Why Sajid Javid should delay Hancock’s NHS reforms

Sajid Javid arrives at the Department of Health and Social Care (DHSC) at a point when the portfolio has never been more high profile. Whilst not technically a Great Office of State, the position of Health Secretary is second only to the Chancellor when the public is asked to rank a member of the Prime Minister’s team.

When Jeremy Hunt was appointed to the post in 2012, he was urged by the then Prime Minister David Cameron to ‘calm down the NHS’. Sajid Javid, another bright, competent minister who does not seek the limelight has been chosen for a similar brief.

His first task will be to prioritise. Under Hancock, the department committed to pursuing four different reforms in tandem this year, covering social care, public health, the NHS and mental health. Whilst laudable, it was always feared that this would be too ambitious a programme for a government facing the dual threat of coronavirus and the biggest waiting list in history.

With fresh leadership installed at DHSC, that fear may be realised. Any new Secretary of State brings their own priorities, leading to difficult choices on the existing programme. One of the most immediate questions concerns the status of the Health and Care Bill, which was due to be laid before Parliament next week.

The Bill is divided in two. Around 85 per cent of the proposed contents will create the legal basis for new, regionalised structures to promote the integration of care in England – signalling a big step away from the competition and market-led doctrine introduced in the 1990s and accelerated under the Lansley reforms. These are the brainchild of Sir Simon Stevens, a passionate advocate for integration of health and care. Stevens leaves his role next month with his legacy uncertain, but the NHS leadership remain eager to see the proposals carried into law at the earliest opportunity – having set a deadline for the legislation to achieve Royal Assent before April next year.

The remaining 15 per cent of measures contained within the Government’s White Paper would strengthen the ability of the Secretary of State to intervene in the health service. Whilst disliked by some in the Health Community, the proposals are premised upon the genuine need to ensure that consolidation of powers within NHS England is accompanied by enhanced Ministerial accountability. Included within this are proposals to set the NHS’s priorities on a more flexible basis, and to direct responsibilities between different arm’s length bodies.

Prior to the events of Friday that led to Hancock’s resignation, there was already suggestion that the political dark clouds were gathering around the Bill. Within Downing Street there is scepticism about the optics of embarking on a reorganisation amid worsening NHS performance figures, while unnamed Conservative backbenchers were quoted as being concerned about the so-called ‘power-grab’.

Their issues with the accountability elements of the Bill may be as much a case of personality as substance. Hancock’s departure provides a moment to reassess. The Health community will see this as an opportunity for the proposals to be watered down. But these calls should be resisted.

Direction and management are not the same thing. The Bill is unlikely to advocate for a return to Aneurin Bevan style day-to-day management of the NHS (where every bedpan drop was to reverberate around Whitehall). Instead, it signifies an attempt to rebalance towards political accountability. Indeed, there is an arguable case for Javid to explore whether these measures could go further, should he decide that this is the moment to reset the relationship with a new NHS CEO at the helm.

Throughout all of this, the NHS will be applying intense pressure on Javid to proceed with the Bill to hit their April deadline – last week’s NHS Board Meeting went so far as to suggest that any substantial delay “could adversely impact” the NHS recovery. Is this legitimately true? History from the 2000s suggests that big shifts in the NHS’s superstructure do little to address core priorities such as waiting times – and could even be counterproductive. As Isabel Hardman highlighted, they can also drive local political rows – typified by the ongoing debate over the new Integrated Care System (ICS) boundaries.

Efforts to better join up care are sensible in principle. But there is a risk that in attempting to sell the package to a Conservative Party still scarred by the 2012 reforms, the benefits of integrated care have been overstated.

Javid should feel empowered to push back on these sections of the Bill. This is one of the benefits of being a newcomer: to ask the stupid questions that may not be stupid at all. Will this improve patient outcomes? Is this a public priority? Does this make the service more accountable to the taxpayer? If he asks these questions, he may be surprised by the responses.

Accepting a few months’ delay would be framed by Labour as their victory but has limited other political consequences. The new structures would continue in shadow form until April 2023. Backlog recovery in areas such as mental health and cancer could become the focus for the entire NHS. And change and transformation capacity could be deployed towards other priorities – such as embedding digital medicine consistently and tackling the health inequalities borne out by the pandemic. The Bill could still be brought forward in the Autumn, giving the Health Secretary precious time to assess the measures it contains. This will be especially important if he decides to carry forward – and expand – the measures to strengthen ministerial oversight.

When former Health Secretaries were interviewed for a recent series, one dominant theme in their advice to successors was to give yourself space to think. With coronavirus, Javid does not have that luxury. But when it comes to NHS reform, he would be wise to follow his predecessors’ words of wisdom carefully.