While Hunt’s predecessors don’t necessarily agree on what the health secretary role actually entails, they do agree that the attitude of the incumbent is the deciding factor, writes Edward Davies

Politicians have been accused of dismantling it, weaponising it, and playing football with it, all within the last few months. Like it or not, the NHS is inherently political, but the big question is how political should it be?

Since its inception there have been boards, executives, committees and laws all aimed at defining and formatting the relationship between ministers and the service.

‘Is it possible to truly to separate policy from execution?’

But for all that, what there has never been is any real consensus – how far should the health secretary be involved in running the health service?

Or to put it in William Waldegrave’s words: “Is it possible, in any business or in any organisation, truly to separate policy from execution?”

Service and secretary

The quote comes from one of 10 interviews with former health secretaries published by the Health Foundation last month, charting the relationship between service and secretary back to Ken Clarke in 1988.

Ed Davies

The health secretary is a unique post for which there is no job description, covering the riskiest organisation in the UK with little guidance how it should be done. The book aims to fill some of that void.

Each interviewee has a unique take on what the relationship should be from Frank Dobson’s “I have no problem with command and control” to Stephen Dorrell’s “I did try to behave like the chair of the board”.

But what is absolutely clear is that whatever intention, structure or legislation may be in place, when push comes to shove, behaviour trumps everything.

The book contains numerous examples of this in colourful anecdote and language but perhaps the clearest comes from Alan Johnson’s time and the emergence of problems at Mid Staffs.

‘When push comes to shove, behaviour trumps everything’

“When Mid Stafford broke, Bill Moyes [former chief executive of Monitor] was trying to tell me that was his responsibility and not mine [to remove the chair and chief executive of Mid Staffordshire Foundation Trust] because it was a foundation trust. Now, politically it would be very nice if you could get away with it and say, ‘That’s yours. That’s your can of worms.’

“But I told him, ‘You know, piss off. I’m dealing with this.’

“Bill was probably right that the legislation said he was responsible… [but] you’re the secretary of state. There is public money going in there. You are responsible.”

Crucial context

The scenario was then repeated with his successor, Andy Burnham, who saw Johnson’s interim chief executive in place and demanded a permanent person in post: “Monitor [refused] to replace the chief exec at Mid Staffs so we forced the issue just because it wasn’t acceptable to me.”

But Burnham also points out that the health secretary’s behaviour is not just dependent on his or her personality or background – context is also crucial.

‘People think about Mid Staffs but the thing that was most immediate for me was swine flu’

“In my time… people think about Mid Staffs but the thing that was most immediate for me was swine flu,” he said.

“I remember being in the secretary of state’s office, asking, ‘What does it mean?’ They explained the arrangements that were going to kick in – ‘gold command’ and all this kind of thing. I remember David Nick [Nicholson] winking to me saying, ‘We’re in command and control mode now.’ It was a self-reflective, self-deprecating, joke.

“But it was important. We did have to go into that mode, very much so. And people wanted us to.”

The number 10 connection

Similarly, a number of the interviewees talk about the context of the relationship between the Department of Health and Number 10 and how that influenced behaviour.

“When I moved to the Department of Health, I remember one of my special advisers who had moved with me coming into my office and saying: ‘You’ve got to get Number 10 off our back,’” recalls Patricia Hewitt.

Or to put it in Ken Clarke’s simple and colourful words, it is the health secretary’s job to stop prime ministers “stamping their little foot” every time a health crisis emerges.

The task at hand

So what does all this mean for Jeremy Hunt, back in post earlier this month?

Well, many of his predecessors have explicit advice: take your time, avoid legislation, think about the workforce, even enjoy yourself.

But the take-away message is a rather more fundamental one than that: give yourself some space and reflect on what your job actually is and how your behaviour will affect that.

Those that have done the job do not necessarily agree on what it is, but they do agree that the attitude of the incumbent is the deciding factor.

‘The attitude of the incumbent is the deciding factor’

Virginia Bottomley’s interview ends with a thoughtful reflection on this, which ultimately gives its name to the book Glaziers and Window Breakers: “There are different times in politics, and it does go in cycles. Sometimes you want a window breaker and sometimes you want a glazier.

“Ken was a window breaker and he was brilliant. But after that you get William Waldegrave who was a glazier. And my job, after the election [in 1992], was that we’d got some trusts and fundholders up and running, and my task was to get all of that beyond a tipping point.

“Quieten it all down. Show them you care. And then a new set of problems will arrive and you need a Ken to break the windows again.”

So does Mr Hunt need to be a glazier or a window breaker?

Edward Davies is policy fellow of the Health Foundation and co-author of Glaziers and Window Breakers