For those who haven’t been paying attention, massive changes are taking place at the top of the NHS.
Leadership Shake-up in NHS England
Amanda Pritchard, the Chief Executive of NHS England (essentially the CEO of the English NHS), has been forced to resign. She made two unimpressive appearances before the Commons Health Select Committee, prompting them to take the extraordinary step of writing to express their lack of confidence in her. Such a brutal career end is nearly unheard of.
Sir James Mackey has stepped in as interim Chief Executive. Having worked with him before he was knighted, I can say he is a great leader and an excellent manager. However, he is also known for his single-mindedness, earning him the nickname “The Jim Reaper.”
Mass Departures and Workforce Reduction
Alongside Pritchard’s exit, the Finance Director, Chief Operating Officer, and Chief Delivery Officer are all leaving. Furthermore, there are plans to shrink the workforce by half—Jim Reaping, indeed.
I realise that mass sackings of NHS managers doesn’t elicit much sympathy, but this is big stuff. I have long argued that the 14 years of Conservative government weakened the senior leadership of key public services. Talent was pushed out or retired, and sycophants, mostly from public schools thrived in their place. Labour have been too slow to realise that if they want to turn around public services they need better leadership. This looks the first steps in clearing out over promoted, under talented place holders who lingered from the last Government. Lets hope that DWP and HMRC have a similar defenestration.
Understanding NHS vs. the Department of Health and Social Care (DHSC)
For those unfamiliar with the internal workings, it’s important to clarify the distinction between NHS England (NHSE) and the Department of Health and Social Care (DHSC):
- The NHS is the operational arm that provides healthcare services. NHS England is it’s head office, which all of the individual Trusts report to.
- DHSC is the civil service arm responsible for setting policies, standards, and overseeing NHS finances.
Historically, there has been a division between the NHS, which operates independently from ministers, and civil servants, who are under ministerial control.
The Future of NHS Leadership
The question now is whether Sir Jim will remain as CEO of NHSE or transition to the role of Permanent Secretary at DHSC. Notably, the DHSC Permanent Secretary position is currently vacant, with Chris Whitty temporarily covering it. This coincidence raises eyebrows. If Sir Jim weren’t expected to stay in a top role, it seems unlikely he would have been allowed to make so many sweeping changes.
A joint NHSE/DHSC CEO-Perm Sec role would be controversial but not unprecedented. When Alan Milburn was Secretary of State, he appointed Sir Nigel Crisp to hold both roles simultaneously.
The Political Implications
The Conservative government previously reduced ministerial accountability for NHS performance, causing public frustration during the Lansley “reforms.” The 2012 Health and Social Care Act went so far as to remove the Secretary of States responsibility for the health of citizens for the first time since the NHS was established.
Now, Labour’s Wes Streeting is positioning himself as the key figure in NHS reform, centralising power around himself and Sir Jim. However, by doing so, he is also making himself accountable for any failures. With a slim majority in his own seat, a misstep could cost him not only his ministerial position but also his place in Parliament.
There is a fundamental trade-off between accountability and decentralization. Streeting has swung the pendulum far toward central control. Personally, I would prefer a more decentralized system, with more autonomy for clinicians locally to shape services for patients. The NHS Sir Jim will build will have clear and influential clinical leadership at national level. Locally I am not so sure.
The Role of Integrated Care Boards
Another unresolved issue is the future of Integrated Care Boards (ICBs), which represent the remnants of the failed internal market approach to NHS management. Their future, and their staff’s future’s remains uncertain.
A Familiar Cast of Characters
I’m not a conspiracy theorist, but DHSC recently appointed a new Non-Executive Director to jointly chair the board overseeing the DHSC/NHSE transformation. Their name? Alan Milburn.
Even more intriguing, my old colleague Mike Farrar—who worked closely with both me and Sir Jim, as well as Alan Milburn—has come out of retirement to serve as interim Permanent Secretary at NHS Northern Ireland. Farrar authored the NHS Plan, which underpinned NHS transformation during the Blair years.
Meanwhile, Professor Ara Darzi—a top surgeon and former advisor to the Blair and Brown governments—has just published a performance review of the NHS.
It almost feels like someone is getting the band back together.
Mmm…! It’s all intriguing stuff. Like you I worked with Jim briefly and Mike quite closely on and off over the years. It really does look like some of the old gang are looking to do a farewell tour of their old hits. I really hope they can pin down what makes an effective leader and harness those who can make sustainable change across some disparate systems and organisations. Working in Cumbria as the CEO of the CCG it was apparent that everyone just wanted to look after their own few pieces of the jigsaw and actually didn’t really care about the bigger picture. Trying to get a single accountable structure in place across a region will be essential to plan and implement the change that is needed. The ICBs were always doomed to fail as they never had the clout to deliver system leadership. Create Integrated Care Organisations or Regional Health Authorities or whatever you want to call them – across regional footprints that make sense – with talented CEOs at the helm who have the interests of the patients and the needs of their areas at the forefront of delivering change. And then perhaps we can start making the improvements that we so desperately need.
And in the meantime events have moved much faster than I thought on Wednesday. There seem to be a lot of people in denial about what we have just seen. The purchaser/provider split is over. Commissioning is ended. That whole era of the NHS came to a stop. GP independent contractor status is drawing to a close, although this will be a much more gradual process. Trusts will be grouped together into regions, with shared services functions. Huge stuff
Thanks, leadership has been a problem in the NHS for decades. When I joined we had a whole load of discharged former cold warriors who got moved into NHS management under Major. There will be leadership talent in the system, but identifying it, equipping them with the skills to lead, and getting them into place with the right support will take years. And the exact same thing needs to happen across Government – HMRC and DWP are in an even worse state.
ICBs were a weird mess, as if the Government got part way through dismantling the internal market, provider/commissioner split, but somehow ran out of steam, or gave up when it got to hard. That wasn’t unusual during the period 2010 onwards – ambitious reforms or changes would be announced, some good, mostly bad, but which were abandoned part way through.
Labour seem to have failed to realise how urgently they needed to get the right leadership in place and the right structures to deliver better public services. Without that the money they are putting in will be wasted.
Huge stuff indeed. In reality there never has been an internal market whereby commissioners could in reality commission services from a range of providers. We could tinker on the margins and make some piecemeal changes in primary and community care but in reality if the Trust said on yer bike we had nowhere to go – so in practise we were very expensive pen pushers and glorified bankers. Once a year , during contract negotiations, we turned into peacocks full of show but ultimately spurned by our mates. It was a very expensive ritual dance where we pretended to hold all the cards but we knew full well the money just needed to be handed over or else the Trust would sink further into the mire. I just hope the system that replaces it will have clear lines of authority and accountability to get the job done.
Yes, I suspect that most years the amount of funds that actually were invested differently as a result of commissioning decisions was less than the cost of the commissioners themselves. The PCT I ran was slightly different in that we had community hospitals so we had our own beds, which we could use to bend models of care more than most, but even then it we didn’t touch the sides