Ten ways to be secretary of state for health

What is the role of a health secretary?

So what do the former health secretaries think? All acknowledged the accountability for what is now an over £100bn (€140bn; $150bn) a year operation. “There is a custodian role to play, and an accountability to discharge,” as Alan Milburn put it. Some put a heavier emphasis on the public health role—either from experience or desire. Lansley famously wanted to turn the department into one for public health, with the NHS becoming the task of a junior minister once NHS England with its annual rolling mandate had been set up. Faced with one almighty row over Lansley’s legislation and not wanting another, the prime minister blocked that. Andy Burnham said that perhaps “the primary duty” was protecting public health, a view that may have been coloured by a flu pandemic being declared on his third day in office.

But beyond that there were many differences in emphasis. Some underlined the stewardship role while 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 are making changes and to try to get past the resistance you usually get from the staff, and certainly from the public . . . You have to preside over change and explain it,” he says.

There was unanimous agreement that ministers should not be involved in the day to day nitty gritty management of the service. As Alan Johnson put it, “I don’t think when a bed pan falls on the floor in Tredegar it should echo around Whitehall any more.” But there was a wide range of views over how that might be achieved, and how far in practice ministers could and should be distanced from broader operational matters. “Is it possible in any business or in any organisation, truly to separate policy from execution?” William Waldegrave asked.

All agreed that the personality and behaviour of the incumbent matters. Virginia Bottomley (though she was far from the only one) was obsessed with media coverage—in her case because she cared about its impact on staff and patients; Stephen Dorrell’s approach was more “chair of the board.” Alan Johnson brought gentle, humour laced reassurance to the task, with a hint of steel.

Johnson relates that when the Mid Staffordshire scandal first broke, “Bill Moyes [executive chair of Monitor] was trying to tell me that [it] was his responsibility and not mine [to remove the trust’s 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.’ Bill was probably right that the legislation said he was responsible. [But] you’re the secretary of state. There is public money going in there. You are responsible.” Andy Burnham had a similar clash with Monitor when he took over and discovered that the chair and chief executive were still interims. So he forced the issue.

Healthy relationships?

The relationship between the health secretary and the prime minister, something not often discussed and which clearly varies with the prime minister of the day, also matters. Clarke’s relationship with Margaret Thatcher was famously rumbustious, and both liked to make their mind up by furious argument. Alan Johnson was among those who felt that part of the job was to try to keep the prime minister out of it. There is too often, and under all governments, a search for some eye catching announcement, driven from Number 10: “They want to say something on health . . . so what can you fish up?” as Johnson puts it. Frank Dobson describes trying to resist the desire of the Blairite Downing Street for “an initiative every 20 minutes.” Clarke was most blunt. “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 they are allowed to panic “then suddenly the prime minister will just insist on going to Rotherham and making pronouncements on what they are doing . . . 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.”

There are many ways of looking at the relation between health secretaries and the service over the years. But for a quarter of a century now, the goal can be seen as seeking to create what Labour in the 2000s described as a “self improving” NHS—the approach that Lansley took to an extreme by seeking to lay down in law how it should work.

Aside from foundation trusts, and the re-introduction of choice and competition, Labour also introduced several other distancing mechanisms—the National Institute for Health and Care Excellence (NICE), which advises on which treatments the NHS should and should not provide; the Independent Reconfiguration Panel, which advises on hospital restructurings; and the oddly named Cooperation and Competition Panel, which advised on the application of procurement and competition law as these came into play during Labour’s time. At no point were ministers statutorily required to accept their rulings. They were, in that sense, all advisory. But in large measure they worked because, as Dorrell points out, ministers allowed them to, letting them shelter ministers from controversial decisions.

Lansley says of his successor, Jeremy Hunt, that despite the legislation he does still intervene and “he knows he shouldn’t.” But Lansley argues that it will get “harder and harder over time” while arguing that “we will only know in 10 years’ time” if his mighty changes have worked.

NHS England

Intriguingly, the former health secretaries are split on the merits of NHS England as a statutory independent commissioning board. But not along party lines. Frank Dobson argues that “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.” Johnson likewise says, “There was absolutely no way that I would have set up this huge quango, NHS England . . . 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.’”

Patricia Hewitt, by contrast, believes it does have some merit, and Milburn, while condemning it as a “monstrous bureaucracy” does see it as “a stepping stone” on the long journey of distancing ministers from management.

The architecture of the NHS may have changed, he says. “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. 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, in a sense, Ken [Clarke] was trying to do. That, in the end . . . is what I was trying to do. That’s an uncompleted journey.”

Dorrell, by contrast, says he has never really believed in the parallels with the BBC or the independence of the Bank of England, for which he was an advocate. He points out that he abolished a previous attempt at separating ministers more from management—the NHS Policy Board. And while firmly holding the view that ministers should keep out of day to day operations he is equally clear that in the end, in a tax funded system, “you can’t legislate away responsibility.”

Clarke cheerfully proclaims himself the only MP left who believes that Lansley’s reforms, once they settle down, “will have a beneficial effect” while arguing that the enormous bill was “just hubris”—when all of it, or almost all of it, could have been done without legislation.

Waldegrave, who back in 1991 implemented the purchaser-provider split that Clarke devised and with which we still live, observed that the job “depends on whether you think the system at any given time is in need of policy reform. I came to think it did.” As did Clarke, Milburn, and Lansley, but others—Bottomley, for example, or Dorrell, Hewitt, and Johnson—were, broadly speaking, there to implement or to enhance or adapt a broad thrust of policy that had already been agreed.

As Bottomley puts it, “Sometimes you want a window breaker and sometimes you want a glazier. Ken was a window breaker, and he was brilliant. But after that you get William Waldegrave who was a glazier . . . And then a new set of problems will arrive and you need a Ken to break the windows again.”