HEALTH AND POLITICS Ж Access this paper online to listen to Nick Timmins and Ed Davies, policy fellow at The Health Foundation, discuss health secretaries past and present the 6 June 2015 10 ways to be health secretarybmj 350:1-36 No 8011 | Clinical research ISSN 0959-8138 JOBS, COURSES, AND CAREERS 350:1-36 No 8011 8011 No 350:1-36 Adolescent Management of As Jeremy Hunt begins a second term as health secretary, Nicholas Timmins asks 10 previousbullying and hypercalcaemia depression CPD/CME hours | 6 June 2015 | 6 June Bronchiolitis in Australia’s incumbents for their gems of wisdom on how to do the job children: shame: how not NICE guidance to treat refugees here is no handbook on how to be health secretary and two chief executives of NHS secretary of state for health. Well, up England have operated them. to now there hasn’t been. The Health But their existence has brought to the fore Foundation, however, has got as the question of how far health ministers can in close as anyone is likely easily to get reality be removed from day to day operations in Tby interviewing 10 of the last 11 former health an almost entirely tax funded system. How far secretaries—from Ken Clarke onwards—about should they be, if the service is to remain account- what they think the role is, what it should be, able to its patients and taxpayers? How far can and what it was when they were there.1 policy, which is clearly in the purview of minis- The move was prompted in part by Andrew ters, genuinely be separated from strategy, from Lansley’s decision, as part of his monster health implementation, from operations, and from man- The10 manyways faces act in 2012, to set NHS England up as a statu- agement? In other words, what is the role of the ofto ex-health be torily independent commissioning board—ful- secretary of state for health in relation to the NHS? RESEARCH CLINICAL secretarieshealth filling, on paper at least, the long held desire of 1988-2012secretary many in the NHS to somehow “depoliticise” the What is the role of a health secretary? NHS by taking ministers out of the day to day So what do the former health secretaries think? Johnson put it, “I don’t think when a bed pan management of the service. Seeking, in the words All acknowledged the accountability for what is falls on the floor in Tredegar it should echo of Lansley’s white paper, Liberating the NHS, to now an over £100bn a year operation. “There around Whitehall any more.” But there was end “political micro-management,” “political is a custodian role to play, and an accountabil- a wide range of views over how that might be control,” and “political meddling” in the service ity to discharge,” as Alan Milburn put it. Some achieved, and how far in practice ministers so that the country could have an NHS “free from put a heavier emphasis on the public health could and should be distanced from broader day-to-day political interference.” Given the com- role—either from experience or desire. Lansley operational matters. “Is it possible in any busi- plexities of the structure that Lansley created, famously wanted to turn the department into ness or in any organisation, truly to separate pol- this might, in the eyes of some at least, be a case one for public health, with the NHS becoming icy from execution?” William Waldegrave asked. of “be careful what you wish for.” the task of a junior minister once NHS England All agreed that the personality and behav- The idea of some sort of independent board with its annual rolling mandate had been set iour of the incumbent matters. Virginia to run the NHS goes back “I don’t think when a up. Faced with one almighty Bottomley (though she was far from the only decades. The British Medical row over Lansley’s legislation one) was obsessed with media coverage—in Association trailed it in 1970. bed pan falls on the and not wanting another, the her case because she cared about its impact on The Royal Commission on the floor in Tredegar prime minister blocked that. staff and patients; Stephen Dorrell’s approach NHS in 1979 reported that “the it should echo around Andy Burnham said that per- was more “chair of the board.” Alan Johnson establishment of an independ- Whitehall any more.” haps “the primary duty” was brought gentle, humour laced reassurance to ent health commission or board Alan Johnson protecting public health, a view the task, with a hint of steel. to manage the NHS was one of that may have been coloured by Johnson relates that when the Mid Stafford- the solutions most frequently advocated in evi- a flu pandemic being declared on his third day shire scandal first broke, “Bill Moyes [executive dence”—though the commission itself, while in office. chair of Monitor] was