13 July 2007
New Health Secretary Alan Johnson is launching a much-needed charm offensive – starting with a clinician-led NHS review. Seamus Ward assesses the chances of tackling the problems stacking up in his in-tray
What is an incoming health secretary to do when he arrives at the Department of Health's Richmond House headquarters and finds the NHS in disarray? It might seem like a line from Yes, minister but the obvious move is to announce a review. So it was that last week Alan Johnson launched an inquiry into how the service should look over the next decade.
The view from behind Johnson's desk is probably the toughest to face a new Labour health secretary since Barbara Castle got the job in 1974. She had to contend with a financial crisis in the wake of the 1973 oil shock, problems over nurses' pay and a revolt over NHS pay beds.
This is very much on Gordon Brown's mind – on becoming prime minister he vowed to make the NHS his 'immediate priority'. He will need all Johnson's skills (not to say his background as a union leader) to calm some turbulent NHS waters in the wake of Patricia Hewitt's departure from the government. Although she wrote to Brown to urge him not to change policy, it seems some changes are inevitable.
Johnson has a hefty in-tray but one senior NHS figure says he is the right man for the job. 'Frank Dobson was appointed to reassure Old Labour when Blair first came to power; [Alan] Milburn to drive through the radical changes to create the new market; John Reid to make sure the reforms were implemented and to bring down waiting times. Hewitt was seen as a safe pair of hands but she lost the unions and the public. Now Johnson is with us with a brief to calm the unions and convince the public that it's safe to go into hospital.'
He will be helped by his new sidekick at the department, Sir Ara Darzi. The appointment of the pioneering surgeon as health minister in the Lords and head of the review seems like an inspired move. Darzi is respected by doctors and, as a practising surgeon, has sufficient gravitas to appeal to the public. His review is designed to win clinicians back into the fold by asking them how the NHS should be run. It is a calculated gamble by Brown and Johnson, because Darzi is unlikely to keep quiet if he feels his findings are not being taken seriously.
The review is due to produce an interim report before this autumn's Comprehensive Spending Review, and the full report in time for the sixtieth anniversary of the founding of the NHS next summer.
There is no doubt Darzi's ears will receive a severe bashing over the coming months when he asks clinicians and patients how the NHS can provide better access to safer, high-quality, value-for-money care.
Doctors and nurses are in open revolt over pay, job and service cuts and the use of the independent sector to treat NHS patients. Patients are protesting about hospital downgrades and closures and often seem more worried about contracting infections while in hospital than the risks of their hernia or heart bypass operations. Some trusts' financial positions are so bad they cannot continue in their present form, while the quality of care remains worryingly patchy in some parts of the country.
The new administration will also have to handle sensitively last week's revelations that all the suspected bombers in London and Glasgow had links to the health service – a review of NHS recruitment has already been announced.
Devolution will bring fresh political pressures as the health services in Scotland, Wales and Northern Ireland continue to diverge from the English model. There are already grumbles of discontent as English voters look north or west to see patients enjoying free prescriptions, free personal and nursing care or access to a cancer drug that has been denied in England. Meanwhile, the staff in England will see their colleagues over the border enjoying their pay award in full.
As Darzi listens, Johnson will launch a charm offensive. The British Medical Association, Unison and the Royal College of Nursing are threatening industrial action over April's pay awards but it is likely the government will tough it out, adhering to the belief that public sector pay inflation fuels inflation in the wider economy.
But without a pay olive branch to offer the unions, what can Johnson do? A former Union of Communications Workers general secretary, he has been roundly welcomed by the health unions as someone they can do business with. But have his hands been tied?
'You don't put Alan Johnson in charge without thinking the unions are unhappy,' says Richard Brooks, associate director for public services at the Institute for Public Policy Research. 'He is very good at taking the heat out of conflicts but he needs to balance keeping up the pressure for improvement with gaining the trust of the workforce.'
He adds that pay can be something of a red herring in government-union relations. 'The lesson from recent history is that it is possible to increase the pay of NHS staff significantly and simultaneously lose their support. Johnson has got to give them messages about the pace, scale and direction of reform – he needs to get professionals to sign up to the reasons for reform and the specific mechanisms for reform. Once you do that you change the nature of the debate,' he says.
Johnson will also have to face up to the health paradox that has haunted Labour for the past few years – despite the billions of pounds it has poured into the service, the quarter of a million more staff, the signs of improvement such as shorter waiting times, the 46 new hospitals and improvements in cancer survival rates, voters remain unconvinced that the health service is off its sick bed. A BMA survey last month found that only a third of the public believed Labour's reforms had improved the NHS.
Voter disapproval of Labour's health policy is shoring up Tory confidence. Despite the much-vaunted 'Brown bounce' in the opinion polls, surveys show the Conservatives are ahead on health. This is core Labour territory and Number 10 will expect the new health secretary to regain this lost ground. But Conservative leader David Cameron clearly feels that in health he now can do to Labour what Tony Blair once did to the Tories on law and order. A measure of his belief is his retention of Andrew Lansley as shadow health secretary in his extensive shadow Cabinet reshuffle on July 3. Lansley is an experienced operator, having held the post since November 2003.
If all these external factors were not enough, Johnson enters a department that was heavily criticised by the Cabinet Office's capability review, published last month. The department was said to be woefully below par on strategy and leadership, although it had delivered its objectives. Hugh Taylor, the department's permanent secretary, and David Nicholson, the NHS chief executive, hope that its internal restructuring will improve communication with the service and boost its strategy and leadership capacity.
