In this blog, Marcia Saunders expresses her worry that the new powers which the Health and Care Bill gives to Sajid Javid represent a threat to the NHS as we know it. Marcia Saunders is a retired NHS administrator with over 40 years experience. Among other roles, she is the former chair of North West London Local Education and Training Board (Health Education England), former chair of North Central London Strategic Health Authority, former chair of Brent and Harrow Primary Care Trusts and the former Assistant Director of Havering Council and Bedfordshire Council Social Services.

Major reorganisations of the National Health Service are unrelentingly frequent, and as a now-retired senior manager with some 40 years’ experience of the NHS and social services I have taken part in at least a dozen.  All involve disruptive structural change and all have been destabilising, expensive and distracting and have a poor record of achieving their stated objectives.  

The timing for another reorganisation couldn’t be worse, when everyone needs to be focused on recovering from the pandemic and dealing with the backlog. Yet here we have one in the Government’s Health and Care Bill (2022), with its main thrust being the centralisation of power in the hands of the Secretary of State.

This is far from the objective with which the Bill was initially announced. That was to do away with the  worst of the Lansley Reforms of 2012 and abolish clinical commissioning groups.  It was touted as “the Bill the NHS wanted ”  and it’s replete with words like ‘permissive, flexible, local.” 

The reality is very different. The Bill  gives unprecedented powers to the Secretary of State to issue directions to NHS England, the NHS’s governing body, alongside the weakened  local governance and accountability arrangements of the new Integrated Care Systems.  

The Secretary of State already has immense power, much of it carried out through formal delegations, enhanced by the production of an annual Mandate through which he sets out his priorities and requirements for the coming year. The question repeatedly being asked is simply  “Why”?  That is, what powers does the Secretary of State need that he currently lacks?  

The Bill is currently in its committee stage in the Lords, one of whom asked the other day for a single example of an occasion when the Secretary of State had found that he needed a power that he didn’t already have. There was no answer, and indeed the NHS’s longest-serving Secretary of State, who presided over seven years of cuts, austerity and the run-up to the pandemic, is on record as saying he couldn’t think of any time when he needed additional powers.

Clause 39 of the Bill encapsulates the proposed powers of direction. Concerted questioning in committee session by Lords from all sides revealed their alarm at the potential for such powers to undermine key decisions such as fair resource allocations and properly conducted procurement. They sought obvious safeguards such as defined timescales for start and cessation, and clear definitions of need and purpose. Above all they stressed that in every case there must be full assurance as to how the public interest test was being met and that each directive had formally to be laid before Parliament. 

They declined to be a ‘rubber stamp” of the Bill. The government's responses were so inadequate (e.g. that a direction might have to be made too quickly for all of that) that in the end amendments that had initially been put forward as ‘constructive’ were withdrawn in favour of scrapping Clause 39 in toto.

With a straight answer to the “Why” question unforthcoming, what else is going on that may be significant? The PPE contracting scandal, rife with political preference and high levels of laxity and fraud, is well known. Less highly publicised are: 

• Sajid Javid’s recent suggestion that failing hospitals be turned into independently run Academies, along the schools model, thus removing them from the NHS.

• The government’s refusal to ban those with shares or other interests in private companies from sitting on the boards of the new Integrated Care Systems.  These are the boards that will make decisions over local resource distribution. 

• The sale of GP practices in parts of London to private companies, some with USA connections.  Through its UK company Operose Health, the USA company Centene took over 37 GP practices last year.  This is currently subject to judicial review in the High Court on the basis of failure to exercise due diligence and failure to consult patients and stakeholders.

• The recent refusal by the NHS Chief Executive, as Accounting Officer and on the basis of ‘poor value for money’,  to authorise a contract for £270m to private hospitals for help with the backlog unless directed to do so by the Secretary of State (Guardian 14.01. 22). The Direction was duly given and Sajid Javid’s explanation that the purpose was to ‘create increased capacity and protect the NHS’ was laughable. NHS capacity is determined by the numbers of doctors, nurses, support staff and essential services such as staff education and training,  in all of which there are currently huge shortages as a result of a decade of austerity, cuts, Brexit and now pandemic exhaustion. Whistling up empty beds won’t do it, as the earlier, largely unused Nightingale hospitals have shown.   

What more power does the Secretary of State need? Why does he need it? Is it about further privatisation of health services and also the NHS’s commissioning system?  Private health insurance is, after all, among the most profitable and ‘productive’ enterprises in the USA. I was  born and grew up in the USA, and that’s what it sounds like.