Since the reorganisation of the health service, many people have been left wondering who can or should decide the future of healthcare provision, says Holly Jarman

History tells us that separating policy and management is virtually impossible in health services. Many governments have tried and failed to take the politics out of the NHS by reforming its structure and governance.

The coalition government is no exception to this, although there is no doubt they have tried.

The reorganisation of healthcare delivery and governance in April 2013 was big, even by the standards of NHS England.

NHS chief executive David Nicholson famously said the reform demanded “such a big change management you could probably see it from space”.

Power struggle

The reform, launched under the banner “liberating the NHS”, rests on some familiar ideas.

Commissioning GPs and increasing provider competition were seen as ways to improve the quality and efficiency of care.

The Department of Health was viewed as too big and dictatorial, while mid-tier management bodies in the NHS such as strategic health authorities were seen as bureaucratic and superfluous. It was also considered possible and desirable to create a structure for the NHS that would be immune to politics.

Holly Jarman

‘Many are left wondering who can or should decide the future of healthcare provision in England’

In the Centre for Health and the Public Interest’s latest report, A reorganisation you can see from space: The architecture of power in the new NHS, we argue the government’s reform has instead created great uncertainty surrounding who now makes health policy in England and, contrary to its original intention, this has not resulted in an NHS with less political interference.

Recently both the chair of the Care Quality Commission and the chair of NHS England have complained about Jeremy Hunt’s decision to phone hospital chief executives to discuss accident and emergency waiting times and, more generally, about political interference in NHS England’s mandate.

Meanwhile, a power struggle seems to be developing between two of the most significant bodies in the new structure charged with regulating and overseeing the delivery of NHS care. Monitor and NHS England have apparently different views about how competition policy within the NHS should be enforced and how efficiency savings should be made.

This has left many wondering who can or should decide the future of healthcare provision in England.

The diminished DH

Without a doubt the authority and capacity of the DH has been much diminished. The reforms explicitly tried to reduce the secretary of state’s power over the NHS, moving resources and authority to NHS England, Monitor and other agencies.

‘Without a doubt the authority and capacity of the DH has been much diminished’

With so much power taken away from the minister and a government committed to cutting civil service numbers, it stood to reason that the DH itself would experience cuts.

Many former functions of the DH have been hived off into agencies. Public health, for example, is now in the hands of Public Health England and local government. The role of the remaining DH officials is also uncertain.

There is confusion about the role of the chief medical officer, which stayed with the DH but is now flanked by Public Health England and the medical director of NHS England.

Today, the DH is back to being the “thin rim” around the NHS which it was back in 1983: approximately 150 senior civil servants governing a limited set of functions with a limited range of tools.

As our report shows, many of the DH’s former top team have moved to NHS England where their key tool is commissioning. Traditionally, health ministers of any and all ideologies have appreciated the services of strong managers who know how to serve ministerial authority. Those people are now disproportionately in NHS England.

Monitor’s expanded remit

In contrast, Monitor’s “DNA” is more KPMG than DH. Monitor’s role expanded with the reorganisation.

Always an assertive body, Monitor wasted no time in challenging others for control over the NHS. Once a financial regulator for the NHS, now it is increasingly viewing itself as the guardian of the NHS in the patient’s interest.

‘Monitor’s “DNA” is more KPMG than Department of Health’

Who staffs Monitor? Unsurprisingly, for a body set up under Alan Milburn that gained greater power and a new executive team under Andrew Lansley, it is top heavy and filled with private sector backgrounds rather than government or NHS experience.

If the purpose of Monitor is to create a pro-competitive regulatory culture and bring new blood from the private sector, then it is a bigger success than many of its predecessor organisations in NHS management.

Unstable mix

Is this new structure stable? There are three serious contenders to be the centre of a NHS that currently has no real centre.

The DH has few people and few tools, but it does have the health secretary. The people and tools previously used to run the NHS out of the DH are now in NHS England, where they focus on purchasing.

Monitor has a wide remit and range of regulatory tools and is clearly staffed to bring the culture and priorities of management consulting and city law firms into the health service.

Incoherence in the centre, ambitious ministers and a structure that still holds the government accountable for NHS performance are an unstable mix.

The new structure of NHS governance does not change the fact that the public and media will continue to attribute the success or failure of health policy to the government.

It seems likely, therefore, that the secretary of state will keep the responsibility for health while being unable to effectively use the tools to solve problems that arise in the NHS.

Holly Jarman is a research assistant professor with a joint appointment at the Centre for Law, Ethics, and Health and the department of health management and policy at Michigan University