ‘control’ does. Repeatedly. ‘By general management,’ it says, ‘we mean the responsibility drawn together in one person, at different levels of the organisation, for planning, implementation and control of performance’.

Put another way, here was a mechanism that provided more of a lever for ministers to set policy and for something down the line to happen as a result – another turn of the performance management screw – even if the primary objective remained to get decisions taken at the point ‘where action can effectively be taken’. As a result, even within the Griffiths solution, the tension between centralism and localism that had been at the heart of the NHS since its foundation still played out.

This was, however, undoubtedly the moment when the NHS moved from being largely an administered system to more of a managed one.

A powerful case can be made that the Griffiths report saved the NHS – by putting someone in charge. Certainly without the arrival of general management there would have been no one to implement Working for patients with its creation of allegedly self-governing NHS trusts and the introduction of the purchaser/provider split some 8 years later.

Less noticed at the time – and less analysed since – was that the report also reinforced the role of the politically appointed chairs at both regional and district level. It was they who were to appoint the general managers. And they retained a separate reporting line – separate from that of the managers – to the very ministers who had appointed them. Over time, and particularly after the 1991 reforms, their influence was to grow.

The recommendations were profoundly controversial. The Royal College of Nursing launched a huge advertising campaign asking why the NHS nurses should be run by someone ‘who doesn’t know their coccyx from their humerus’. Fowler agonised for 8 months over accepting the report. The implementation circular went through 14  drafts before being issued – in part because while many of the civil servants in the department liked the report’s recommendations for strong local management, they strongly disliked the threat to their empire posed by a small, strong and separate local management board. In the end, Fowler bit the bullet. Both the management board and the supervisory board came into existence, more or less as Griffiths had recommended.

The other key element of the Griffiths report was that it was the first formal attempt to distance politicians from the day-to-day management of the service – through its mainland Europe-like, company-like, structure of a supervisory and management board. The secretary of state was to chair the supervisory board, not the management one. The role of the supervisory board was to be ‘oversight’ of the NHS. Setting objectives, approving the budget, taking strategic decisions, receiving reports on performance – not managing the service. That, in theory, was for the management board. Very deliberately, these changes were designed to take effect with no requirement for legislation. They were new management arrangements, not – as in the case of the 2012 Act – new statutory ones.

The subsequent history of the management board is long and tortuous. It went through assorted incarnations of being a board, and then a management executive, then an executive, each of which was recast in various ways at various times. It is well set out in The executive years of the NHS by Brian Edwards and Margaret Fall.

Only the most crucial changes will be outlined here, the interest of this study being more in the relation of ministers to the service, and thus what happened to the political ‘distancing’ arrangement of the supervisory board.

The short answer is that the board fell into desuetude. It met for the first time in October 1983, and regularly for the first 2 years of its life. It met less frequently thereafter. In the run up to the 1987 general election, its meetings were repeatedly cancelled, and when Fowler and Clarke moved on in the wake of the general election, John Moore, Fowler’s successor, had little understanding of it and little interest in it. The board had helped oversee the introduction of general management, although its impact is hard to assess, not least because it met in private (as did the management board) and neither body published any minutes. It is clear, however, that its precise role rapidly became decidedly imprecise as ministers in practice remained in charge and still took most of the crucial decisions. As Norman Fowler put it, in a phrase that in part became the title of his political memoir: ‘Officials advise. Ministers decide.’ And that applied equally to the supervisory board. Indeed, as early as November 1986 the arrangements had been rejigged so that, while the supervisory board continued, Tony Newton, the health minister, started to chair the management board, an arrangement that clearly diluted the theoretical split between the two. The supervisory board was finally scrapped in June 1988. It had met only six times over the previous 2 years. Len Peach, the Chief Executive of the management board at the time, judged that it had become ‘a waste of time… ministers got bored with it… they had already heard the debates beforehand’.

By now the NHS was deep into the huge financial crisis of 1987 that led first to Margaret Thatcher’s review of the NHS, then the return of Ken Clarke, this time as health secretary. The NHS was well on the way to the monumental row that accompanied Working for patients with its introduction of the purchaser/provider split, ‘self-governing’ NHS trusts and GP fundholding. The so-called NHS ‘internal market’.

As the white paper was launched in early 1989, the NHS Management Board was reorganised once again. It became the NHS Management Executive with Duncan Nichol as its Chief Executive.

Nichol was clear – there is an official circular to this effect – that ‘separating the role of managers from ministers will be a prime consideration. The implementation of policy will be the responsibility of the management executive’. And with the huge undertaking of introducing the purchaser/provider split under way, Clarke reintroduced the strategic/management split at the centre. He created an NHS Policy Board to sit above the management executive, its membership consisting of a mix of ministers, senior officials, three business people and a couple of the regional chairs.

Its intention was at least as much to provide some strategic oversight to the massive changes in the way the NHS was to function as it was to distance ministers from management – although Clarke did seek to signal that was indeed the intention by insisting that the headquarters of the management executive be in Leeds, not in Whitehall or London. It was a decision that, over time, exhausted many of the most senior people on the management executive as they spent countless hours on trains up and down to London, endlessly dragging behind them an overnight suitcase.

Of the early meetings of the board, one civil servant recalls that they consisted ‘of the secretary of state [Clarke] dominating the meeting, both by his manner – he smoked a large cigar in a no-smoking area – and by the way he used the opportunity to expound his own views, opening up certain areas for discussion while keeping others tight’.

The 1990s

William Waldegrave took over from Clarke as Secretary of State for Health barely 5 months before the purchaser/provider split went live in April 1991. He refreshed the membership of the policy board.

Waldegrave’s judgement is that the policy board ‘did some good in its early days’ – in overseeing the establishment of the purchaser/provider split and the resulting structures. But his overall judgement is that ‘it didn’t do all that much’ because the policy board/management executive split repeatedly came back to ‘the inherent difficulty of the whole thing – is it possible, in any business or in any organisation, truly to separate policy from execution?’ This is an issue to which we will return, while simply noting for now that Stephen Dorrell scrapped the policy board in 1995.

The 1991 reforms – the purchaser/provider split – came, as do almost all government reforms, not just in health, with its paradoxes. Its rhetoric was that it was about decentralisation. The substitution of some market-like mechanisms for direct management of the service from the centre (in so far as there was in fact any direct management). By implication, that meant less day-to-day involvement of ministers in running it. So self-governing NHS hospitals were to compete for the business of two sets of purchasers – health authorities and GP fundholders.

Paradoxically, however, the purchaser/provider split also strengthened the control of the centre. For a start, a huge wealth of guidance and rules poured out of it as everyone tried to work out how to make this so-called ‘internal market’ work, without it causing total disruption.

In addition, the arrival of allegedly self-governing NHS trusts saw the creation of many more boards, and thus many more, decidedly hands-on, chairs. Many of them were business people and Conservative party supporters. All of them were committed to making the internal market work. Waldegrave and his successor Virginia Bottomley may have been much more emollient figures than Ken Clarke. But the net result was something of a reign of terror as the new activist chairmen (and they mainly were men) along with the hospital general managers – who had all, unilaterally and overnight, restyled themselves ‘chief executives’ – alighted on poorer performers with the instruction to ‘clear your desk by tomorrow’. The culture became so poisonous that in June 1992 Duncan Nichol had to appeal publicly for an end to such ‘macho management’.

Griffiths and the new purchaser/provider split had thus between them produced a dual reporting line: a managerial one through the management executive, while at the same time enhancing the separate, politically appointed one – at the very least an ‘eyes and ears’ line – from chairs to ministers.

Both made it possible for ministers to institute top-down reform – issuing instructions about priorities and having some hope that they would be implemented. It was a possibility that ministers and the department could not resist to the point where Alan Langlands, Nichol’s successor, promised in 1994 to try to reduce the flood of paper pouring out into the service. As he put it, ‘When you have more than 50 priorities, the truth is that you have no priorities at all.’ By now, the tendency of NHS management, to borrow the phrase popularised a decade later by David Nicholson and Patricia Hewitt, to ‘look up, not look out’ was becoming increasingly established, when the price of perceived failure could too often be your job.

This reign of terror gradually eased and the power of chairs slowly diluted. The introduction of at least nominally ‘self-governing’ NHS trusts, with district health authorities and GP fundholders doing the purchasing from them, inevitably called into question the role of regional health authorities. These were subject to repeated restructuring, culminating in their abolition in 1996. The 14 regions were scrapped and replaced by eight regional offices of the NHS management executive – and later on by four – with their officials becoming civil servants. Virginia Bottomley presented all this, when it was announced in 1993, as ‘a lighter approach geared to developing the potential of purchasing’. And there was truth in that. But, as she said in her statement, the management executive also took on ‘a clearer identity as the headquarters of the national health service’. Or as Alan Langlands was later to put it, the NHS now had for the first time, through the management executive and its regional offices, ‘a single, corporate, management structure at the centre of the NHS’.

The regional chairs – who no longer had authorities to chair – in fact survived because Bottomley still valued them as her ‘Lord Lieutenants’. The eyes and ears who would tell her ‘what she did not want to hear’. But their role was much reduced, becoming in time essentially one of advising on appointments, including to the boards of NHS trusts, in their patch. An NHS Appointments Commission was later to further depoliticise these appointments while also, along the way, doing something about the gender balance, if not much about the ethnic mix. The dual reporting line gradually diluted and then, in Labour’s time, disappeared.

One further, rarely discussed, factor increased the centralising tendency. It may sound slightly technical, but it matters. The Permanent Secretary of the department had always been its accounting officer – personally answerable to parliament, chiefly through the Public Accounts Committee, for the safeguarding of public funds and ensuring that money is only spent as parliament intended. The NHS Chief Executive, however, and in time chief executives further down the NHS food chain also became accountable officers, personally responsible not only for that but, as the appointment letter says, ‘day-to-day operations’. The Treasury’s accounting officer letter is often said by new chief executives at all levels in the NHS to be the most terrifying thing they receive on appointment. During Alan Langlands’ 6-and-a-half-year tenure as NHS Chief Executive, for example, he faced no fewer than 28 hearings in front of the Public Accounts Committee – and its hearings, as anyone who has ever attended them can testify, can become a form of blood sport. When personally answerable for NHS performance it is hardly surprising that successive NHS Chief Executives felt the need for some degree of influence and control.

Thus, while a key aim of the so-called ‘internal market’ was to push purchasing and operational decisions down the line to the point where they could most effectively be taken, the new arrangements in the mid-1990s can also be seen, as Rudolf Klein has put it, though in slightly different words, as a new high for the tide of centralisation that had been slowly creeping up the beach.

Furthermore, thanks to a separate but related review in 1994, the management executive also gained a significant role in policy formation and thus in advice to ministers on matters other than implementation. The department’s policy division was largely broken up. The idea was that policy had to pay regard to the realities of implementation and to its costs. In its earliest incarnation, this shift of policy advice towards that of experienced NHS managers worked well. It was to work much less happily later.

The 2000s

Over the following years, slowly but surely, the power of the management executive vis-à-vis the power of the civil servants in the Department of Health rose, to the point where – as Scott Greer and Holly Jarman have put it in their study of the department – it became ‘a department dominated by the NHS’ or more precisely by NHS managers. This trend – the gradual disempowerment of the department’s traditional civil servants – was reinforced when Labour arrived in 1997 and it became special advisers, both within the department and at Number 10, rather than civil servants, who became the key policy advisers (and deciders) for ministers.

With Tony Blair’s promise effectively to double NHS spending in real terms, and along with the NHS Plan in 2000, came the myriad waiting time targets – an absolutely command and control approach to that issue. Among hospital chief executives, the waiting time goals became known as ‘P45 targets’, as Blair and his delivery unit held monthly stocktakes with health ministers to ensure that progress continued. The department now had some decidedly well-oiled machinery that was capable of ringing hospital chief executives weekly where insufficient progress was being made.

