3. The views of the former health secretaries on…


…restricting the role of politicians

William Waldegrave ‘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 with some kind of non-party political support. You shouldn’t be, as the secretary of state, accountable at all for the providers, except that, for reasons of history, the great majority of the providers, belonged to the state. So, you had to be at least accountable for them not stealing the money, and audit and propriety and so on. The theory was that the minister should do the prioritising, but not run the services.’

Alan Milburn ‘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. I would say that the limits are around strategy, objective, and focus on putting the enablers in place that get the stuff delivered.’

Jeremy Hunt ‘The one thing that I would keep from the Act is the independence of NHS England… Had it [the Five year forward view] 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. But 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.’

[And] ‘We’ve 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 announement-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.’

Stephen Dorrell ‘But 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?’

Andrew Lansley ‘I couldn’t take the politics out of the NHS. I could to some extent take the politicians out of it. Then, of course, what you have is politicians arguing with the same noise level about a restricted number of things. And that is in fact what they’re doing. They are actually arguing about one or two targets, and money, and not much else actually because there isn’t much else to argue about. It may work. I don’t think it’s naïve, but I think it is optimistic to see this particular change happen quickly. So it is not removing politicians. It is at least restricting them. Trying to hamstring the politicians a bit.’

Andy Burnham ‘You simply cannot have £100bn-worth of public money without democratic accountability. 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? I’d like to pull it back in some way, restore the secretary of state’s duty, with respect to providing a comprehensive health service. It doesn’t mean that you then pull everything back in. But I do think it’s good if secretaries of state don’t get too involved. It’s a hard balance. It’s very hard.’

Frank Dobson ‘You put it to me that my period was seen as a period of strong command and control because there were a lot of centrally decided initiatives – setting up NICE, and the Commission for Health Improvement, National Service Frameworks. Well, I entirely agree with that. I have no problems with command and control. It is part of the secretary of state’s job. As for the current split of NHS England as a statutorily independent commissioning board? Well it is 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.’

Virginia Bottomley ‘How far can you take the politics out? Well Ken [Clarke] set up the NHS Executive in Leeds to try to get that sort of separation. That involved an awful lot of first-class tickets, and chat on trains! Ken absolutely believed in principle that the executive and the trusts should be more autonomous. He absolutely believed that politicians should be away from the direct management. My instincts were more to worry away, if there was a problem, know what the problem was. The old bedpan metaphor continues to run.’

Kenneth Clarke ‘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. 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.’

…the Lansley reforms

Andrew Lansley ‘Of course, we will only know in 10 years’ time if it’s worked – if there are not annual reorganisations of the NHS. I did have to have what was undoubtedly the biggest reorganisation it has seen. But in order not to have every new secretary of state walk in the door and issue a new white paper that changes all the structures. That is what happened, because they could. Because the law pretty much said the NHS is whatever the secretary of state of the day at any given moment decides it is. Now we actually have a proper statutory definition of what it is, how it’s run, who’s in charge of what – it is all there. In my view the Five year forward view is compelling evidence for the benefit of the 2012 Act. Because it set up NHS England – gave NHS England that voice. You put it to me that it is possible it won’t get changed for many years not so much because it is all working perfectly but because the row that was generated by what you did means that no one will want to do it again. Yes, that is entirely possible, and that is also deliberate. They’ll live with whatever they’ve got, because nobody in their right mind will try to argue with it.’

Alan Johnson ‘There was absolutely no way that I would have set up this huge quango, NHS England, to protect ministers from [public accountability]. If we get back in, we have to get rid of all that competition stuff in the Act, so we get rid of the lawyers and find a way that helps people integrate their services. But it will be important that people don’t perceive this as another top-down reorganisation. So NHS England has to stay.’

Kenneth Clarke ‘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. The scale of disruption in introducing them was ridiculous. That enormous bill was just hubris. I argued to him that he didn’t need a bill. That that all of it, certainly almost all of it, could have been done within his existing powers. The reason Andrew failed was because he couldn’t explain it. He got immersed in all the technicalities and even I couldn’t follow what he was going on about. He needed some broad-brush stuff, instead of which he immersed himself in the detail so that nobody understood it, and everybody got fearful that some dreadful change was being made. It was over-elaborated. But the underlying point was OK. So I supported Andrew Lansley’s reforms.’

Alan Milburn ‘What has happened is that they’ve wasted 5 years, the system is in absolute turmoil. No one knows what they’re doing. There is no clarity, there is no direction. Broadly, something that was broadly, broad brushstrokes, moving in the right direction is now broadly moving in the wrong direction. That’s what you call the worst Secretary of State for Health ever and that’s what happens when you remove politics. That’s what happens when you put a policy wonk in charge of what inevitably has to be a system over which political judgements have got to be made. That’s just how it is folks.’

