The Department of Health is the department the government wants - lean, responsive and focused. But is that what the health service needs? Scott Greer says the DoH should start answering back to government

The Home Office hogs Whitehall headlines these days. If there is anything the press likes more than health policy, it is foreign criminals on the loose.

So it is the Home Office that was publicly and humiliatingly declared 'not fit for purpose' by John Reid when he arrived there. But the NHS has problems of its own: too many contradictory policies, often poorly thought out and developed without enough attention to implementation. And when we find those kinds of co-ordination, policy, and strategy problems in the public sector we usually lay them at central government's door, at the Department of Health.

Rightly so. The DoH has been involved in recent policy fiascos. But that is what is asked of it by its masters. It is the department politicians say they want when they seek to make the bureaucracy more responsive: small, working through agencies, almost free of civil servants at the top ranks, less committed to job security, focused on delivery, willing to respond to central direction, and filled with subject specialists rather than generalists.

Look hard at the DoH, as Holly Jarman of the London School of Economics and I did in the new Nuffield Trust report The Department of Health and the Civil Service: from Whitehall to department of delivery to where? It is a far cry from the bowler-hatted experts many still imagine when they think of Whitehall. It is, rather, a department reorganised into crisis and often charged only with implementing policies that come from a mixture of special advisers and outside consulting firms.

It is scarcely a Whitehall department. We examined the biographies of the top 32 officials in the DoH. Sixteen are former NHS. Six are former private sector. Only one is a career civil servant. And in the DoH, the lower ranks of the senior civil service, where we might expect to find Whitehall civil servants and expertise, networks, organisational memory and the other requirements of joined-up government, have been radically thinned out.

When we looked at pay grades, we found a radical increase in the numbers of agency heads and other high earners, and evidence of the enormous pruning carried out at the bottom end of the senior ranks.

Turbulence at the top

It is a constantly changing department. Consider the last six years:

  • three major reorganisations of the DoH itself, with strange consequences such as the sidelining of finance just as payment by results was developing;
  • the programme to reduce the DoH by 720 staff, more than a third;
  • a Gershon review commitment to savings of£6.47bn by 2008 - the highest 'efficiency savings' of any department);
  • talk of more cuts, soon;
  • the mass reorganisation of arm's length bodies, which meant a 50 per cent cut in their numbers, as well as a 25 per cent staff reduction and£500m savings by 2008;
  • the Lyons review (moving more than 1,000 staff out of London, although the large operation in Leeds gave the DoH a head start);
  • and one-off moves such as the transfer of most of the old management executive human resources function in Leeds to the DoH and then to the NHS Confederation, where they became NHS Employers. This turbulence is reflected at the top, where most senior staff (excluding ministers) have fewer than five years in post.

It is the department the Blair government and Brown Treasury want. Number 10 has been deeply involved in the DoH, with special advisers such as Paul Corrigan and Simon Stevens far more influential than most of the DoH, and the Treasury has cited it as a model department.

It is clear enough that it is doing much of what the government prescribes. It is doing well with the Lyons (decentralisation) agenda, principally because it can build on its large Leeds operation. It has the largest Gershon savings target, has already cut staff, is moving on its rapid timetable to merge and cut arm's length bodies, and has strong links with the centre. Independent sector treatment centres were cited by the Gershon report as an example of good practice. The new commercial directorate tries to extend such procurement success - or at least carry out a mission to change the DoH culture in a commercial direction.

It is the department governments want. While the pace of reorganisation, new policy, hirings and firings, and other changes has clearly increased under Labour (in line with the budget), the trends that produced this department are hardly unique to the Blair government.

The DoH as it is today is a function of many decisions by governments since 1983: to focus on managing the NHS from the centre; decisions to avoid traditional civil servants; decisions to listen to special advisers (often ones based outside the DoH, in Treasury or Number 10) despite - or because - they lack the policy skills of the Whitehall machine; decisions to listen to big consultancy firms for the same reasons; decisions to opt for a department of the English NHS rather than a department focused on wider health issues; and above all decisions to reorganise the NHS and the department incessantly - decisions that over time would weed out those who would object.

There is no way that Labour could have created this department, so far from the civil service norm, if it were not for Conservative policies, the creation of a managerial cadre that could be hired to staff the DoH, and both parties' lack of trust in public management. In other words, the DoH's 'decide and do' culture was a successful forced implant by politicians who often have good electoral reasons to prefer fast, impressive action even if it is reckless and contradictory.

But should it be the department the government wants? The problem is that the DoH, which should be the lever for policy change across the health sector, is itself all too likely to bend in policy-makers' hands.

The DoH is a high turnover organisation with pared-down middle management, questions about retention, some alarming results in staff surveys, and a focus on bringing in outside, managerial expertise (sometimes with overt goals of forcing cultural change) that has sidelined other valuable HR goals.

It is very difficult for the DoH to construct functional, goal-oriented teams that can connect across policy fields and make things like payment by results or independent treatment centres work. Retention at the top is parlous, and layoffs hit the middle.

How can it function with the limited memory and high transition costs that come with high turnover? It is no wonder that it has often found it hard to produce explanations of 'how it all fits together', even though that is what many in the NHS, and public, most want. There is no reason to expect that the DoH understands how it all fits together on the gritty, technical level on which policy must work.

A tough sell

The combination of turnover, reorganisation, narrowly managerial tasks and multiple cultures within the DoH is particularly challenging in light of the scale of its tasks and the scale of the same issues in the health system. What keeps the commercial directorate, for example, from negotiating clinically unworkable deals? What mechanisms identify policy contradictions? What ensures that finance is appropriately represented at the table? What, in general, is the level of knowledge of overall health policy in the DoH?

None of the negative consequences should be news to people who work in the NHS. The same incessant reorganisation, upsizing and downsizing, job shuffling and instability that affects the health services also affects the DoH.

And while it might be grimly satisfying to know that it does indeed taste its own medicine, policy problems at the top mean managerial disasters at the bottom.

Ultimately, the solutions are unlikely to be complex. If the problem is to do with excessive turnover, excessive reorganisation, lack of policy expertise and strategic thinking, bad retention, and consequent cynicism, then more reorganisation and more studies are not required.

Continuing the recent strengthening of the policy function, improving retention, and improving organisational memory is what is required. In other words, good management, and perhaps bringing back some mandarins.

The savings in outside consultancy contracts might be soon dwarfed by the savings from better health policy. But the first effect of more policy expertise, understanding and memory would be to produce a department that would tell ministers and their advisers if what they wanted was impossible, contradictory, or silly. Selling that to ministers might be more difficult.

Scott Greer is assistant professor of public health at Michigan University and holds a research grant with the Nuffield Trust under its policy theme 'Role of State, Devolution and the NHS'. For more information about his research paper, go towww.nuffieldtrust.org.uk