The Primer provides a rapid guide to the most interesting comment and analysis on the English health and care sector that has not (usually) appeared in HSJ.

Muddled micromanagement

During NHS England’s short lifespan it has had two chairs and, as of this week, three chief executives.

Its first chair, the fairly low profile Sir Malcolm Grant, put his head above the parapet on Friday to write a piece getting well stuck into government for taking more control over the national body (he also welcomed Amanda Pritchard as the new CEO). Sir Malcolm doesn’t pull punches in the Times Red Box article, arguing the proposal in the Health and Care Bill “opens the door to a muddle of second-guessing and micromanagement”. 

He urges Sajid Javid, who has inherited the plans from Matt Hancock, to “disavow this approach and ditch the new powers, empower [NHSE’s] new chief executive and focus not on internal management but on hammering out the answers to the large unresolved strategic questions” such as NHS funding and social care reform.

Sir Malcolm says NHSE should retain a “significant measure of operational independence”, although what’s really being fought out is a bit more than purely “operational”. Under Simon (now Lord) Stevens, NHSE has been able to set the strategic direction for the service, and publicly negotiated with government. Sir Malcolm lauds Lord Stevens as a “formidable opponent to permanent secretaries and ministers alike in securing focus and resources behind the NHS enterprise”.

Is it too much to speculate that the appearance of this piece immediately after the appointment of Amanda Pritchard indicates that she herself is not planning to roll over in the face of government desire to take control? Some who work with her have observed that, while she doesn’t have Lord Stevens’ record of political maneuvering, she has seen the real benefits of NHS independence, both as Guy’s and St Thomas’ chief, and then as NHS England chief operating officer; and doesn’t want to watch them evaporate.

The response

Henry Hill, ConservativeHome news editor, wrote a response to the above in the Telegraph on why some, especially politicians, think ministers do need powers of direction over the NHS. He argues: “Whilst it might displease the mandarins, the NHS is simply too big and too important to be allowed to run itself. Ordinary people need a chance to exercise control over the institution that could mean life or death for them or their loved ones. At present, private healthcare is only an option for a privileged minority.

“The rest of us must be able to look to Parliament – to write to our MP, to hold the government of the day responsible. Without that special political oversight, the NHS is too much like an ordinary monopoly. And ordinary monopolies are bad for consumers, and get broken up.”

It’s far from the last we’ve heard of this argument. So far, Mr Javid has not come down one way or the other on the issue. Will he fight on for the new powers of direction, in the face of what will obviously be strong opposition from Labour; or will he make amendments to the bill to drop them altogether? There could well be a middle way of putting more caveats and controls around how and when the powers can be used.

Antisocial insurance

With the backdrop of huge waiting lists and an urgent need for more funding, there are signs in the papers of how an even more toxic political debate could bubble up around the health service, something Ms Pritchard will want to keep at bay. 

James Forsyth, a prominent Conservative journalist, writes in the Times on how “NHS waiting lists could scupper the Tories”. Interestingly he calls for a return to payment by results tariffs in the NHS to energise the recovery (just as the NHS has shifted to system reward payments instead). 

But he also floats a more radical policy approach: “Post-covid might seem the right moment to rethink the whole NHS and entertain ideas such as health insurance. But the Tories have little interest in doing so. Since 2016, they have tried to turn themselves into high priests of the national religion that is the health service and any talk of different models, even ones that maintain universal access to care, is regarded as heretical.”

Meanwhile in another Times piece, the campaigning doctor and author Rachel Clarke was characteristically dramatic about the current predicament, arguing: “Not one of my NHS colleagues believes the NHS as we know it can survive much longer.” Dr Clarke is a champion of the NHS, but her piece also gave rise to letters to the editor arguing for a move to a much more private funding system.

Nigel Edwards, Nuffield Trust chief executive, took to Twitter to give warning to anyone thinking that a move to an insurance model might offer solutions.

Understand the lyrics

Professor Anton Emmanuel, a top gastroenterologist and clinical lead for NHS England’s race equality work, has written a blog tying together the racism surrounding England’s final defeat at Euro 2020, the row over the RNLI’s role rescuing refugees, and discrimination in the NHS.

He writes: “Institutional racism does exist and is associated with ethnic disparities in health outcomes. We need to understand what the term ‘institutional racism’ means, based on the Macpherson report, namely that there is a collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin…. 

“This systematised discrimination connects to a sense that diversity and inclusion poses a threat to some people’s sense of Englishness, and in turn fosters the culture that results in the social media abuse directed at the black English footballers. There is a disconnect between the overt racism of one section of society and the dignity of another. This has been highlighted in the last few days: following Nigel Farage’s repellent description of the RNLI as a ‘taxi service’ for migrants there has been a remarkable 30-fold increase in public donations to the lifeboat charity.

“The NHS, like the RNLI and the current English football team, are well regarded by the public. In many ways these institutions are part of what define us as a nation. We have a chance to be proud of an anti-racist NHS that transforms itself for the benefit all of its staff and every citizen.”