As Alan Milburn has said – and this continued well beyond his time until the targets were reached – ‘it was relentless focus. The Prime Minister holding me to account, the delivery unit holding the department to account, me holding the department to account and the department holding chief executives to account – with the NHS knowing that this was the absolute top priority, because people were suffering and dying.’

Or as Duncan Selbie, a former NHS manager who was the director general of performance and programmes in the department at the time, has put it, ‘No one ever got fired if they were trying hard, and any amount of effort went in to help. But for the first time in the NHS there was a clear line of sight from the Prime Minister down to the chief executives on the front line, and again, for the first time, there were consequences.’ The fact that it was clinicians, and not just managers, who made the changes needed was not entirely lost to sight. But it was the chief executives who were held accountable.

The disempowerment of the traditional civil service reached its peak in 2000. Following the departure of Alan Langlands as NHS Chief Executive, Alan Milburn, the health secretary, took the remarkable decision to merge the jobs of Permanent Secretary and Chief Executive of the NHS.

As Greer and Jarman have calculated, by 2005, when Nigel Crisp departed and this unhappy experiment of the two jobs becoming one ended, of the top 30 leadership positions in the department, only one was held by a classic civil servant, the others being NHS managers, clinical ‘czars’ or recruits from the wider public and private sectors. It is possible to take issue with those precise figures; but the essential point is well made.

Unfortunately, this generation of managers proved in the longer run to be good at neither policy nor some crucial aspects of management. Quite remarkably, the service plunged into a significant overspend despite record levels of growth. Ministers struggled to find the advice that would help them bring full coherence to the mixture of choice, competition and foundation trust status, plus wider use of the private sector, that had become the key drivers of NHS policy. This approach was intended to produce a ‘self-improving’ NHS and reduce the reliance on ‘targets and terror’ (in other words, command and control) as the means of raising the quality and quantity of services. Under Patricia Hewitt in 2005, the jobs of the Permanent Secretary and the NHS Chief Executive were once again separated, and the traditional civil service started to come back into its own.

Labour’s time also, however, saw three key – and on the whole successful – distancing mechanisms. The first was the arrival in 1999 of NICE, now the National Institute for Health and Care Excellence. NICE has not taken all the heat out of the decisions about which treatments the NHS should and should not provide. But with one or two exceptions – Patricia Hewitt urging primary care trusts to provide Herceptin ahead of NICE’s appraisal and the issues around the Cancer Drugs Fund – NICE has shielded ministers from having to make these key decisions. Mainly because they have allowed it to. There is no statutory requirement for ministers to accept NICE’s decisions.

The second is the Independent Reconfiguration Panel, set up by John Reid but initially used by Patricia Hewitt and Alan Johnson. Reconfigurations are referred to it. It provides a stamp of approval or otherwise, sometimes with some amendment to the original proposition, and makes recommendations to ministers. In other words, it provides an element of independent and clinical judgement to local NHS proposals for change. Ministers can shelter behind its verdict, removing them from the management decision. As Alan Johnson put it, ‘I didn’t entirely tie my hands’ by saying he would never overturn its recommendations. But he did tell parliament, ‘I can foresee no circumstances in which I would intervene.’

The third was the Co-operation and Competition Panel which Johnson set up to hear complaints about the breach of procurement and competition law as Labour’s policy of competition and choice to produce this ‘self-improving’ NHS moved to the fore and that law came into play. The panel was purely advisory, not statutory. Ministers could have rejected its advice. But again, quietly and effectively, and because ministers allowed it to, it took difficult management and indeed legal decisions – on whether to intervene – out of the hands of ministers. It left those who had a complaint with the choice of accepting its verdict or going to court. It never got taken to court.

Aside from these three specific mechanisms, of course, the whole thrust of Labour’s reforms was intended to take politicians out of direct management. Foundation trusts were statutory bodies, set up as public benefit corporations part-way between the public and private sectors – in an attempt to make the freedoms that NHS trusts had theoretically enjoyed, but had gradually lost, a permanent reality. They were overseen by their own regulator, Monitor, which was the only body which could approve them, and technically it was only Monitor, not ministers, that could fire their boards and chief executives when performance went awry. The Care Quality Commission (CQC) had become a full-blown NHS inspectorate, with its own ability, technically without ministerial approval, to be able to close hospitals. The purchaser/provider split, with its mimicking of market-like mechanisms, rather than those of direct management, survived.

The 2010s

It is against this background that Andrew Lansley legislated in 2012, making the mistake, in some people’s eyes at least, of writing it all down in law.

The Health and Social Care Act is a dauntingly large piece of legislation, and this study does not go into every aspect of it. Key to it was Lansley’s view that the way the NHS was to be managed and operated had to be written down in tablets of legislative stone so that it became ‘permanent’.

‘The evidence of the past was very clear,’ he has said. ‘That because the nature of the legislation was that you change the secretary of state and you can change the policy on virtually everything in the NHS, because the health service at any given time was basically what the secretary of state under the legislation decided it would be.’

His white paper was littered with phrases about ending ‘political micromanagement’, ‘political control’ and ‘political meddling’. Both his new commissioning board and the providers were to be freed from ‘day-to-day political interference’. His goal, he said, was to allow the NHS ‘to take a more autonomous long-term view of their own role… [knowing] that things would not change just at the behest of the secretary of state, or even more a change of government’. Thus it would no longer be possible, for example, for Labour’s policy to change from the active promotion of choice and competition under the Blairites to Andy Burnham’s declaration as secretary of state in 2009 that the NHS was to be its own ‘preferred provider’.

To borrow a phrase of Nigel Edwards at the time, perhaps the most important thing to understand about Lansley’s reform is that it made the NHS less of an organisation and more of an ecosystem.

The NHS was no longer to be an organisation with a chief executive at its centre, however little power that chief executive had in reality to engineer real change at the local level. It became instead more of an ecosystem – something much closer to a regulated industry that operated without a single management chain. NHS England was no longer the headquarters of the NHS. It was instead merely a commissioner and an overseer of commissioners, even if it was a powerful one through which almost all the money flowed. It could not, however, even set NHS prices (the tariff) on its own. That task was to be shared with Monitor. But Monitor – in addition to retaining its statutory oversight of foundation trusts – also acquired a statutory responsibility for enforcing procurement and competition law, operating beneath the Competition and Markets Authority. The Trust Development Authority (TDA) became responsible for those organisations not yet ready to become foundation trusts – and for those which would never get there. Clinical commissioning groups did the bulk of local purchasing, with the boundaries between that and specialist commissioning already starting to move over time. In addition to Monitor and the TDA’s regulation (though the TDA strictly speaking is not a regulator) there was the CQC which could place its own requirements on NHS organisations to improve. Between them and the host of other bodies that came to litter the NHS landscape – Public Health England, Health Education England, clinical senates, academic health science centres and networks, strategic clinical networks, and so on – all this was meant to provide a series of incentives and penalties, duties and pressures that would produce the ‘self-improving’ NHS of Labour’s dreams. One where ministers merely set the priorities and the outcomes desired through a rolling annual mandate, and then left the NHS alone to deliver it. Or as one of David Cameron’s special advisers was later, somewhat cynically and despairingly to put it, what was devised was, at least in theory, ‘a perfectly incentivised perpetual motion machine’.

As David Cameron and his colleagues were soon to discover, thanks to Lansley, ministers really had foregone command and control in the NHS – on paper at least. Although, as we shall see from the interviews, that did not stop them, regardless of the legislation, from seeking to reinstate at least a degree of control.

Lansley’s declared aim of creating an NHS ‘free from day-to-day political interference’, was something that many had yearned for over the years – that yearning perhaps being an example of ‘be careful for what it is you wish’.

The idea of an independent NHS board – or some version of it – has roots that stretch way back into history, although the precise definition of what sort of board should run the NHS was often missing, and, when it was present, varied over the years. The British Medical Association trailed the idea in 1970. The 1979 Royal Commission reported that ‘the establishment of an independent health commission or board to manage the NHS was one of the solutions most frequently advocated in evidence. There are a number of possible models including the British Broadcasting Corporation, the Post Office, the University Grants Committee, the Manpower Services Commission.’ But while many of the arguments in favour ‘are attractive’, the commission said, it was unpersuaded, offering a string of reasons against, including duplication of effort between the board and the department.

Norman Fowler – who implemented the Griffiths report, the supervisory board and the management board – said in 2008 that ‘by the end of my time [1987] I was basically in favour of a Health Service Commission, one that would have been one step away from the Department of Health. The department had some extremely good advisers in it but the management knowledge, the direct experience of running and managing big organisations, was not actually a skill the department had. A health commission, with a separate board, separate chairman, separate chief executive, but with power, would have been the right way forward.

‘I remember putting this once in conversation to Margaret Thatcher, and she thought about it and said, “No, I don’t think we can do that, they’ll say we’re just doing this as a prelude to privatising.” And that, regrettably, is exactly what they would have said. I’m interested now to see that 10 or 15 years later [in 2008] it tends to be something that the Left of politics actually puts forward, as opposed to the Right.

‘I hope it could successfully take some of the day-to-day politics and the day-to-day ministerial involvement out. It’s certainly never going to be problem free because there are issues that come up which are obviously profoundly important, and there’s no way round that. But if you ask me what is the best way of running an organisation as massive and complicated as the health service, I would not say that it was to have all the strands going back to the health department. It would be much better to have it run as you would run any other big organisation, but with that organisation being responsible to the minister.’

Assorted Labour ministers, as we shall see in these interviews, also considered the idea. And it is one that, now that it is in existence, divides views among former health secretaries – but not on party lines.

It is just one of the issues we review as we explore their views around ‘What is the role of the health secretary?’ and ‘What should it be?’

Analysing the views of the former health secretaries

What follows is an attempt to produce an analysis of the views, set out as edited transcripts in part 2 of this book, of the 11 former health secretaries who so kindly agreed to be interviewed. It should be said that some were able to find more time for this than others, so the transcripts are not of equal length. Part 3 selects some key points on particular topics from across the interviews.

Although the broad framework of questions was the same – ‘What is the role of the health secretary? What should it be?’ and so on – the conversations inevitably went off in many different directions with many different emphases. If time were no object, it would have been good to interview everyone again to put points each had raised to the others. Some of the views most often quoted in this section are from some of the more distant holders of the office. In part because it turns out that distance lends a greater perspective. And it should be stressed that what follows is one interpretation of their collective views. It would be possible to produce a very different one, drawing on the same interviews – which is one yet further encouragement to read them.

The transcripts contain the odd minor revelation. It is well known that Margaret Thatcher got cold feet in the summer of 1990 over the introduction in April 1991 of the purchaser/provider split, the so-called ‘internal market’ reform of the NHS. She had Ken Clarke and the department’s senior executives in to Number 10 and was close to pulling them until Clarke made it clear that if she did so, he would resign. What has not been known – or not known until Clarke’s successor William Waldegrave recently published his memoir, A different kind of weather – is that when he took over 5 months before the reforms were to go live, she was prepared to ditch them again.

‘She made it absolutely clear to me that if I wanted to cut the throat of all these reforms, that was fine as far as she was concerned,’ Waldegrave says. Along with Duncan Nichol, the NHS Chief Executive, ‘we persuaded her, and it was a matter of persuasion, that the thing made sense and it wasn’t just Kenneth trying to cause trouble. But it was clear that she had no particular commitment to it at all.’

John Reid – the one health secretary since Ken Clarke we failed to engage with, so he is not represented here – famously went on to describe the Home Office as ‘not fit for purpose’ after he left health. Patricia Hewitt does not use that phrase. But she makes crystal clear her view that ‘the leadership and capability within the department’ was ‘wholly inadequate’ when she took over in 2005 – the unhappy period when the jobs of Permanent Secretary and Chief Executive of the NHS had been combined into one; when the NHS managed to achieve a significant overspend despite record levels of growth; and when a whole bunch of other things went wrong.

