What should Jeremy Hunt do next to the NHS?

The Tories barely talked about the NHS during the election campaign. It was an area of Labour strength, and one Ed Miliband and Andy Burnham were keen to talk about as much as possible. But now they’re back in with a majority, the Conservatives are keen to start talking about the health service again, and to start trying to erode that Labour poll lead on the issue.

David Cameron and Jeremy Hunt yesterday announced their plans for a seven day NHS, but though announcements are always very handy for getting attention, the Tories need to strike a balance between lots of new initiatives and too much meddling that upsets people again. For however many years he has as Health Secretary, Hunt must work out how to fill his time, and how to improve the way voters view the Tories on the NHS. He has always been keen to pitch himself as the ‘patients’ champion’. But what do former Secretaries of State think he should be doing?

I’ve been reading a fascinating collection of interviews with former health secretaries about their time setting health policy and responding to different crises in the service. They’re quite a diverse bunch: from Ken Clarke to Andy Burnham and from Alan Milburn to Virginia Bottomley. But all have given their advice for the collection, published by the Health Foundation as a welcome present for the Health Secretary as he settles back into his job.

Here are some of the more striking nuggets from the interviews.

1. You can’t take politics and politicians out of the NHS.

Ken Clarke suggests that the next Secretary of State spend their time ‘fighting off every pressure to start politicising [the NHS] again’. But Alan Milburn sees politics as a good force in ensuring public services improve, warning of the risk of people saying ‘if only the politicians got out of this, everything would be wonderful’. He adds:

‘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.’

Most of the former ministers recalled instances where they or their colleagues had thought they’d removed themselves from the health service, only to end up intervening – or trying to intervene – when something went wrong. Stephen Dorrell thought ‘the more you intervene, the less effective management is, and therefore the higher the risk that you’re allegedly trying to manage. But he also seemed rather cynical about some of the things the Health and Social Care Act was supposed to do in terms of taking politics out of the NHS:

‘As you know 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. 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?’

Andy Burnham said his experience over Mid-Staffs ‘actually took me away from the idea of independence’ because he was told that Monitor had made interim appointments to run the hospital. ‘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’. On rather smaller issues, politicians can’t resist getting involved because they want to make political announcements: Andrew Lansley argued that Jeremy Hunt ‘knows he shouldn’t’ set out policy on hospital food and car parking charges, but that ‘it’s stuff which NHS England has in practice decided and ministers are badging for political reasons’.

2. Sometimes it’s a good plan to leave things as they are.

Virginia Bottomley’s description of the different types of Health Secretary became the book’s title – ‘Glaziers and Window Breakers’. She said sometimes the health service needs a ‘window-breaker’, like Ken Clarke, and sometimes it needs someone like William Waldegrave to work as 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.’

I suspect Jeremy Hunt sees himself very much as a glazier. Andrew Lansley, a rather noisy window-breaker, seems to suggest that Hunt should be a glazier, anyway, saying that Simon Stevens, Malcolm Grant, and Bruce Keogh should take ownership of policies now that the election is over, adding that the seven-day service is ‘much more likely to succeed because NHS England is leading it’. Though Lansley seems to anticipate rather a long period of glaziers sitting around and watching the health service, rather than reforming it again, saying ’we will only know in 10 years’ time’ if his reforms have worked.

Lansley disagreed with his predecessors on whether he really needed to introduce those reforms using legislation. He also points out that ‘I got my legislation. [Alan Milburn] did not get his, not in the form he wanted it’. But Ken Clarke said ‘that enormous bill was just hubris. I argued to him that he didn’t need a bill. That all of it, certainly almost all of it, could have been done within his existing powers. But he built it up into this monumental refunding of the NHS. The reason Andrew failed was because he couldn’t explain it.’

But perhaps Hunt might fancy dealing with the administration of the health service. Frank Dobson, who uses colourful language throughout his interview, suggests that this is the ‘first thing’ the Health Secretary should set to work on:

‘Before we had this purchaser/provider split, the NHS spent four pence in the pound on administration, and it now spends at least 12. So that is £8bn more going on administration because of the money following the patient and all these bloody contracts and Christ knows what. So I think that the first thing the new health secretary should say is: “Well let’s try to cut back on all this crap.”’