trying to tell me that [it] saying many of the arguments in favour “are But beyond that there were many differences was his responsibility and not mine [to remove attractive” came down against the idea. in emphasis. Some underlined the stewardship the trust’s chair and chief executive] because it The precise definition of what sort of board role while others saw it as being the advocate was a foundation trust. Now politically it would should run the NHS was often missing, and, for change. Clarke put this most clearly. “The be very nice if you could get away with it and when it was present, varied over the years—from job is to lead change in response to changing say, ‘That’s yours. That’s your can of worms.’ a BBC-like structure, to a management board, to demands and medical advances. To explain why But I told him, you know, ‘Piss off. I’m dealing something along the lines of the more recent you are making changes and to try to get past with this.’ Bill was probably right that the legis- independence of the Bank of England. the resistance you usually get from the staff, and lation said he was responsible. [But] you’re the In Glaziers and Window Breakers: the Role certainly from the public . You have to preside secretary of state. There is public money going in of the Secretary of State for Health in Their Own over change and explain it,” he says. there. You are responsible.” Andy Burnham had Words, the Health Foundation has not sought to There was unanimous agreement that min- a similar clash with Monitor when he took over assess the success or failure of the new arrange- isters should not be involved in the day to day and discovered that the chair and chief executive ments. They are still immensely young. Only one nitty gritty management of the service. As Alan were still interims. So he forced the issue. the bmj | 6 June 2015 15 HEALTH AND POLITICS UK HEALTH SECRETARIES Kenneth Clarke William Waldegrave Virginia Bottomley Stephen Dorrell Frank Dobson Alan Milburn July 1988 to November 1990 to April 1992 to July 1995 to May 1997 May 1997 to October October 1999 to November 1990 April 1992 July 1995- Modernised 1999 June 2003 Clarke was also Implemented the Abolished regional the GP contract Abolished GP Warned NHS it was minister of health from purchaser-provider health authorities, and encouraged fundholding and would in “the last chance 1982 to 1985, when split, stopping Margaret turning them into experimentation have liked to dump the saloon.” Got Tony he implemented the Thatcher from killing it outposts of NHS with new forms of purchaser-provider Blair to double NHS Griffiths report on NHS off. Launched ambitious management executive. contracting. Produced split. Legislated for NICE spending in real terms. management. As health “Health of the Nation” Bit the bullet on a a white paper stuffed and the Commission for Brought in foundation secretary he introduced public health targets. major reorganisation of full of ideas that Health Improvement trusts, choice and the purchaser-provider “[The job] London hospitals. Labour, knowingly or (forerunner of competition, the tariff, split, NHS trusts, and unknowingly, adopted. today’s Care Quality and independent sector depends on “Sometimes you GP fundholding, all via “Of course, it Commission). treatment centres the hugely controversial whether you want a window- Introduced national and rejuvenated the 1999 white paper think the system breaker and doesn’t work if service frameworks and purchaser-provider Working for Patients. at any given sometimes you you change it NHS Direct. split. “I closed more time is in need of want a glazier” every five years” “I have no “I’m afraid there hospitals than policy reform. problems with is not a surfeit most people had I came to think command and of politicians hot dinners” it did” control. It is part who think that of the secretary of their historical state’s job” purpose, having got power, isn’t somehow to give it away” Healthy relationships? If they are allowed to panic “then suddenly the oddly named Cooperation and Competi- The relationship between the health secre- the prime minister will just insist on going to tion Panel, which advised on the application tary and the prime minister, something not Rotherham and making pronouncements on of procurement and competition law as these often discussed and which clearly varies with what they are doing . and you can’t have that. came into play during Labour’s time. At no the prime minister of the day, also matters. They start stamping their little foot and going point were ministers statutorily required to Clarke’s relationship with Margaret Thatcher for photo opportunities and trying to get com- accept their rulings.