Indeed, the politicians’ view that the department, or its management systems, was not always wholly up to the job is a recurring one. Clarke says that in the mid-1980s, and ahead of the Griffiths reforms ‘there wasn’t a management system worth the name’. Frank Dobson says of the late 1990s, ‘it is not the fault of the top civil servants because they are displaying the characteristics that have been expected of them. But it tends to be staffed by people who produce a learned treatise on why the latest initiative has failed, rather than getting somebody who from the start makes sure it works’ – though he very firmly excludes Alan Langlands, the NHS Chief Executive at the time, from that judgement. Hewitt’s criticisms in the mid-2000s have already been referred to.

As the history above makes clear, the ‘top of the office’ arrangements in the department varied markedly over the years. But several health secretaries noted one unique feature of health – that, for many years, it had three permanent secretaries: the departmental Permanent Secretary, the Chief Medical Officer and the NHS Chief Executive. In the days before an NHS Chief Executive it had two – a Permanent Secretary and a Chief Medical Officer, who back then, was Chief Medical Officer not just to the department but to the government as a whole.

That, of course, reflected the unique nature of the department’s responsibilities. That it is clinicians – not just doctors but the whole range of clinicians – who deliver the NHS on the ground, even if the influence of the medical profession collectively on health policy has declined over the years.

The status of these three permanent secretaries varied over time. Frank Dobson declares his surprise when he discovered that Ken Calman, the then Chief Medical Officer, was not involved in policy discussions. He insisted he should be. Given the importance of clinicians in the NHS, Dobson says ‘the idea that major issues are going to be discussed with the Prime Minister, and the Chief Medical Officer isn’t going to be there, seemed to me quite bizarre’. Alan Johnson, who aside from health was secretary of state for work and pensions, trade and industry, education and was home secretary to boot, says, ‘I have never known a department like it… so while the secretary of state was responsible, there was this triumvirate [at the top], well actually a quartet when you include me.’ Only defence, with its armed forces chiefs of staff, who have an ultimate right to go direct to the Prime Minister, was reckoned in that way to be remotely comparable. Others noted how, by the 2000s, health was decidedly different to other departments, with most of the senior officials being NHS managers, rather than it being a classic Whitehall department.

Almost all the health secretaries had held ministerial jobs elsewhere. And despite health having the reputation of being the graveyard of political ambition, the vast majority had held other cabinet posts, often after, as well as before, being health secretary. Almost all said it was by far their most challenging job. The sense of stewardship. The sheer emotion that health generates. And the sense of accountability – and often for things they could not in reality be directly accountable for. All those contributed to the challenge, along with the permanent sense that a scandal or a crisis or just a huge public dispute could erupt at any moment. ‘The toughest job I ever had,’ says Clarke who, among other posts was chancellor, education and justice secretary, as well as being home secretary.

‘Unbelievably demanding,’ says Hewitt, who spoke of lying awake at 3am as she worried about the top of the office after Nigel Crisp’s departure, a time when almost everyone who was senior was there in an acting capacity. The requirement to ‘walk towards the guns’ when things went wrong, as Virginia Bottomley puts it. ‘You had to do the heavy lifting and walk towards the guns… [taking] responsibility for difficult news. I can’t imagine how I survived at all!’

What is the role of the secretary of state?

At the most elementary level, all of the former health secretaries interviewed acknowledged the accountability they held for what is now a £100bn-a-year plus business. ‘There is a custodian role to play, and an accountability to discharge,’ as Alan Milburn puts it. Some put a heavier emphasis on the public health role, either from experience or desire. Andrew Lansley famously and ideally wanted to turn it into the department of public health, with the NHS being the responsibility only of a junior minister once he had set up his commissioning board – NHS England – as a separate statutory body with its annual rolling mandate. David Cameron, faced with one almighty row about Lansley’s legislation and not wanting another, blocked that. Andy Burnham said that perhaps ‘the primary duty’ is to protect the public health, a view perhaps coloured by a pandemic of swine flu being declared by the World Health Organization 3 days into his tenure of the job.

But beyond that, there were many differences in emphasis. Some underlined the stewardship role. Others saw it as being the advocate for change. Clarke put this most clearly. ‘The job is to lead change in response to changing demands and medical advances. To explain why you’re making changes and try to get past the resistance you usually get from the staff, and certainly from the public – although I think people who work for the services have become less aggressively resistant to change.’ Explaining that new requirements – the rise of the numbers of elderly with chronic conditions, for example – means changed services. ‘You have to preside over change and explain it,’ he says.

But Waldegrave shrewdly observed that the job also ‘depends on whether you think the system, at any given time, is in need of policy reform. I came to think it was.’ As, clearly, did Clarke, Milburn and Lansley, while others – Bottomley, Dorrell, Hewitt, Johnson – were, broadly speaking, there to implement, or to enhance, or to adapt a broad thrust of policy that had already been agreed.

Dobson said the job was to implement any manifesto promises because the failure to do that ‘is the most damaging part of politics’. But it was then to ‘try to help all the people involved do their jobs as well as they would like to do them, by removing obstructions and lunacies out of their way and really trying to make the system work, rather than constantly tinkering and pissing around with it’. Though he observes that was ‘an alien concept as far as the Blairite Downing Street was concerned, who wanted an initiative every 20 minutes’.

Which brings up a subject rarely discussed – the relationship between the health secretary and the prime minister. Clarke’s relationship with Thatcher was famously rumbustious – but, as he has said elsewhere, both liked to make their minds up by furious argument. Stephen Dorrell said the role of the health secretary is determined to some extent by the views of the voters, those of the incumbent, and those of the Prime Minister. The views of the incumbent will vary – ‘I have a very strong view about what the role ought to be… which is that you’re not responsible for making all the decisions’. The voters matter because they expect the secretary of state to be accountable. And the prime minister, ‘because for the prime minister, the health secretary is a kind of risk manager. They only have one objective for a health secretary, which is to keep the NHS out of the newspapers… That’s what leads health secretaries into what I think is a blind alley, which is believing that risk management is best delivered by more control.’

Alan Johnson was also among those who felt that part of the job was to manage the prime minister and try to keep him or her out of it. ‘There were things I didn’t want to do that Gordon [Brown] insisted we did like free prescriptions for patients with cancer.’ Not, he felt, a good use of the money when the vast bulk of prescriptions are dispensed free and there is an annual cap available, currently £104, on how much any individual pays. There was – is – often a search for some eye-catching announcement, driven from Number 10. And that has happened under government of all colours. ‘They want to say something on health – so what can you fish up?’ as Johnson puts it.

Patricia Hewitt says: ‘It would help if you had prime ministers who had thought more about health policy and the NHS, and how the two were best approached, before they became prime minister. And that then informed their choice of health secretary. The chance of that would be a fine thing! Not very likely to happen.’

Clarke is most blunt about it. ‘When a prime minister gets panicked and starts intervening, I think it is the duty of the secretary of state to get him or her out of the way. Most of them don’t have the time to know anything about how the health service is run.’ If the health secretary ducks when a crisis occurs, ‘then suddenly the prime minister will just insist on going to Rotherham to start making pronouncements on what they’re doing or something, and you can’t have that. They start stamping their little foot and going for photo opportunities, and trying to get command and control – which they can’t.’ Dobson too sought to resist ‘an initiative every 20 minutes’ even though his period is seen by many as one of the heights of an attempt to run the NHS by command and control.

What should the role be?

There was complete unanimity that ministers should not be involved in the day-to-day nitty-gritty management of the NHS. As Alan Johnson put it – pretty much on behalf of all of them – ‘I don’t think when a bed pan falls on the floor in Tredegar it should echo around Whitehall anymore.’ But after that, there was a wide range of views.

First over how that might be achieved. And second over how far ministers should be, and in practice can be, distanced from broader operational matters – in other words, over how far it is possible, in the real world, to separate policy from implementation, and thus policy from operations and management.

Frank Dobson was the one who declared that – up to a point – ‘I have no problem with command and control. It is part of the secretary of state’s job.’ He cites a range of examples, including his own interventions to get the meningitis C vaccine sorted, to get digital hearing aids introduced and to provide more modern prostheses. He also describes deciding how NHS Direct would be trialled, and then insisting that the civil servant who had got it up and running, but who had been promoted and moved elsewhere, should be brought back.

‘It may have helped that before I was an MP I worked for the Central Electricity Generating Board and I had to organise things and get them done. I worked at making things work before I was an MP. So that may have coloured my view.

‘So my attitude to policy was, “Okay, right that’s the policy, well how do we implement it? Because there isn’t a Rolls Royce machine that is going to implement it”.’

In Dobson’s view, the split of NHS England into a statutorily independent commissioning board is, quite simply, ‘bollocks… the idea that the NHS is going to be this independent organisation, without political interference, and this, that and the other, is just rubbish and it has proved to be just rubbish.

‘Every time anything crops up the [current] secretary of state intervenes and blames somebody else. Because this distancing has meant that he can blame somebody else but not accept any blame himself. Which I think was probably the object of the exercise. But it doesn’t mean that there isn’t political interference… he clearly is interfering all the time.

‘I think the person who takes the decisions should carry the can and the person who carries the can should take the decisions. There isn’t any way in the end… that people will not expect the health secretary to be responsible, and take the blame when things go wrong.’

Stephen Dorrell is no more in favour of a statutorily independent board, although in less colourful language. ‘When people said to me what did I think about the coalition setting up an independent board, I used to say, “Well, I am the person who abolished the last one!”.’

The NHS Policy Board was created by Ken Clarke, although interestingly its role does not feature highly in his memory. It sat above what was then the NHS Management Executive, partly to provide some strategic oversight over the 1991 reforms as they came in, and partly to provide some distance. It was, notably, not independent of ministers, and not statutory – any more than was the management executive, a key part of whose function in the eyes of Duncan Nichol, the then Chief Executive, was ‘separating the role of managers from ministers’.

Waldegrave revamped the policy board. But he faced what he says is the ‘inherent difficulty of trying to separate the management from policy… I didn’t want anybody else, perhaps wrongly, to be chairman of the policy board. So I made myself the chairman. It was implicitly saying that the secretary of state should not just be policy, but should also be an executive. Perhaps I shouldn’t have chaired it. But then this is the inherent difficulty of the whole thing – is it possible, in any business or in any organisation, truly to separate policy from execution? I certainly thought then that to see the policy through, I had to retain the strategic control of what was happening…’

Virginia Bottomley saw the policy board as being ‘outside advisers’. It met in series with the bi-monthly meetings of the then very powerful regional chairs. It might, she says, ‘have been very useful when the NHS reforms were being set up. But creating agendas for both became ridiculous. You tell me Stephen abolished it. Well, he was completely right.’

Dorrell says he attended the board when he was a junior health minister and Clarke was health secretary, while personally ‘not really getting it’ – what it was for. ‘I think I cancelled two, or maybe even three meetings, of this assembly at short notice, thinking I had better ways of spending my time. And it became an embarrassment. It had got to the point where it either had to meet or I had to abolish it. So I abolished it.’

As already noted, Dorrell’s view is that the health secretary should not be responsible for every decision. ‘What you are responsible for is outcomes and structures and incentives. You are responsible for the effect of the decisions, but you’re not responsible for the decisions themselves.’ He agreed that he sought to behave more like the chair of the board of a company than the chief executive – and, in not only this author’s judgement, but in the eyes of others, he is the health secretary who came closest to that. Alan Langlands, who was chief executive at the time, met him, outside crises, once a week – to compare notes and get a lead where he needed it, or when Dorrell wanted to give him one. He was a ‘non-interventionist chairman,’ Langlands has recorded. ‘A big-picture chairman. He was interested in ideas and did not want to get bogged down in detail.’ This does not mean that Dorrell did not introduce change. A significant and modernising revamp of the GP contract, for example, happened on his watch.

