I’ll start by saying upfront that while I understand the need for democratic accountability and oversight for large amounts of public money, even the system we have troubles me. It is rare indeed for ministers to have any background or expertise in the department they are leading. Nor have they been chosen by the electorate for the brief they are handed. They are often shuffled from post to post for party political expediency before they have had a chance to master their brief. So I for one am all for things being run at arm’s length by “technocrats.” For “technocrats” read “people with genuine expertise and experience in that service or area who actually know what they’re doing.” But we have the system we have, hence my reflection.
Let’s consider some recent events. Over at the Department of Work and Pensions, before Iain Duncan Smith resigned, he’d presided over the “bedroom tax” fiasco, the botched and delayed introduction of Universal Credit, and the gross incompetence of private contractors carrying out fitness to work assessments on people with disability.
His principled resignation over the size of cuts to the Personal Independence Payments (not included in any electoral mandate through the Tory manifesto) can’t mask the damage his policies had already done to poor and disabled people. And it seems to be motivated as much by his animus towards George Osborne.
In education Nicky Morgan was brought in as the emollient, calming figure after Michael Gove’s ham-fisted reign as secretary of state. Yet there she was, last month announcing the “forced academisation” of schools, however well they are performing, essentially saying: “You will have autonomy, and if you don’t want it we will force autonomy on you.”
Not only is there no credible evidence that academies or free schools outperform local authority maintained ones, but this policy didn’t appear in the manifesto “mandate” either. She then showed a tin ear by telling a teachers’ trade union conference that it was the teaching profession’s fault that we now have a morale and recruitment crisis because teachers talked down the profession. There was no acknowledgement of ministers’ role in this. Then Morgan snarled a lot of fighting talk at the conference hall—teachers just needed to knuckle under and accept ministerial authority.
Being an NHS doctor these past 27 years, I do want to talk about healthcare. Before the 2010 election, three successive Labour governments had invested an additional 4-5% funding into the NHS over the previous decade. This was a record funding uplift in the NHS’s history, unsurpassed since then. Performance in access and waiting times were improving. Public satisfaction and staff morale remained high. A range of national service frameworks and improvement programmes were in place.
Of course the system was imperfect. It was criticised for being too focused on access and waiting targets and not sufficiently on outcomes for patients, as well as too subject to a bullying, top-down, command and control culture. The Mid Staffs scandal broke during the last Labour government. During the Labour years, so called “world class commissioning” had proved anything but. And not enough of the new money went into community and primary care services, partly due to the culture of targets.
For all this, the service was generally well regarded and steadily improving. It needed some tweaking. And Lansley even had the germ of an idea around more outcomes focused approaches and more freedom for local health economies to decide their own priorities. What we got instead, as we all know, despite pre-election promises of “no more top-down reorganisation,” was what Sir David Nicholson—then chief executive of NHS England—referred to as “a reorganisation so big it could be seen from outer space.” This plunged the NHS into three years of chaos, just at a time when it needed all its institutional memory to tackle dwindling funding and rising demand. Even senior Tories now admit it was the biggest policy mistake of the coalition government.
It’s not as if Lansley wasn’t told that his reforms were fraught with danger. We aren’t being “wise after the event.” There was advice aplenty both from within government from the opposition and from a range of external commentators. He ploughed on regardless. No wonder the civil service “risk register” was never released despite requests for its publication.
He could have taken a leaf from Claudio Ranieri, the manager of Leicester City, current Premier League leaders. They had finished the previous season on a winning streak. He was tempted to bring in his own staff and his own methods, but he was wise enough to take soundings; see how things already worked; and go for mature, quiet evolution, not revolution—a few tweaks here and there, with calmness and stability.
This brings us to Jeremy Hunt, Lansley’s successor as secretary of state for health. He was brought in to be a more consensual player, with better communication skills and emotional intelligence. He inherited not only the wreckage of the Lansley Bill, but a rapidly worsening financial crisis and the fallout from the Mid Staffs inquiry. And he was by comparison an upgrade, I guess.
After the 2015 election, Hunt too went rogue though, picking a needless fight with the vital workforce of NHS junior doctors and embroiling himself in a pointless, damaging industrial relations dispute. He’s repeatedly got figures wrong—for instance on NHS staffing levels—and misinterpreted or misused data on weekend mortality; he’s failed to acknowledge the true extent of the NHS deficit or workforce crisis and promised seven day services when we can barely afford to maintain current performance levels over five days; and meanwhile compounded these errors with needlessly provocative public pronouncements. He hasn’t shown any desire to stop digging a deeper hole for himself.
I have been critical, I know. And although I’ve never voted Conservative, I would be critical of ministers from any party who behaved in such ways.
So what would I like to see in an “ideal minister” if I was filling out a person spec or an online dating form? I guess it’s the following. They would:
• Have some background, credibility, or expertise in the area they were responsible for. This would be an unlikely bonus though.
• Failing that, they would realise, with humility, the limits of their own expertise but set out through their diligence and intellect to understand everything they could about the sector, taking wide advice and getting up to speed with their departmental brief.
• Crucially, this advice would not just come from special advisers (“SPADS”) who are also often sector-naïve. It wouldn’t just come from ideologically driven, party political, policy think tanks with magical thinking. It would come also from those who were sceptical or challenging.
• They would listen to civil servants, analysts, and other technical experts about the risks of implementation—the “what if” questions. That’s what the civil servants are traditionally there for—not simply as party mouthpieces. Since 2010 the government has been very impatient with the civil service, wanting to hire and fire permanent secretaries and to bring in more political appointees. All that wisdom, caution, and experience is being disparaged and discarded.
• They would be realistic about the scale and pace of their ambitions, and not be engaged (as Gove, Lansley, and Duncan Smith were in their own ways) in overpromising and being involved in some kind of macho race to see who could “transform” and “take on vested interests” in their service most quickly.
• They would make their stewardship of the service they were accountable for a serious, purposeful business, not a platform for their own self aggrandisement or ambition. They would focus on the “how” of delivering change, not just the “why,” and substitute effective programmes of change for soundbites and spin.
Most importantly, they would work closely with the professional groups—whether police or army officers, teachers, social workers, local government officials, or NHS clinicians and managers. For only by taking the workforce with you and earning their respect, do you have any realistic chance of leading a public service well.
Now close your eyes and think of ministers in the current government exhibiting those ideal characteristics.
Hard, isn’t it?
David Oliver is a consultant physician at the Royal Berkshire NHS Foundation Trust.
He was seconded to Whitehall until 2013 as national clinical director for older people.
He is currently president of the British Geriatrics Society and writes the weekly “Acute Perspective” column in The BMJ.
Competing interests: None declared.