The department has been divided into an 'NHS-facing' division and a division that deals with the rest of Whitehall (principally the Treasury). In a reshuffled pack, finance and investment director Richard Douglas will concentrate on negotiating with the Treasury, while the 'NHS-side' has appointed a new finance, performance and operations director, David Flory, the former North East Strategic Health Authority chief executive.
Brooks says that reassuring the public is the key element of Johnson's job, especially with Brown reportedly eyeing a snap election. 'Out of all the public services, the public gives the NHS most importance; the state of the health service conditions people's attitudes towards the public sector as a whole. Clearly, the NHS is where Labour has placed its big financial bets, yet it still has the extraordinary situation where most people think the health service is getting worse,' he adds.
The NHS Confederation has urged the service to improve its customer focus and is looking to companies such as John Lewis and BT for advice. This will please Brown in two ways. It fits into his idea of a 'big tent' government, while more courteous staff would begin to tackle one of patients' biggest gripes. Nigel Edwards, the confederation's policy director, believes there will be 'a push on quality, patient experience and dignity'. This is already in train, as the Darzi review will look at how to improve patient care.
One of the features of the run-up to Brown's premiership was his 'listening tour' of the country. The cynical might point out that this was Brown attempting to shed his image as an old-fashioned centrist politician by spouting warm words about learning from patients and staff and devolving as much decision-making as possible to the NHS coalface.
However, it seems Brown and his aides did learn something from the tour and are acting on it. Before they embarked on it, they believed that improving access to GPs, particularly early in the morning, after work and at the weekends, was the biggest issue for the public. They were surprised to find that it fell behind issues such as lack of communication, dignity and unfriendly staff. Although there is certain to be an initiative on GP opening hours – Darzi's review will look at improving access and integrating primary and secondary care – an early priority is a major initiative on healthcare-acquired infections, particularly the 'super bugs' MRSA and Clostridium difficile. Last week Johnson announced an extra £50m to tackle the problem.
The idea of creating an independent board to run the NHS on a day-to-day basis has been consigned to the bin, although the Tories remain wedded to it. Instead, Brown's 'big idea' might be to enshrine the rights and responsibilities of patients, staff and minister in a new NHS Bill of Rights. Johnson has confirmed that ministers will consider creating an NHS constitution once Darzi's review is complete.
King's Fund chief executive Niall Dickson says a constitution could be launched as the NHS approaches its sixtieth birthday next year. 'Do not expect this government to create an independent NHS board – that idea has probably died, but there might be moves to underline the commitment to greater operational and managerial autonomy,' he says. 'Gordon Brown hinted at his intentions when he called for a new settlement for the NHS – a settlement that would be clearer about where government accountability lies and with ministers taking a step back,' he adds.
Although this would follow the current fashion
for constitutions, Dickson believes some degree of central control will be maintained. These could include a smaller number of meaningful targets; clearer accountability at local and national level; improved professional practice for clinicians; and financial incentives that support good health outcomes, not just activity.
Brown has said he will usher in greater public and staff involvement in local NHS decisions. Sources say he might use the example of foundation trusts, which have board members drawn from the local population and their own workforce. When foundation trusts were first established, chancellor Brown had many rows with Tony Blair and then health secretary Alan Milburn over their financial freedoms and was successful in limiting these, such as ability to borrow. But now he might find them to be a useful tool in gaining public and staff confidence.
One Whitehall source suggests that he might even loosen the financial grip on foundations. 'It helps that when he's talking about foundations he will not be looking over the table at Milburn,' another source quipped.
Despite the Darzi review, most commentators believe that Brown will deviate little from the Blairite path in health. This is further supported by his installation of an unashamedly New Labour health secretary and two key appointments within his office. Gavin Kelly, a former research director at the IPPR (one of Blair's favourite think-tanks), and Greg Beales, who worked on NHS reform in Blair's Prime Minister's Delivery Unit, will advise Brown on health. Beales is known to be a firm supporter of the NHS market and GP practice-based commissioning.
'In the past, Brown and his allies have been associated with central levers and state-run services, but there are signs that he will press ahead with choice and diversity,' says Dickson. 'It will require political courage to create the right incentives and to make fundamental changes in who provides services and how they are delivered.'
Johnson's early promise that there will be no structural change will help win over staff. But one of the unions' greatest problems is the use of the private sector to treat NHS patients, through independent sector treatment centres. Johnson might have some leeway here and it has been reported that he will review the use of the private sector in the NHS.
Private health care providers have shown signs of being less interested in the second wave of ISTCs because they are no longer guaranteed payment irrespective of the number of procedures carried out. Johnson and Brown might make a virtue of this as they try to charm the unions back on side.
For all the difficulties that Johnson will face, he will still preside over health spending that has tripled to around £90bn since 1997. He will want to ensure the NHS makes the most of this cash. The pace of investment cannot be kept up and when the Comprehensive Spending Review reports this autumn, the NHS is likely to do relatively well – but nowhere near the 7% annual real-terms increases of recent times.
The CSR settlement and Darzi's reports will be pivotal moments in the development of health policy under Brown and Johnson. But for the next few months, patients, doctors, nurses and other health care workers will have their say. Darzi will listen; the question is, how will the government react?
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