But, Dorrell says, ‘all this stuff about creating independent decision making and getting the health service out of politics blah, blah, blah… Well, that’s exactly the same speech that we used to make in favour of the health authorities that were statutorily independent. They existed in statute. They had responsibilities defined in statute. So what’s changed?

‘I’ve never quite believed these parallels with the BBC or the Bank of England’s independence. The BBC is completely different. Voters don’t need to be persuaded that journalism should be independent of politics. They don’t want politicians interfering, so that one’s easy to explain. The Bank of England is trickier. But essentially it only has one target, which is much easier than the NHS which is full of competing desirable outcomes. I was an advocate of an independent Bank. But we don’t yet know, in truth, how the voters will react if inflation gets out of control because the Bank has got its interest rate policy seriously wrong. When we get to that, then we’ll know how well the voters take to the principle of an independent Bank of England. Will they really accept that Mark Carney has an existence in their lives independent of George Osborne when Mark Carney or his successor bogs up and George says it’s nothing to do with him? That will be the test.’

The Independent Reconfiguration Panel has helped, he says. But in practice ‘it has reflected the will of ministers at the time – to allow a process to take place and to give themselves excuses. As far as voters are concerned, the ministers were responsible for the reconfiguration that they’d allowed to happen. You can’t legislate away responsibility.’

That point seems irrefutable in a tax-funded system. When Mid Staffordshire first broke, Alan Johnson had the entire top team in his room and turned to David Nicholson as the NHS Chief Executive. The two agreed that there was no alternative but to get rid of the chair and the chief executive. But Mid Staffordshire, famously, had just become a foundation trust, and Bill Moyes, Monitor’s Chief Executive and chair, piped up and asked, in one sense entirely correctly, ‘under what legal authority, secretary of state, are you going to do that?’ – given that under Labour’s legislation it was Monitor who approved foundation trust status and had the power to replace boards and chief executives. Johnson replied: ‘Look, this is what we are going to do. I’ve spoken to the Prime Minister about it. I’m up in the House tomorrow answering questions about it. I am the Secretary of State for Health. And I’m responsible. And that’s what we are going to do. I don’t give a damn what the legislation says.’

In his interview, Johnson confirms that story. ‘Now, politically, it would be very nice if you could get away with it and say, “That’s yours. That’s your can of worms”.’ Moyes was probably right that the legislation said he was responsible, Johnson says. ‘But I told him, you know, “Piss off. I’m dealing with this.”… You are the secretary of state. There is public money going in there. You are responsible.’

Personally, he says, ‘there was absolutely no way that I would have set up this huge quango, NHS England, to protect ministers from that. There was no way I would have pursued that because it was never going to work. Parliamentarians aren’t going to put up with being told, “Nothing to do with us. Write to NHS England”.’

The lesson that has to be drawn from this is that behaviour trumps legislation. And arguably that can be seen in the time of Jeremy Hunt, the first health secretary actually to operate with Lansley’s statutorily independent board in place. For example, it was Hunt in 2013 and 2014 who decided to inject extra cash for winter pressures; who issued guidance on hospital car parking charges and hospital food; and who personally called hospital chief executives whose A&E performance was slipping – though Hunt says this was in order to understand what was causing that, not to berate them. By early 2015 Oliver Letwin and Eric Pickles were members of a cabinet committee fretting over the NHS’s day-to-day performance in the run-up to the general election.

A tortured debate could be held over whether the first three of these examples are matters of policy or of implementation – an issue to which we will return.

But even Andrew Lansley – the high priest of the ‘depoliticisation of the NHS’ and who enters a fierce defence of his reforms in his interview – concedes that ministers are still intervening on operational issues, whatever the legislation says. ‘I [do] think they’re still intervening – of course they are – but it will get harder and harder over time.’ Of Hunt’s actions, he says ‘he knows he shouldn’t’. But Lansley argues that some of these apparent interventions are ‘stuff which NHS England has in practice decided and ministers are badging for political reasons’. Which, in itself, begs the question of where the divide lies.

Jeremy Hunt was not interviewed for the first edition of this study, but is included for the second. 18 months into his tenure, however, and when challenged that he had at that stage proved a highly interventionist health secretary, he had declared, ‘Any health secretary of any government, with a democratic mandate, has the right to decide on a few priorities. The areas that they think most need change. So I have picked on the areas that I want to focus on. Improving compassionate care – the Francis agenda. Transforming the way we deal with dementia. The technology revolution, and out-of-hospital care. These are areas that I am particularly focusing on. And I think any secretary of state would have those priorities.

‘And I do not think you could do a job like mine without deciding on a few priorities and focusing on how to change those. But I think the day-to-day micromanagement is something that happens less. And I think we have a system that is evolving – it is new. And a system with a mandate where a vast majority of NHS delivery is left to NHS England to deliver as it sees fit and in accordance with what is in the mandate. And it will evolve.’

But ‘I do not think it was ever going to be the case that the secretary of state could step right back’. Asked if that meant that the absolutely pure model of depoliticisation outlined in Lansley’s white paper will never be achieved, he said: ‘I think we are evolving in that way. But we also have to recognise that we are a democracy. And people want to hold people like me, rightly, accountable for over £100bn of public money, and so there are always going to be times when the health secretary has to involve themselves in operational issues.’ His more mature view – more mature because he eventually held the job for 7 years – is reflected in this edition.

Johnson’s view that ministers are responsible does not mean that he believes there are not ways in which some of the politics can be taken out of the NHS, or at least diluted – and that there are ways that some management decisions can indeed be distanced from ministers. All ministers quoted NICE. Johnson used the Independent Reconfiguration Panel that Reid had set up. While, like a wise politician, he ‘never said never’, he did say: ‘I can foresee no circumstances in which I would intervene’ against its recommendations. And he stuck to that. He also set up the Co-operation and Competition Panel. Its non-statutory task was, in Labour’s new world of choice and competition, to advise on competition issues when they arose in the NHS. Johnson admits that choice and competition ‘never really got my juices flowing’ as the key driver for change. But he says of the panel, ‘I can’t remember much about it. It did its stuff and I don’t remember it ever causing us any problems, which is a measure of its success. And now Andrew Lansley has turned it into this monster through legislation, so now we have competition lawyers sitting in the corner every time two hospitals talk to each other.’

Ken Clarke may have set up both a supervisory and a policy board, and indeed had packed the NHS Management Executive off to Leeds in an attempt to separate the management out more from the politicians. But he is deeply unconvinced that a statutory board will seriously depoliticise the NHS. ‘I did used to tell Andrew that his belief that you could depoliticise the whole thing by having this statutory separation for NHS England was highly desirable but very naïve. I said, “You will still find you’re in the middle of rows about bedpans dropped in wards”. He did try to go to huge lengths to detach himself totally from a lot of decision making.

‘Every secretary of state has been trying to depoliticise the daily management of the system, detach themselves from it, because the political arguments are ludicrously unhelpful.

‘But faced with huge petitions and MPs lobbying you in the House of Commons you will never entirely get away with saying “This is nothing to do with me. I have no powers over this”. I think we’re a long way from ever achieving that. But we’ll see how it goes.’

If Johnson’s view is that he would never have set up an independent NHS England, Labour ministers in fact looked at the idea of at least some sort of independent board several times. Gordon Brown trailed the idea in public, ahead of taking over from Tony Blair. Andy Burnham, Johnson’s successor, examined it. ‘The board was discussed at the point of transition [between Tony Blair and Gordon Brown] and Gordon’s team got interested in it. But when we thought about it, it quickly dropped away when you thought about the implications. So we backed off. You simply cannot have £100bn-worth of public money without democratic accountability. I remember people saying, “You couldn’t have MPs writing and the secretary of state saying ‘Oh, don’t ask me’”, which is kind of what happens now.

‘If politics has a respectable role, it’s obviously in providing accountability for taxation. And if that doesn’t apply in respect of the NHS, then what does it apply to?’

Furthermore, Burnham says, he had a similar clash with Monitor to Johnson’s when he discovered that the chief executive and chair at Mid Staffordshire were still interim appointments. ‘I asked “Why haven’t we got the best in the NHS in there now?” and was told, “Oh well, [it is] Monitor – they don’t want to put anybody in. And you set up Monitor and it’s your foundation trust reform.” I basically at that point realised that it just doesn’t work in that scenario. You have to be able to override systems, and the requirements for public safety and good governance means that politicians will occasionally have to step in.’

He adds however that ‘I do think it’s good if secretaries of state don’t get too involved’ while adding that it is ‘a very hard balance’. He would not, he says, get rid of NHS England, though he would probably ‘pull it back in some way’. That ‘doesn’t mean that you then pull everything back in. The Chief Executive, who was based in the department, probably could sit outside of the department and that is a healthy thing – that arm’s-length arrangement. It’s not about saying we just get rid of NHS England. There is a respectable case to be made for running the NHS separate from the government structure, outside the department.’ But ‘there is a debate to be had about statutory independence’.

In Milburn’s time, an independent board was not on the agenda: there was far too much to do in getting the NHS Plan up and running. But he favours in theory the distinction between strategy (something for ministers) and operations (something for clinicians and managers). ‘You separate yourself from the operations, and deal with the strategic. That is the theory. The only thing that buggers it is the practice!’ he says.

The whole thrust of his reforms – giving hospitals a greater statutory underpinning of independence through foundation trust status than NHS trusts had enjoyed, creating the first version of Monitor, introducing a tariff, and the independent sector treatment centres, along with the policies of choice and competition – was about that, he argues. ‘Setting overall objectives, aligning resources behind objectives, sticking to strategy, and keeping out of operations, broadly.’

Organisationally and architecturally, he says, the NHS is a very different model to 1948 and the years of the 1970s. ‘But culturally and politically, it isn’t. We changed some architecture but we haven’t changed culture and we haven’t changed politics. That’s why it’s really hard. Because every time there’s a problem – guess what? Some poor bugger – whether it’s me or Ken Clarke or Jeremy Hunt – will get dragged to the despatch box and have to answer for themselves.

‘In the end, the only thing that can break that is politics. Politics is the trap. And the only thing that can break it is politics. I’m afraid there is not a surfeit of politicians who think that their historical purpose, having got power, is somehow to give it away. That’s what you’ve got to do. That’s what, in a sense, Ken was trying to do. That, in the end, with foundation trusts and markets and all that stuff, is what I was trying to do. That’s an uncompleted journey…

‘So you ask does that mean that I think the idea of NHS England as a statutorily independent body is something that I broadly approve? Well, I think it is a stepping stone. I mean it’s a monstrous bureaucracy. But it is definitely part of that.’ Patricia Hewitt too looked seriously at some sort of independent board. ‘Although the Lansley reforms have created the most appalling mess,’ she says, ‘and a lot of good people and capability have been weakened or destroyed in the process, there is also, I think, a very strong team in Simon Stevens [Chief Executive of NHS England] and those around him. The independence, or greater degree of independence, of NHS England, and the very clear responsibility that they have got for the NHS is, I think, helpful.

‘I was actually quite attracted by the idea of an NHS commissioning role. I had very interesting discussions, both with my special advisers and with officials about it. And they just said, “It’s impossible. You cannot give away responsibility for £100bn. The secretary of state has to be responsible to parliament for that.” Now, actually the secretary of state remains accountable to parliament for it, even under the 2012 Act. But I felt very strongly that there were far too many issues, including clinical issues, coming onto my desk, in a very Nye Bevan way, really. The bedpan dropping in Tredegar. It was quite ludicrous. And you needed an NHS leadership.

