The Evolution of NHS Management: A Historical Perspective
When Nye Bevan established the National Health Service (NHS) in 1948, he had a clear understanding of the challenges that awaited him as health secretary. He famously remarked to a gathering of nurses, “Every mistake you make, I shall bleed for… all I shall be is a central receiver of complaints.” This poignant observation has resonated with every subsequent health secretary, as they have all grappled with the responsibility of addressing the public’s grievances regarding the NHS. This week, Wes Streeting took a significant step by abolishing NHS England, effectively bringing the management of the health service back under direct governmental oversight.
In his announcement to Members of Parliament, Streeting claimed that this move was something the Conservative Party had secretly desired but failed to execute. However, this assertion is somewhat misleading. The Conservatives were indeed responsible for granting the NHS operational independence from the Department of Health through the controversial Health and Social Care Act of 2012. Over the past decade, they have grappled with the ramifications of those reforms, which originated from the mind of then-Conservative health secretary Andrew Lansley.
In an effort to rectify some of the most problematic elements of the Lansley Act, the Conservatives legislated in 2022, yet they retained the operational autonomy of NHS England. Many members of the party believed that this independence was one of the few sound reforms introduced by Lansley. Interestingly, the notion of independence was not even Lansley’s original concept. It was a hastily conceived idea that he was tasked with developing over a weekend when David Cameron whimsically requested a policy to make the NHS independent, akin to the Bank of England. Lansley and his aides were perplexed: in what way could the health service be compared to the nation’s central bank? While they never fully resolved this fundamental question, they devised a plan to establish what was initially intended to be called the NHS Commissioning Board. This body was designed to manage the NHS on a day-to-day basis, free from political interference, with politicians allowed to set the direction only through mandates issued every few years.
For many years, even those who criticized Lansley’s reforms often viewed the independent management of the NHS as beneficial, as it mitigated petty political meddling. Moreover, it allowed ministers to deflect responsibility, placing the burden of accountability on the chief executive of the NHS rather than on elected officials who would face questioning in the House of Commons.
Challenges of Accountability in Public Health
However, this arrangement has never functioned as intended, nor should it have. As Bevan predicted, it ultimately falls upon ministers to answer for the NHS’s performance, especially when it falters. The idea of “removing politics” from public service delivery is inherently flawed, as it implies stripping accountability from elected representatives. Politics is fundamentally about enacting change and getting results, yet it often devolves into petty partisanship.
Streeting’s reform initiative is not merely about enhancing transparency regarding who holds power over the NHS. There must be a tangible advantage for ministers in such a significant transformation; otherwise, they might, like their Conservative predecessors, choose to persist with the status quo, merely streamlining operations and ensuring compliance from NHS leaders.
The true motivation behind this upheaval is not just the ability to directly receive complaints but rather the desire for greater control. Despite Streeting’s assertions that he aims to decentralize the NHS and bolster local accountability, he has already clashed with outgoing leaders, including Amanda Pritchard, over the extent to which he should be setting the strategic direction and driving improvements, rather than leaving it solely to those officials.
One of the critical issues that led to the dissolution of NHS England was its failure to articulate a clear strategy for meeting productivity targets, with Pritchard’s vague assurances falling short of ministerial expectations. Consequently, ministers are eager to delve deeper into these matters and are unlikely to delegate productivity outcomes to local administrators.
Long-time observers of the health service recognize the cyclical nature of such performance-driven management cultures, having witnessed similar dynamics during the New Labour era. Perhaps this time, Streeting will avoid some of the more oppressive elements of that past culture, which permeated the health service and fostered a climate of fear surrounding target compliance and management bullying. However, it is all too easy to proclaim a desire to enable the health system to thrive while inadvertently replicating the very behaviors one seeks to avoid. After all, the Conservative government established NHS England as an independent entity while vowing “no pointless top-down reorganization of the NHS.” It is ironic how often administrations find themselves enacting precisely those measures they once promised to avoid.
Nevertheless, one inescapable truth remains: this government must enhance the NHS’s performance. Failure to do so will inevitably lead to the same consequences Bevan foresaw, with ministers suffering the political fallout of the health service’s shortcomings.