Patricia Hewitt ‘Now, there’s not much about the 2012 Act that one can admire. What Lansley did really was utter folly, in terms of this massive Act. 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. Although the Lansley reforms have created the most appalling mess, 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 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.’

Stephen Dorrell ‘I voted for the 2012 Act and there were reasons why I did so, and I am quite happy to defend why I voted for it. 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.’

Jeremy Hunt ‘The complexity of the structures proved to be extremely unhelpful… some of the fragmentation was, frankly, completely ridiculous. So we had to simplify things. And we found a wonderful workaround with Monitor and the TDA which was that you would have legally separate bodies with exactly the same people on the board, and we were then able to bring NHS Improvement and NHS England much closer together. You remind me of David Bennett’s quip that the Act has not been changed, it has simply been ignored. Well, as far as we could!’

…the Department of Health

Andy Burnham ‘All departments have a very different feel, they really, really do. The feel of the Treasury is “We don’t have to listen to anybody. This is where it’s at. Who are these people out there?” The feeling in DCMS is, “Why would we try and do anything? We’re so weedy.” And then DH is more self confident than that, but… They all have their own culture informed by the service beneath them. The Home Office definitely has a very tough, no-nonsense feel to it – because of the police involvement and prison involvement. But I like DH. I think I warmed to it more. Friendly but very worldly wise. Health is probably more political as well. Not necessarily party political. But in terms of the people believing in the thing that they’re in.’

Patricia Hewitt ‘Is the job impossible? No, it’s not impossible, but it is unbelievably demanding. It was very odd coming from a much more classic Whitehall department [the Department of Trade and Industry] to move into the Department of Health, where most of the senior officials were NHS managers. There wasn’t a strong Whitehall tradition there.’

Kenneth Clarke ‘I always joke with Jeremy [Hunt] that being minister of health is a political deathbed in most western democracies. In every western democracy, health is the most controversial subject that politicians encounter, because it’s so emotional and there are such tensions and competing interests. It’s also one of the most important.’

William Waldegrave ‘Secretary of State for Health is the most powerful managerial job in Whitehall, or was then. If you were a powerful enough minister with enough coherence and enough support from senior management, you could actually change things. Even the Secretary of State for Defence can’t do that. The chiefs of staff can just say, “No,” and go to the prime minister if they want to. The job at Work and Pensions, [where there are tens of thousands of staff delivering benefits] might be comparable, but I never did that one.’

Alan Johnson ‘Health is different to the other departments. You’ve got a much bigger budget. You’ve got the daily grind of issues that come up to a much greater extent than anywhere else – because, you know, Mrs Jones fell out of bed in a Portsmouth Hospital and was seriously injured, and they want to be seen in their local paper to be raising it on the floor of the House. In health you are making the administrative decisions. Do you close that hospital? Do you move that chief executive? Those administrative decisions have to be with the secretary of state because they impact. It’s very different to the DWP and the Home Office and Education. You try to do that with the police, or the head of MI5, it would be a ludicrous thing to do.’

…key moments and turning points

William Waldegrave ‘When I was appointed, Mrs T [Thatcher] said to me, “Kenneth [Clarke] has stirred them all up, I want you to calm them all down again,” and then made it absolutely clear to me that if I wanted to just cut the throat of all these reforms that was fine as far as she was concerned. I then went along with Duncan Nichol and we had a meeting with her in Number 10, just before she went to Paris, just before she fell. We persuaded her, and it was a matter of persuasion, that the thing made sense and wasn’t just Kenneth trying to cause trouble.’

Alan Johnson ‘When Mid Stafford broke, Bill Moyes [the Chairman and Chief Executive of Monitor] was trying to tell me that was his responsibility and not mine [to remove the chair and chief executive] – because it was a foundation trust. 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.” But I told him, you know, “Piss off. I’m dealing with this.”’

Andrew Lansley ‘The idea that you could just do this stuff without legislation – well it’s for the birds. The whole point was that I knew perfectly well from recent and painful experience of my predecessors, that trying to do NHS legislation is a nightmare. I therefore resolved to do it once and hope my successors would hardly ever have to do it again. Because the institutional structures in the NHS would be proofed for the longer term. We will only know in 10 years’ time. I think it would be an enormous blessing to my successors if they did not have to legislate again.’

Andy Burnham ‘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 to me saying, “We’re in command and control mode now.” It was a self-reflective joke. But it was important. We did have to go into that mode, very much so. And people wanted us to.’

Jeremy Hunt ‘So we then had a series of very challenging meetings with Philip Hammond and his Treasury officials [on the 70th birthday settlement for the NHS]. 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.” And that was a very big moment for me… they got the signal from Theresa May that she wanted to do a deal… so we got there. Unfortunately, the Treasury did not get the signal that she wanted to do a deal on social care. So that is still unfinished business as far as I am concerned.’