‘But the creation of the commissioning board – which in a sense was a logical next step from recreating the split between the Permanent Secretary and the NHS Chief Executive – I think that does have some merit.

‘The distinction between policy and implementation is never as clear as people sometimes pretend. If you make policy without understanding both the constraint of implementation and the possibilities of implementation… then you will get policy wrong. Therefore there is absolutely a risk, if you split it in the way that the commissioning board does, then you weaken the input of implementation into policy. You have to guard against that.’

But, she says, ‘The Five year forward view is essentially a letter which says that “with incredible effort on efficiency, and productivity gains, and some big changes in terms of behaviour, and prevention, etc we can close a large part of [the financial gap]. But we cannot close it all”.

‘I think that’s really powerful. And it would be quite hard to do that with the Chief Executive within the department. Probably impossible. They could do it privately, to the health secretary. But that’s a very different matter from doing it publicly with the authority of the board behind you. Of course there are disadvantages. But that strikes me as quite a big advantage, particularly in the highly uncertain political environment that the UK finds itself in.’

How the world looked in 2015

So what emerges from this? Well, everyone save the man himself was withering about Andrew Lansley’s 2012 Act. ‘That enormous Act was just hubris’ Ken Clarke says, even as he adds that ‘I’m the only politician in the House of Commons who says that Andrew Lansley’s reforms, on the whole, seem to be quite beneficial, and once they settle down they’ll have a good effect.’ Lansley, almost needless to say, is deeply sanguine about it all. Despite the language in his white paper, it wasn’t, he says, about ‘removing politicians’. It was about ‘at least restricting them. Trying to hamstring the politicians a bit. Of course, we will only know in 10 years’ time if it’s worked.’

But what also emerges is that there is in fact both cross-party agreement, and cross-party disagreement, about the merits of a statutorily independent board. On both the Labour and Conservative side, some see advantages in it, some not. Clarke says: ‘The reason I think it is working so far is that the board [NHS England] is not actually asserting itself as a rival centre of power. It is actually giving a clinician-led – apparently clinician-led – lead to policymaking.’

It will work, he says, so long as there is a very close working relationship between the Chief Executive and the minister – something that he argues applies equally to the independence of the Bank of England. As Clarke quintessentially puts it, so long as there is a genuinely close working relationship ‘then he [the governor or the Chief Executive of NHS England] can be as independent as he likes, so long as he is not doing anything that the secretary of state is getting too upset about!’

Almost all the health secretaries were clear that the distinctions between strategy and operations, between policy and implementation, and between strategy, policy and management are, quite simply, not as clear as the policy wonks like to make them in their beautiful organograms of how the NHS is meant to function at any given time. It’s a muddled world. There is ‘the inherent difficulty’, as Waldegrave puts it, of whether it is possible ‘in any business or in any organisation, truly to separate policy from execution?’

All the health secretaries agreed that the personality of the incumbent, and the way they choose to operate, or the way they instinctively operate, matters – whatever the legislation says. From Virginia Bottomley (though she was far from the only one) being obsessed about the media coverage – in her case because she cared about its impact on the staff and patients; to Stephen Dorrell’s more chair of the board-like behaviour; to Frank Dobson ‘wandering up and down the ministerial corridor in my stockinged feet, like the non- executive chairman’; to the mighty reforming drive of Clarke and Milburn (whatever your views on the merit of those changes); to the gentle, humour-laced, reassurance that Alan Johnson brought to the job, along with a hint of steel. In each case, behaviour matters. It trumps legislation.

And, for all the fact that most of the changes that directly affect patients in the NHS are clinically driven – by medical advance or by evidence that shows there is a better way of organising services, or by patients’ views of the service, or by changing clinical needs – the main policy changes to the infrastructure and the incentives in the NHS come from politicians. The guardians of the taxpayer’s pound. Or at least they do in the politicians’ eyes.

Milburn says: ‘Now I might have been either a terrible secretary of state, or I might have been just an aberration, but reform didn’t come from the system.

‘Why do people, whether it’s right or wrong, why do they now rather, through rose-tinted glasses, look back fondly on my time? Why? Because they feel that there was clarity. There was energy. There was determination. And there was shared mission because actually we were smart enough, I hope, to construct a shared view of what we wanted to do. It was because politics was driving it. So I think you’ve just got to be a bit careful with this debate because it can very easily turn into – “if only the politicians got out of this, everything would be wonderful”.

‘If they do, fuck all would happen because what do systems do? What do bureaucracies do? They don’t change. By definition they don’t change so you’ve got to have a shock. Politics should be able to provide shock.’ Clarke certainly provided one. So did Lansley, though as the other health secretaries make clear, that was another matter.

Dorrell says: ‘You’ve heard me say it, times without number, that actually health policy hasn’t changed. Frank Dobson would like to have changed it and wasn’t able to. But apart from him, no health secretary has wanted to change policy since 1991, which is the day when it really did change. We used to have a provider-led system; we now have a commissioner-led system. That is different. But it’s the last time anybody fundamentally changed health policy. The question lies between the concept and the execution. That’s where the story is – and the disability, the powerlessness of commissioners, is the result of consistent execution failure. But that’s hardly surprising when successive governments have reorganised the commissioner side every 5 years. Well, of course it doesn’t work if you change it every 5 years.’

There is a lot of truth in that. But as already noted, Waldegrave’s first observation was that ‘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’.

Andy Burnham says: ‘It all depends on the context, it really does. I would encourage you to think about this, because every secretary of state operates in a different context. I’ll give you two things I know very, very well. Number one was a financial meltdown, which you remember well. It was one of those things where the system almost collectively loses its way. It does need to be, one by one, brought back into a proper financial position. I saw Patricia do that, and it was successful.

‘The second example from my time was swine flu… people think about Mid Staffs. But the thing that was most immediate for me was swine flu. I remember being in the secretary of state’s office, asking, “What does it mean?”. They explained the arrangements that were going to kick in – ‘Gold Command’ and all this kind of thing. I remember David Nick [Nicholson] winking at me saying, “We’re in command and control mode now.” It was a self-reflective, self-deprecating joke. But it was important. We did have to go into that mode… and people wanted us to. Very clear advice, instructions to PCTs, instructions through NHS Direct. We did have to have some negotiations with the GPs. But once that had been done, it had to be implemented in full. In those early days when the pandemic had been declared, it was pretty serious. Although it turned out not be as bad as people feared, it was pretty frightening for a while.

‘When the Lansley reforms came along, we said, “what are you going to do in a similar situation?” The beauty of the secretary of state’s power is that it is there. Yes, in ordinary times you would expect an individual to use it with a very light touch and permissive feel. That would be the ideal. But there will be moments where, because it’s there, you can use it to its full benefit to protect the public.’

Or to put it another way, in Virginia Bottomley’s words, there is an irregular cycle to these things – how far management responsibility can be devolved when policy is changing. She came, she says, ‘to like the idea of an independent board… some distance from ministers for the NHS’. And some distance, in one form or another, was something that all those interviewed favoured.

‘But there are different times in politics’ she says, ‘and it does go in cycles’. There is a truth in that which she did not mention but which can, for example, be traced back to Enoch Powell’s hospital plan and his ‘water towers’ speech, or to Barbara Castle’s promotion of the need to do something about the ‘Cinderella services’.

‘Sometimes,’ Bottomley says, ‘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 my job, after the election [in 1992] was that we’d got some trusts and fundholders up and running and my task was to get all of that beyond a tipping point. Quieten it all down. Show them you care. And then a new set of problems will arrive and you need a Ken to break the windows again.’ Just as Milburn did.

For all that, however, there is a long-run journey here that can be seen to be playing out. The service moved from being an essentially administered one in the 1950s and 1960s to a managed one in the 1980s as ministers searched for levers that they could pull so that democratically elected politicians could be more confident that nationally expressed policy was implemented on the ground. In the 1990s, more market-like mechanisms (though nothing like a proper market) were instituted in an attempt to move away from that directly managed service to what Labour later called a more ‘self-improving’ one.

Put another way, the long-run story is that as the NHS moved through these three stages ministers first sought more control over the management of the service then tried, far from always successfully, to give it away.

That long-run period did indeed involve genuine attempts by ministers to distance themselves from the management of the service – even as, paradoxically, those very changes not only made command and control more possible, they also sometimes required it. The laying down of market rules, for example, or the introduction of independent sector treatment centres as an attempt to boost competition.

It is also impossible to ignore secular trends here. For example, the arrival of information technology – essentially computing and email. First computing made it possible to collect more data to analyse and understand and use to influence performance. And then email provided a speed of communication up and down the NHS that was unthinkable at any time until the late 1990s. Both proved powerful centripetal forces.

But, as Dorrell says, ‘it’s all about pushing it down. If you don’t do that, you have a bunch of disempowered managers.’

Or, as Clarke puts it, ‘every secretary of state has been trying to depoliticise the daily management of the system, detach themselves from it, because the political arguments are ludicrously unhelpful’, even if, as Hunt observes, ‘people want to hold people like me, rightly, accountable, for over £100bn of public money, and so there are always going to be times when the health secretary has to involve themselves in operational issues’. So the question remains. Where does the balance lie? And is it in the right place right now?

But that’s my interpretation of what the health secretaries said. Read the interviews, and form your own view.

The new dispensation

That was where the questions stood in early 2015, quite early in the time of Jeremy Hunt. Hunt would go on, by more than a year, to be the longest serving health secretary.

So how were these questions answered? Well, the first and most obvious conclusion is very differently to how they would have been if Andrew Lansley had remained in post. Behaviour was – yet again – going to trump the legislation.

Hunt became health secretary in September 2012. His marching orders from David Cameron were, he says, simple: ‘Calm down the NHS.’ What the Prime Minister wanted, absolutely, was a glazier – not another energetic window breaker after the trauma of getting Andrew Lansley’s 2012 Act through parliament.

Given that he was in post for almost 7 years, Jeremy Hunt’s tenure inevitably went through phases, though these tended to run into each other. First there was becoming ‘the patient’s friend’, with the quality of NHS care and its safety running as a prime concern throughout his time, like letters through a stick of rock. The second early-to-mid phase was characterised by frustration with the arrangements he had inherited, to the point of seeking first to ignore them, then to work around them, and finally to rearrange them – without taking the legislative powers to do so. Then there was a long period of survival given the lack of money, and what this was doing to NHS performance. And finally, the settlement – the achievement of a 5-year revenue deal for the NHS to coincide with its 70th anniversary. This was only the second time that the NHS had been given such a long-term settlement – even if there were holes in it. In the midst of this, there was a long and bitter dispute with junior doctors that saw medics take strike action for only the second time in the history of the NHS. And throughout the entire 7-year period lingered the continued failure to tackle the ever more pressing issue of reforming the funding and operation of social care.

The patient’s friend

The opportunity presented itself immediately, if not to calm things down then to at least move away from the furious arguments about structures, privatisation and markets that Lansley’s Act had engendered. For within weeks of Hunt’s arrival, the second Francis Inquiry was due, which had been hanging like a gibbet moon over the NHS. Everyone knew it was coming. And it inevitably reprised the dire events at Mid Staffordshire hospital as it strove to turn itself into an NHS foundation trust at the expense of nursing numbers and the quality of care.

Hunt seized on the Francis report. Partly for what looked to many outsiders to be low political reasons – Andy Burnham, Labour’s shadow health secretary, had been secretary of state at the time Mid Staffordshire was authorised to become a foundation trust. But also for principled ones. Hunt was genuinely shocked and dismayed by what he read; by the tales he heard directly from patients and their relatives who he took the time to meet. And indeed by the sentencing, as he took office, of care workers for the criminal abuse of patients at Winterbourne View in Bristol – a privately run NHS facility for people with learning disabilities.

In his first major speech Hunt seized on these examples to warn about ‘the normalisation of cruelty’, which he said was ‘perhaps the biggest problem of all facing the NHS’. He further cautioned, ‘We have to be much clearer about the consequences if leaders fail to lead, and fail to drive high-quality care throughout the organisation’. He told managers: ‘You wouldn’t expect to keep your job if you lost control of your finances. Well, don’t expect to keep it if you lose control of your care.’

Managers were clearly in the firing line. Hunt was the patient’s friend. In the succeeding months, he continued to highlight a string of NHS failings. A new maternity scandal at Morecambe Bay; the cancer patient who resorted to phoning the police because staff would not listen to him; the death by drowning of a dementia patient who fled the hospital despite being under a regime where he was supposed to be observed every 15 minutes.

To one senior figure in the Department of Health this was a first instance of Lansley’s Act at work. ‘Most previous health secretaries felt the need to defend the service, even as they acknowledged and criticised whatever the failure of the day was. The distance [that the creation of NHS England] provided allowed Hunt to be, much more plainly than before, the patient’s advocate. We had expected that the creation of an independent board was likely to make the secretary of state the champion for patients – holding the NHS to account for improving health care outcomes.’

Hunt’s own view is: ‘That was just me. I think it is the job of the secretary of state to hold public services to account for how good a job they are doing. If I had been here before Lansley’s Act, that’s what I would have done.’

The degree to which Hunt highlighted the service’s failings in these early days led to accusations he was deliberately undermining the service and refusing to acknowledge that it was doing any good. Indeed, a year in, his own minister in the House of Lords, Earl Howe, said: ‘Whilst we don’t want to cover up the bad… There is a need I think for more balance in the messaging… And the language that we use. I’m not keen on the phrase “failing hospitals”… I’ve said to Jeremy Hunt, and he totally agrees, that ministers in particular have got to take the opportunity whenever possible to celebrate the excellent and the good.’

Ofsted-style ratings

In practice, Hunt’s language did tone down not least, perhaps, because the longer he was in office, the more the failings might be seen as happening on his watch. What did not change, however, was the core concern of that first speech – patient safety. It contained the announcement of a study into whether Ofsted-style ratings could be applied to hospitals.

Where did this suggestion come from? The two-fold answer is that while Hunt was no more knowledgeable about the NHS than the average MP, he had made his money running an education business. He knew something about schools. And in the final week of the London 2012 Olympics, for which he had been responsible as then culture secretary, but a time when he knew he was getting the health job, he had run into Tony and Cherie Blair at a Paralympics swimming event. He asked for advice. Tony Blair’s reply was ‘talk to Paul Corrigan’, one of Blair’s former health advisers. Corrigan, according to Hunt, told him that the most important reform of schooling had not been academies, or free schools, or Michael Gove’s then agenda, but the creation of Ofsted way back in 1992. A properly independent schools inspector, with, as Hunt puts it, ‘the power to fail schools and put them into special measures. I was absorbing that, and in my first week in the job I was taking home the original Francis report into Mid Staffs [with the second due to land any day]. My first question was “Why can’t we have an Ofsted for hospitals?”’

The report he commissioned favoured a ratings system for general practice and social care, while giving heavily qualified support for its potential application in hospitals. But an Ofsted-style rating – ‘inadequate, requires improvement, good and outstanding’ – was indeed applied to all three sectors, with new posts of a chief inspector in each area created within the CQC. In a sense this put a renewed emphasis on CQC’s origins. Its first incarnation, the Commission for Health Improvement, had been essentially an inspectorate, rather than, as CQC had become, the body that also licensed and regulated providers.

This initial emphasis on safety and quality ran right through Hunt’s time, and he clearly sees that as one of his big achievements. He would like, he says, to be judged as window breaker rather than a glazier when it comes to safety and quality, with a whole set of additional steps too long to list here aimed at driving quality improvement. These include the introduction of the ‘duty of candour’ and of medical examiners, along with the publication of much more quality and safety data, including avoidable deaths in hospital and mortality rates by surgeon, as well as initiatives that included new methods of peer review. He makes an important point – spelt out in the interview – that transparency alone proved not to be enough, with broader culture change also needed. But with millions more patients being treated in ‘outstanding’ hospitals and GP practices by 2019 compared to 2015, the NHS has, he says, the potential over 10 years to become ‘the safest, highest quality health care system in the world’.

The clockwork universe

Hunt’s two best appointments, he says, were Mike Richards to be the Chief Inspector of Hospitals – and Simon Stevens, to be the Chief Executive of NHS England. Stevens’ appointment took effect 2 years into Hunt’s tenure, and some 18 months after Lansley’s Act took full effect. By the time the Act started operating, David Nicholson, the NHS Chief Executive, had rebranded the NHS Commissioning Board as NHS England. He had taken into it all the department’s medical czars, the responsibility for specialist commissioning (some 20% of the total revenue budget), oversight of the GPs contract and much else. Nicholson sought, in his words, to ensure that the new board had some leverage: an ability to make things happen rather than it just being the licensing and oversight body for the 211 clinical commissioning groups, which was Lansley’s original conception. The result was that far from being the ‘lean’ body that the white paper had envisaged, NHS England started life with 6,700 direct employees and another 9,000 odd in the commissioning support units to support the clinical commissioning groups.

The fact remained, however, that legally NHS England was not even first among equals compared with the many new organisations that the 2012 Act created. It was meant merely to be the overseer of commissioning, and most definitely not the headquarters of the NHS. It was just one of the new arm’s-length bodies intended to operate the much more market-like conception of the NHS that Lansley’s Act intended. These included a new market regulator in the form of Monitor which, aside from regulating foundation trusts was now also charged with ‘preventing anti-competitive behaviour’, and a Trust Development Authority to oversee those NHS services (including, still, almost half of all hospitals) that had yet to become foundation trusts. Plus the revamped CQC, Public Health England and Health Education England.

These arrangements have been dubbed by one of the most senior figures charged with operating them as a form of ‘clockwork universe’, in which the various incentives and penalties of this much more market-like approach – of choice and competition – were meant to produce improvement. The immediate result was frustration all round.

Hunt had arrived from the Department for Culture, Media and Sport – something of a ragbag department that exercises its functions almost entirely through its interaction with more than 40 arm’s-length bodies. These ranged from the British Museum to the Horserace Betting Levy Board and the UK Anti-Doping Agency. In one sense, this was no bad preparation for the ‘perfectly incentivised perpetual motion machine’ that Lansley had devised for the NHS, where everything was to operate through statutorily independent boards and regulators. Within this the department’s chief job would be to set the rolling annual mandate for NHS England – what ministers expected it to achieve – and then hold everyone to account.

Hunt says that in many ways he was ‘familiar with the structures in the 2012 Act because when I was culture secretary, I was responsible for the arts. The Arts Council operates operationally independently from DCMS, so the culture secretary doesn’t decide which arts bodies get what funding, that’s decided at arm’s length. But I met with the Arts Council every week and we made enormous progress in important areas. So, I was quite used to the idea of having a close working relationship with someone who has constitutional independence.’

At culture, Hunt had handled his hugely diverse brief by choosing his key priorities and holding a weekly meeting on each of them. He did the same at health. But such is the media and parliamentary spotlight on the NHS that he felt the need to hold all of them on a Monday morning to be on top of the week ahead. The result was his famous Monday morning meetings, with senior figures from NHS England, Monitor, the TDA, the CQC, Public Health England and at times Health Education England queued up for these events alongside a wide range of civil servants and political advisers (including, fairly regularly, Nick Seddon, Cameron’s adviser from Number 10).

The tensions this approach initially caused have been detailed elsewhere. But the key point, as Richard Douglas, the department’s long-standing finance director has put it, is that Hunt’s approach was ‘totally not what Andrew wanted from this. Andrew genuinely wanted to do it in a hands-off way. Jeremy was the exact opposite. Jeremy never recognised the distinct roles of any organisation in the system. For him, whatever the rhetoric, NHS England was the headquarters of the NHS in England, not the commissioning board, which had been designed not even to be first among equals. He didn’t recognise what the Trust Development Authority was, or what Monitor was, or the distinctions between the two. That was not Jeremy’s way of working. These were all people who were to deliver the things he wanted. So, it was a complete contrast of world views.’

And in Hunt’s view, whatever the Act said, and however it was meant to operate, he was in practice responsible for the NHS’s performance. ‘We are a democracy. And people want to hold people like me, rightly, accountable, for over £100bn of public money,’ Hunt has said. ‘You are on a hiding to nothing if you try to pretend that the secretary of state is not in the end responsible for everything.’

Hunt found, however, that he had precious few levers to pull, and that these new arm’s-length bodies were themselves constrained in what they could do. ‘It frankly was completely ridiculous,’ he says, ‘sitting round the table and when you’re trying to, you know, work out the right policy for something’ – whether waiting times, or deficits, or quality initiatives, or how to deal with winter pressures. ‘For example,’ he says, ‘you’d be dealing with Mid Staffs and have to turn to David Bennett [the Chief Executive of Monitor] to talk about one half of the NHS, and David Flory [Chief Executive of the Trust Development Authority] to talk about the other half. And David Bennett would say “Well I can’t actually instruct a foundation hospital to do this and that, but I can try and make it happen through regulatory levers” and David Flory would say “Well… I can instruct [his half]”.’ The complexity of the structures was, Hunt says, ‘extremely unhelpful’. And there were clashes as Hunt sought to manage what was, from the secretary of state’s point of view, the unmanageable. Both Bennett and Flory, for example, refused to fire the chief executives of 11 hospitals that were put into special measures following one of the post-Mid Staffordshire exercises.

Breaking with the Lansley doctrine

In these early days, Hunt was also a policy activist on smaller issues. He issued guidance on hospital food, on car parking charges, and that the name of the consultant in charge should be at the head of every patient’s bed – and he took to phoning hospital chief executives to try to understand the causes of the pressures they were under. Hunt has always insisted these were not, as they were widely perceived, phone calls to chastise chief executives whose waiting times were slipping, but part of a genuine desire to understand. All this, however, felt far more activist than Lansley’s intention of ending the ‘political micromanagement’ of the service.

Slowly but surely that began to change, with the watershed perhaps being David Nicholson’s decision to depart in April 2014, a year into the new dispensation and after more than 7 years as NHS Chief Executive. Relations between them had become somewhat strained, although Hunt was later to judge, ‘There is no more effective manager in the NHS than Sir David Nicholson.’

His departure saw the arrival of Simon Stevens as the Chief Executive of NHS England. Previously health adviser first to Frank Dobson, then Alan Milburn and finally to Tony Blair, Stevens had long been seen by many senior NHS figures as the ‘king across the water’. Even if those who believed the 2012 Act was aimed at the mass privatisation of NHS services were deeply suspicious of his appointment, given he had left his political health advisory roles to take senior positions with United Health, the giant US health insurer. There he had lobbied for Obamacare and worked in Europe and South America. He brought with him an almost unrivalled knowledge of health care internationally and a deep understanding of the NHS and its history. Some may question his abilities as a manager: very few his skills as a strategist and small ‘p’ politician. Indeed, as Hunt says: ‘Simon is a very accomplished politician’.

Stevens’ first substantive act was to produce the NHS Five year forward view (2014), technically a joint production between all the arm’s-length bodies and in practice Stevens’ view of where the NHS needed to go. Nicholson had already produced a document to coincide with the NHS’s 65th anniversary in 2013 that had made the case for better integrated care, with more of it taking place outside hospital, although that had garnered remarkably little attention.

It was the Five year forward view, however, which marked the complete break with the Lansley doctrine. The former health secretary’s white paper had been stuffed with more than 80 references to ‘choice’ and ‘competition’ as the driving force for NHS improvement. The Five year forward view mentioned neither – save for patients needing choice about the nature of their treatment. The simple message was that what the NHS needed was pretty much the opposite of competition – it needed much better integrated care in order to end the near 70-year divisions between hospitals, general practice and community services, while health itself needed to be better integrated with social care. The document was also arguably the first in the NHS’s history to say that the management arrangements to achieve this did not have to be the same everywhere.