Patricia Hewitt ‘The discovery of the overspend was a really shocking moment. As you know, the NHS is not allowed to overspend. In theory it cannot happen. But it did. The top of the department had absolutely no idea that there was a problem until 3 months into the new financial year. They finally got all the numbers and discovered they didn’t sum to zero. As we dug into what was really going on we discovered unbelievable inadequacies in the leadership, capability, and financial frameworks, and the discipline of the department and the NHS, in which the Treasury was also culpable.’

…style and behaviour

Alan Milburn ‘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.’

Kenneth Clarke ‘It wasn’t command and control, although there was this mad illusion that I was supposed to command and control it. That I was sitting there in the middle with all these thousands of staff. I think I was the first to point out that it was the largest employer in Europe apart from the Red Army. You were of course held responsible every time anybody dropped a bedpan, and somehow you had a huge administrative structure, which ensured that you controlled all this. It was hopeless. It was a gruesome, self-perpetuating bureaucracy, riddled with vested interested. It was collapsing.’

Stephen Dorrell ‘I did try to behave like chairman of the board, not Chief Executive of the National Health Service. But 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!”’

William Waldegrave ‘I made myself the chairman of [the policy board]. 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?’

Andy Burnham ‘There are clearly different styles for doing the job. 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.’

Virginia Bottomley ‘The one thing [Margaret Thatcher] said, which always stuck in my mind, is “never turn down the opportunity to explain the government’s case, because nobody else will”. The other thing I felt, this is an organisation that’s got a million people, there are patients, users who are all very emotional and “No comment” isn’t good enough. The message needs to be communicated.’

Jeremy Hunt ‘In the main 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 for the police, even though the home secretary does not direct the police – an element of arm’s-length relationship. I never felt I lacked a power to give directions. I never felt that I couldn’t get the NHS to do what I needed it to do, and wanted it to do.

My big battle cry was quality and safety and I felt the NHS was very receptive to that. 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. But basically it was never difficult to have a big discussion to come to an agreed plan. And 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. When you’ve 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.’

Frank Dobson ‘I believe Simon Stevens once referred to me as wandering up and down the ministerial corridor in my stockinged feet, like the non-executive chairman who knew what he was doing. I took that as a compliment really.’

…advice for the next incumbent

Alan Johnson ‘Make no major speeches for at least a month. Find out exactly what’s going on there. Decide what you want to do in that time because you’ll get a honeymoon period. People won’t expect you to be doing very much. Wherever you can, defer to clinicians. If there’s an issue there, and clinicians take one view, and politicians take another, go with the clinicians.’

Kenneth Clarke ‘Know what you are doing, get stuck in and enjoy it. Health secretary was probably my biggest single challenge. The two jobs I’ve enjoyed most were health and the Treasury. I’m not sure which I enjoyed most, the Treasury probably, because you get into every form of government. But I enjoyed health. It was the toughest job I ever had, much tougher than the others.’

Frank Dobson ‘I was much criticised because I said to some reporter from the Daily Mirror who came to see me that the first thing I was going to do was sit down and have a good think! Which is out of fashion really isn’t it, to sit down and have a good think? I think they need to do that.’

Andy Burnham ‘It’s so much more about the people on the ground than people ever realise. I think Whitehall sucks you into the bodies and the Monitor and the this and the that and actually having a plan for workforce should be the first thing that you do.’

Patricia Hewitt ‘Be very careful. What may appear to be quite a limited change in structures, or in the law, may turn out to be like pulling on a piece of thread and unravelling everything. I do think you have to be very careful, and do a great deal of listening, in order to understand as far as possible what the unintended consequences might be of apparently well-meant changes.’

Stephen Dorrell ‘Stick to the policy that all health secretaries except Frank have pursued – of developing commissioning. In the end, the health secretary is the commissioner in chief. So actually, they should stop obsessing about hospital management, which is anyway a fraction of care delivery. Recognise you’re commissioner in chief, accept responsibility for the commissioning process, and make it work.’

Alan Milburn ‘Buy time. The best political trick I ever pulled off was to publish a 10-year plan. Why? Because it basically bought time. Because it said ‘this is going to be a long journey, it’s going to take a huge amount of time.’

Jeremy Hunt ‘Workforce has to be a part of every plan, and I didn’t appreciate that at the beginning. 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. So my intention was that the 10-year NHS plan should be accompanied by a 10-year workforce plan, produced at exactly the same time, and that the two should match. Because I left, they ended up appearing at different times, and we still don’t have the people plan nearly 2 years after I stopped being health secretary.’

[And] ‘We are a democracy. And people want to hold people like me, rightly, accountable, for over £100bn of public money. 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.’

‡‡‡‡‡ NHS Long term plan, January 2019.