Across England, some 44 sustainability and transformation partnerships were in time charged with working out their own way of getting to the document’s goals: an approach that up to the time of writing has largely held through the successive iterations of this approach. The document also made a very public bid for additional resources – something that previous NHS Chief Executives would, of course, have done in private, but would not have been free to do in Stevens’ very assertive, public way as Chief Executive of an independent board. Indeed, as the spending squeeze continued and performance declined over the years, Stevens’ repeated defence was that the service and social care had not been given the cash that he had called for. No previous NHS Chief Executive could have used that so aggressively as a public defence. Stevens’ arrival thus significantly recast the relationship between Hunt and NHS England, though in a direction that the health secretary says he was entirely happy to see.

Hunt is pretty withering about Andrew Lansley’s Act. ‘I came to a very different view over my time as health secretary about the best way to organise the NHS and I see Andrew’s design as really the logical conclusion of the structures that Ken Clarke implemented with the internal market and Alan Milburn turbocharged with the introduction of the private sector.

‘But that model of health care was designed in a world where the biggest issue was waiting times for elective surgery. So, the big priority of the Blair government was to bring down waiting times for elective surgery and they wanted to create incentives for activity and indeed competition from the private sector… and it worked, it did work. And so Andrew’s reforms, and the reliance on choice and competition, were the kind of logical conclusion of that.

‘But what actually happened towards the end of the first decade of the century was an understanding that the main business of health care going forward was actually going to be wraparound care for older people, rather than discrete replacements of hips and knees. And so when you start thinking about an 80-year-old woman living on her own with the first stages of dementia, diabetes and COPD, the most likely place for her to end up in the world of the 2012 Act is A&E, when actually any doctor would say that the most important thing to do is to give her wraparound care at home so she doesn’t need to go to A&E. And that means joining up services in a way that wasn’t really envisaged in the 2012 Act. So that’s why we did spend a lot of time trying to work out how we could integrate care despite those statutory constraints.’

As a result, Hunt does not disagree with the quip by David Bennett, the former Chief Executive of Monitor, that the 2012 Act may not have been changed in Hunt’s time – ‘It’s just been ignored.’ Indeed, Hunt himself says it was ignored, ‘as far as we could!’

The changes that are summarised here took several years to achieve. But as deficits mounted, and as CQC’s new inspection regime took effect, it became painfully clear that there was no real correlation between whether a hospital was a foundation trust and its rating either as good or outstanding. Some high performing ‘ordinary’ NHS trusts – those that had yet to achieve foundation trust status – were doing better, in terms both of deficits and their CQC rating, than many foundation trusts. The distinction between the two types of hospital was disappearing. As Hunt puts it, ‘The foundation trust regime had not really been that driver for quality that we hoped.’

So, first the TDA and Monitor were merged into NHS Improvement, though not legally because legislation prevented this. ‘We found a wonderful workaround, which was you would have legally separate bodies with exactly the same people on the board,’ Hunt says. And then, step by slow step, with the process largely completed in 2019, NHS Improvement was merged with NHS England. Although, again, not legally and with the legal workarounds needed to achieve this proving even more tortuous.

Long before this was completed, it was clear that NHS England was becoming something very different to just a commissioning board. It was in practice becoming the headquarters of the NHS, although tensions remained for a long time, and are still visible, over the regulatory and managerial roles of NHS Improvement (the old Monitor). And the fact that Stevens could not legally manage or direct NHS trusts – or indeed direct Health Education England or Public Health England. Since 2013, the challenges of fragmentation at the top of the NHS have diminished. They have not, however, been removed.

Equally clear was that, in public at least, the strategy for the NHS – the drive for better integrated care – was being set by Stevens, not by Hunt. But as waiting time targets came to be missed by ever growing margins, and as what had traditionally been winter pressures recurred annually and then ran on through the summer, it was Hunt who was the front person – taking responsibility not just in parliament but in the media.

Early 2018 saw the worst yet of these winters. With the Red Cross claiming it was helping to deal with ‘a humanitarian crisis’ in the NHS, and with doctors saying that patients were dying on trolleys waiting for treatment, Hunt told the BBC what was happening was ‘completely unacceptable’. There was, he said, ‘no excuse’ but ‘we are trying very hard to sort these problems out’. In the past, a winter crisis on that scale might have done for a health secretary. But as Hunt declared ‘I am responsible’, neither the opposition nor the media were able to lay a glove on him. He survived. And that might indeed be part of Lansley’s Act operating. The secretary of state was both responsible, but not responsible, given that the actual operation of the NHS now sat with independent boards.

This divide – Stevens setting out the strategy, Hunt taking public responsibility for the performance – led some to argue that the Act was almost being turned on its head. Stevens acting more like the secretary of state and Hunt more like its chief operating officer. It is an analysis that Hunt, unsurprisingly, rejects. ‘I think right from the start Simon Stevens and I took the view that we were one team. I won’t say we didn’t have disagreements. Some disagreements are inevitable. But we took the view that we were one team, and we had to make the NHS work for the country.’

So while the Five year forward view, and its subsequent iterations, were Stevens’, they were also, Hunt says, his. ‘Given the controversy of the 2012 Act, it made much more sense for the future coordination of different parts of the NHS to be led by the NHS itself and the Chief Executive of the NHS. I agreed with every word of the forward view. I supported it. I wouldn’t have allowed it to come out if I hadn’t agreed with it, and indeed I made changes in a few areas where I wanted the emphasis to be different.’

‘But the thrust of travel I absolutely agreed with. Had it been my document as opposed to Simon’s document it would have been immensely controversial. It would have been dissected. People would have said “This is Lansley mark two, this is another top-down reorganisation,” – and that was the last thing the NHS wanted. It was owned by the NHS. And I think that was Simon’s great genius actually, to recognise that in order to get consent to go forward for very important changes, the NHS needed to feel that it owned the changes, rather than them being imposed by the politicians.’

The same was to apply over what historians may also judge to be one of Hunt’s bigger achievements – even if it received a somewhat lukewarm reception when it arrived. Namely, the 5-year revenue settlement at 3.4% real terms per annum for the NHS that was delivered in 2018 to coincide with the service’s 70th anniversary.

Hunt’s political opponents, and indeed many in the NHS, will always criticise him – indeed blame him – for the long financial squeeze and its effects on performance that marked most of his time in office. The fact remains that, over a long period of austerity with huge spending cuts in other departments, the NHS got a better deal than any other public service, and Stevens and Hunt turned to advantage that winter crisis of 2018 and the looming 70th anniversary.

Indeed, Hunt insisted on staying at the helm when, in January 2018, Theresa May proposed moving him to the business brief. The Prime Minister, he says, was ‘visibly shocked’ when he refused to move. ‘I thought it was probably going to be ending my career in cabinet when I said that, because prime ministers have to choose who they want. I wasn’t trying to play a game, but I genuinely thought it would be dishonourable to stop being health secretary in the middle of the most appalling winter crisis, where the flu situation was at near record levels. And so I just thought it was wrong to change the captain on the ship at that time… I felt I needed to see the crisis through.’

In addition, he says, ‘There was something else important in the back of my mind, which was that it was 6 months before the NHS’s 70th anniversary. I thought that as an experienced health secretary I could negotiate a new financial deal for the NHS in time for that 70th anniversary in a way that a new health secretary wouldn’t be able to. I thought that if I move now, the Treasury will win the battle and there won’t be a new financial settlement for the NHS.’

Again, in public, it was Stevens rather than Hunt making the case for that long-term settlement as a 70th birthday present. But for all Stevens’ powers of persuasion and political savvy – annexing the Brexit campaign’s promise of £350m extra for the NHS, for example – such deals are finally done, and are signed off, by secretaries of state.

Hunt’s version is that ‘I worked hand in glove with Simon. I mean Simon made the noises in public, but I had to back them up in private and do the negotiations in private. What I identified right from the start, in the autumn of 2017 actually, was that Number 10 and Number 11 were never going to believe figures produced by the Department of Health and the NHS in terms of the NHS’s funding requirement.

‘So I persuaded Jeremy Heywood [the Cabinet Secretary] to get the Cabinet Office to do an independent study of what the NHS actually needed, and I argued very strongly that it needed a 10-year plan. If it takes 7 years to train a doctor and 11 years to train a consultant, then you have to have some kind of stability over a 10-year period, and in the end we had a 10-year plan but a 5-year funding settlement. But 5 years is longer than the NHS had ever had before and Jeremy got the Cabinet Office to produce a very good document which showed that the NHS, at a minimum, needed between 3 and 3.5% real terms increases for each of the next 5 years. That then became the starting point at the discussions. Number 10 accepted it, and the Treasury found it very hard to argue against that.’

‘So, we then had a series of very challenging meetings with Philip Hammond and his Treasury officials. But there was a moment in those meetings when the Prime Minister said in a rather exasperated way to Philip, “Let’s face it Philip, the NHS does need more money.” So while she wasn’t necessarily involved in the details of it, the Treasury understood that’s what she wanted to do. Unfortunately, they did not get the signal that she wanted to do a deal on social care, and so that was put back and that is still unfinished business as far as I’m concerned.

‘The landing zone between what Simon believed the NHS needed and what the Treasury was prepared to give was very, very narrow indeed. We secured from the Treasury the very maximum that they were able to give, and that was the very minimum that Simon thought was necessary. So, we got there.’

That settlement came under fire from health think tanks and others for being a revenue-only deal at a level lower than they judged needed, with money for capital, training, education and social care left for another day. Hunt acknowledges that. ‘But it was the starting point. And revenue is the most difficult.’

Opening the door to reform

Likewise, as a starting point, it was on Hunt’s watch that the door to amending Lansley’s Act finally began to nudge open. The Conservative manifesto for the 2017 election stated, ‘If the current legislative landscape is either slowing implementation [of better integrated care] or preventing clear national or local accountability, we will consult and make the necessary legislative changes.’ And that included, in slightly antiquated language, ‘the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy’. In other words, Theresa May’s government looked prepared to take the heart out of the Lansley Act. Her loss of a majority put paid to that in the short term. But detailed proposals for a set of changes to the legislation have since been drawn up by NHS England, with broad backing from the Commons Health Select Committee. These include changes to the procurement rules, which would provide much more discretion over whether services should be put out to tender, thus further diluting the competition elements of the 2012 Act, and a proper merger between NHS England and NHS Improvement.

There are, however, reports that Matt Hancock, Hunt’s successor, would like some additional powers of direction over NHS England as part of that legislation. Hunt appears not to see the need. ‘I never felt that I couldn’t get the NHS to do what I needed it to do, and I wanted it to do… we’d sometimes have a debate about how to do it. Sometimes, we’d have a great big argument, for example when it came to the junior doctors’ dispute. Basically it was never difficult to have a big discussion to come to an agreed plan. So I didn’t particularly find that the NHS was going off doing stuff that I didn’t want, or not doing what I wanted it to.’ He never felt, he says, that ‘I lacked a power to give directions’.

In rather polite language, Hunt is clearly highly critical of the Lansley Act. He sees it as the solution to yesterday’s problems while creating complexity, fragmentation, and ‘frankly ridiculous’ splits of responsibility – which he and Simon Stevens have done as much as they can within the existing legislation to work around.

But the one piece Hunt has said he would keep from the 2012 Act is the statutory independence of NHS England. ‘The independence of NHS England is the bit that has worked best,’ he says. It has allowed the NHS to be seen to be setting its own direction of travel, rather than that being something that the politicians have imposed. And it has allowed ‘a whole raft of decisions that would have gone past ministers to be been taken operationally, independent of ministers’.

‘We have moved away from ministers saying, “I want to make an announcement on cancer and find me £50m that I can just announce for a new cancer plan and get lots of headlines,” and then the next week, “Find me £50m so I can do something on dementia.” All that kind of itsy-bitsy announcement-itis got put at arm’s length and became decisions for NHS England. And I think that depoliticised a lot of the day-to-day decisions by the NHS.’ And, some of Hunt’s early pronouncements aside, that seems a fair judgement.

Where are we today?

In terms of the focus of this study – the role of the health secretary and their relationship with the NHS – where does all this leave us? With the qualification that the long-term impact of COVID-19 may itself change the way the NHS operates.

The 2012 Act essentially had two aims. The first – the core aim – was to run the NHS on much more market-like lines. Its aim, in the words of the white paper, was ‘a system of control based on quality and economic regulation, commissioning, and payments by results, rather than national and regional management’. The second, a consequence of the first, was that by putting the operation of the NHS in the hands of independent commissioning and regulatory bodies, there would be an end to ‘political micromanagement’, ‘political interference’ and ‘excessive bureaucratic and political control’ of the service.

On the first of these – making choice and competition the way to run the service – the 2012 Act has clearly failed and done damage. It has not led to a more market-like way of running the NHS. Indeed, despite some limited growth in the private provision of NHS services, something much closer to the opposite has happened. By way of integrated care systems, the NHS is moving back to a much more managed approach. A large-scale effort at a more local level, but also a more national one, has gone into tackling the huge fragmentation that the Act caused – witness the de facto if not de jure merger of several of the bodies that the Act created. NHS England is becoming something closer to the sort of corporate management board that Chairman of the NHS Management Inquiry Sir Roy Griffiths recommended back in 1983, though of a rather larger size. It is certainly not the sort of board that Andrew Lansley envisaged.

The Act has also clearly changed – indeed diminished – the department’s role. It may work with the secretary of state to help decide his or her priorities. It monitors progress and helps set the mandate – a document that few inside the NHS or outside it pay much attention to, but which does still set the NHS’s priorities for the year, and years ahead. But the department, other than supporting the health secretary’s quizzing of, and demands for action from, NHS England and the other arm’s-length bodies, clearly no longer seeks in any way to manage the NHS and its services. It does retain more of a role in public health, with Public Health England being an executive agency of the department, unlike its partial predecessor, the Health Protection Agency, which as a non-departmental public body was more independent. But this may change. At the time of going to print, government is embarking on a major restructuring of the national public health infrastructure.

On the second essential aim, the judgement has to be much more nuanced. The Act has clearly not ‘depoliticised’ the whole issue of the NHS because, as Hunt says, in a democracy people will quite rightly want to hold the secretary of state to account. But it does appear to have reduced ‘political micromanagement’ of the NHS, even if that has happened in a rather different way to the one Lansley intended. In so far as the service is managed at national level, it is now managed out of NHS England and NHS Improvement, not out of the department.

This author would also share the view of Jeremy Hunt (a politician) and Richard Douglas (an official) that the creation of NHS England as an independent board, along with the mandate – the rolling set of marching orders that ministers agree with the board as the political priorities – has led to fewer, un-resourced, new initiatives being loaded onto the service. This is hard to prove in the absence of a counterfactual. But as Hunt notes (though after a flurry of announcements in his earlier years) – there are fewer ministerial announcements of several million here, or several tens of millions there, to keep ministers in the headlines.

Further, the existence not just of an independent Chief Executive but of an independent board to back him or her, has seen NHS England resist some ministerial requests and demands. In 2017, the board refused to take on responsibility for balancing the books of the NHS as a whole, arguing it did not have the powers to do so. And in the same year, after Simon Stevens had spelt out that the lack of cash meant that some waiting times would increase, the mandate retained the aim of meeting the 18-week wait for elective treatment in 2020. But, unlike previously, it was silent on what would happen in the intervening years. That could be viewed as a good or a bad thing. Rising waiting times are not good, but the absence of a promise to hit them in the short term was at least honest. It reflected the reality, so in that sense was good.

On top of this some key and controversial decisions that would otherwise have been ministerial pronouncements have been taken by NHS England without any visible ministerial involvement. For example, the decision that NHS England could ask NICE to recommend the phasing in of new treatments if they were going to cost more than a given threshold in their early years.

It is also clearly the case that previous chief executives, operating within the department, would not have been able to make such an aggressive and public case for the funding of the service and of social care. Or indeed have set out, as Simon Stevens has, the NHS’s own programme for how it is intended to change. The Act has had the effect of giving the NHS its own voice.

Plainly too, the secretary of state’s relationship to the service has changed. As Hunt put it back in 2014 when he said it was ‘evolving’ – it clearly did evolve during his time. Both as personalities changed, and as what was and was not achievable within the confines of the Act became clear. On both that, and on his evolving approach over how to achieve improvements in quality and safety, Hunt had the advantage, offered to relatively few health secretaries, of a long period in post: the time to learn in office about how best to achieve change, given the circumstances of the day.

At the end of his tenure, Hunt puts it: ‘I felt accountable for the NHS, but in the same way that the culture secretary is accountable for the arts, or the home secretary is accountable for the police, even though the home secretary doesn’t direct the police – an element of [the] arm’s-length relationship. When you have got 1.4 million people working for you, the issue is not the ability to give directions. The issue is whether people are listening and do what you ask them to do. The great skill with the NHS is to find a way where people listen to what you’re saying and respond to it.’

The big question is whether an independent board – with a significant element of an independent voice and its own ability to shape the strategy of the NHS – is a structural change that will last. Or has it been chiefly a function of the relationship between Hunt and Stevens, and their personalities and abilities? At the time of writing, the relative independence of NHS England/Improvement appears to have survived the arrival of Matt Hancock (with the qualifications that, as already noted, it is said Hancock would like more control, and that the COVID-19 pandemic may produce its own changes in the relationship).

But to this author, Hunt appears to have been a somewhat unusual politician in his time as secretary of state. Happy to operate quite often in the background, allowing Simon Stevens’ undoubted talents to be exercised. Happy to forego cheap ministerial headlines, while being willing to take the public flack when things were going badly.

It is worth noting that the one bit of Lansley’s grand plan that David Nicholson favoured was the opportunity for the NHS to operate more independently through a statutory board. And that independence has seen NHS England, rather than ministers, become the primary owner of the move to better integrated care. As Hunt says, up to a point, the strategy has been ‘owned by the NHS’ rather than being seen as something ‘imposed by politicians’.

Whether the goal of much better integrated care will be achieved remains an open question. As indeed does whether the independence of NHS England will survive the departure of Simon Stevens – as and when it happens – or indeed whether it will survive whatever legislation comes next. It may be that Hunt’s tenure between September 2012 and July 2018 is a classic example of behaviour trumping legislation – defined by the particular talents and particular relationship between two key protagonists. Whether that is the case, or whether there is a lasting structural change here, will be the next chapter in the 75+ year saga of ministers’ relationship with the National Health Service.


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  15. Healthcare on the Brink of a Cultural Revolution. Financial Times; 16 January 2011.
  16. Timmins N. Never again: The story of the Health and Social Care Act 2012. Institute for Government and The King’s Fund; 2012.
  17. Waldegrave W. A different kind of weather. Constable; 2015.
  18. The World’s Biggest Quango: The First Five Years of NHS England. King’s Fund and Institute for Government; 2018, p 50
  19. WBQ, ibid, p 50–51
  20. Rating providers for quality: a policy worth pursuing? Nuffield Trust; 2013 (www.nuffieldtrust.org.uk/research/rating-providers-for-quality-a-policy-worth-pursuing)
  21. WBQ p 42–43
  22. WBQ p 54–60
  23. WBQ pp 94 and 108
  24. WBQ p 59
  25. Jeremy Hunt. Wanted: a big hitter to get a grip on contact tracing. The Times; 21 April 2020: 24
  26. The NHS Belongs to the People: A call to action, NHS England; 2013. (www.england.nhs.uk/wp-content/uploads/2013/07/nhs-belongs.pdf)
  27. WBQ p 95
  28. Ministers Reflect interview with Institute for Government. January 2020. (www.instituteforgovernment.org.uk/ministers-reflect/person/jeremy-hunt)
  29. The NHS’s recommendations to Government and Parliament for an NHS Bill. NHS England and NHS Improvement; September 2019.
  30. The NHS’s recommendations to Government and Parliament for an NHS Bill. NHS England and NHS Improvement; September 2019.
  31. WBQ p 108
  32. WBQ pp 80–81

* In this speech, Powell spoke about the huge psychiatric institutions, saying: ‘There they stand, isolated, majestic, imperious, brooded over by the gigantic water tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity.’ These, he said, were ‘the defences we have to storm’ setting ‘the torch to [their] funeral pyre’.

For accounts of the origins, nature and impact of the Griffiths report see: Edwards B and Fall M. The executive years of the NHS. Nuffield Trust. Radcliffe Publishing, 2005; Timmins N. The five giants: a biography of the welfare state. HarperCollins, 2001; Klein R. The new politics of the NHS. Any edition but in the 7th Edition pp117–123.

For an account of the origins of the review and its immediate impact see: Timmins N. The five giants: a biography of the welfare state. HarperCollins, 2001; Klein R. The new politics of the NHS. Radcliffe, 2006. For more academic assessments of the longer term impact of the reforms see: Klein R. The new politics of the NHS; Le Grand J et al (eds) Learning from the NHS internal market: a review of the evidence. The King’s Fund, 1998.

§ For a detailed account of how waiting times were driven down, see Road to recovery. Financial Times weekend magazine, March 13/14, 2010: 14–29.

The fine phrase ‘targets and terror’ was coined by Gwyn Bevan of the London School of Economics.

** For an account of how procurement and competition law came into the NHS see: Timmins N. Never again: the story of the Health and Social Care Act 2012. Institute for Government and The King’s Fund, 2012.

†† For an account of the Act and its passage see: Timmins N. Never again: the story of the Health and Social Care Act 2012. Institute for Government and The King’s Fund, 2012.

‡‡ Speaking at the Nuffield Trust Summit in 2015 he said: ‘If you speak to any of the chief executives I have spoken to about discussions about A&E they would say, I hope, that it is not a call from the boss holding them to account, it is a call from the health secretary to try to understand what the pressures are and how we can help more than we are currently doing.’

§§ Speaking at the Nuffield Trust Summit, February 2014.

¶¶ Speaking at the Nuffield Trust Summit, February 2014.

*** Hunt served for a few days short of 6 years and 10 months, outlasting the record of 5 years 9 months previously held by Norman Fowler.

††† This quote, and several others, are drawn not just from the interview for this book but from one with The Institute for Government for its Ministers Reflect series – www.instituteforgovernment.org.uk/ministers-reflect/person/jeremy-hunt – and from Timmins N. ‘The world’s biggest quango’: the first five years of NHS England. The Institute for Government; 2018.

‡‡‡ Hunt had been appointed by Cameron the week before, but had asked if he could see out the final week of the Paralympics.

§§§ Eg the Getting It Right First Time programme.

¶¶¶ Indeed, Hunt’s letter, approving the name change to NHS England specifically stated that it ‘does not mean that NHS England will now become the headquarters of the NHS in England.’ Hunt J (2013) letter to Malcolm Grant, 26 March, retrieved 15 April 2018, www.gov.uk/government/uploads/system/uploads/attachment_data/file/172945/SofS_to_Prof_Malcolm_Grant.pdf

**** Many would say that realisation had been around for a lot longer.

†††† In fact, the 2002 settlement for the NHS was also a 5-year deal, and at a higher rate of growth.

‡‡‡‡ Whether that particular initiative is a good idea or not has been debated.

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