Under plans announced last week, Welsh health minister Edwina Hart is to take direct control of the country's NHS. Dave West asks if a politician can be trusted with such a sensitive job
Personality and policy have regularly become confused in the 18 months since Edwina Hart took over as Welsh health minister.
One openly populist move, in March, saw her scrap hospital car parking charges. Four months later she publicly ticked off the high profile Cardiff and Vale trust for failing to meet waiting-time targets. She has also intervened in areas from ambulance service performance to hospital food.
Now her attention has turned to the management of the Welsh NHS itself.
Last week the minister announced plans for a "national advisory board" to plan, fund and hold services accountable, with herself as chair.
Unsurprisingly, the idea has drawn criticism from her political opponents. Welsh Conservative health spokesman Jonathan Morgan branded Ms Hart "chief health commissar", accusing her of "blatant" politicising of the NHS in "a way I never thought possible".
His Liberal Democrat counterpart Jenny Randerson has serious practical concerns about whether constituents will accept supposedly clinically justified service closures when they come from a body with clear political sway. "I think it is essential if we are to have credibility for the NHS that we have a strong voice for patients and clinicians and that politicians, specifically the minister, are not involved in day-to-day decisions," she says.
The extensive reconfiguration, which is intended to be enacted by the spring and follows a consultation earlier this year, has a strong flavour of command and control. Twenty-two local health boards, which provide primary care and commission secondary care, and eight acute trusts will be merged into just seven new bodies.
The internal market will be formally abolished. Although it is considered never to have worked properly in the country, there are real concerns that losing the primary-secondary separation could see community services neglected.
Ms Hart will appoint chairs and vice-chairs who, with chief executives, will report annually and in public to her advisory board.
Making such changes in Westminster would be anathema. The Department of Health's controlling instincts have far from disappeared, but localism remains the watchword.
NHS Confederation deputy policy director Jo Webber, while praising Wales for trying something different, says: "We have just been through the next stage review, which is about making sure things are being implemented and delivered at local level. From an England point of view, we want to devolve to the level at which it makes most sense for you to plan and deliver."
The Conservatives' proposals for an NHS board for England would not give the health secretary anything like the same level of direct control as will be enjoyed by Ms Hart.
Despite the harsh words from its political opponents the Assembly government in Wales is a strong Labour-Plaid Cymru coalition, and appears entirely unshaken.
Ms Hart is characteristically defiant, happy to acknowledge both her personality and ideology: "By its very nature, the National Health Service is political - it was established by a political party that believed in socialist principles, and we must never move away from that. I was not prepared, as minister, to consider the establishment of another quango or to say to you, 'That is a matter for the Hywel Dda NHS trust' or another strategic health authority."
Open dissent within the health service has been notable by its absence - in some part, perhaps, because managers wish to keep their jobs in the coming shake-up.
Cardiff and Vale trust chief executive Hugh Ross says: "I think the minister is determined to be visible on this, so her model is very consistent with how she wants to work. I think people will be comfortable with that. Health is already intensely politicised in Wales, as it is elsewhere."
Even privately, managers speak of reluctant acceptance that the health service in Wales will be a regular political football, and the attitude to Ms Hart's interventionist style is one of resignation rather than outrage.
The British Medical Association, too, is just about toeing the line. It would "much rather a fully arm's-length approach", says Welsh secretary Richard Lewis, but "at least with this arrangement, the buck will stop firmly with the minister, of which there can be no doubt".
Wales has developed its own system under devolution and, combined with the size of the country, some say, this has naturally resulted in high profile, interventionist ministers.
A similar situation has been seen in Scotland, with health minister Nicola Sturgeon visible on several issues, recently saying the private drug top-ups issue will be thrown to MSPs for debate. Compare this with Westminster, where national cancer director Mike Richards is preparing a report in private.
Chris Ham, professor of health policy and management at Birmingham University, explains: "All the evidence is that ministers [in devolved governments] have taken a very close interest in how the NHS works. Channelling that through an advisory board seems to be a matter of presentation rather than substance. Because the politicians are very close to what is going on they are drawn into controversial issues of that kind."
Ms Hart, as well as citing democratic socialism, argues the new system is simpler and therefore more effective for the NHS in Wales.
Managers are generally hopeful that this will be borne out, solving major problems caused by the division between trusts and boards.
The Welsh NHS Confederation pushed for local mergers so, although it would have preferred an arm's-length national organisation, it has broadly welcomed the plans.
Scott Greer of Michigan University's school of public health has published several books on devolved health policy. He believes size does matter: "There is no good case for having a big management and regulatory structure such as England's when most people know each other and the local situations. "You could say this reorganisation gives Wales a more streamlined system without the apparatus of an internal market that never worked - not under Thatcher, not now."
But the devolution argument is rejected out of hand by the Welsh Conservatives. Jonathan Morgan argues: "True devolutionists don't grab all the power for themselves but devolve responsibility to managers and clinicians to lead strategic change and deliver the services we need. The scope for innovation will be lost because people will be conscious of ministers looking over their shoulders."
Acting director at the Welsh Institute for Health and Social Care Marcus Longley accepts devolution and Wales' particular setting have an influence. He puts the plans down to the minister's personality more than devolution, and many managers agree.
Because Ms Hart already gets involved, Mr Longley says, she could argue she has not made a significant change to the national structure. Therefore, though it may disappear under other ministers, Mr Longley feels the problem is perhaps more immediate: "There is a real danger that the minister becomes too hands-on. One danger is that she cannot be sufficiently detached from day-to-day problems to exercise leadership."
Does Hugh Ross, who at Cardiff and Vale has been the direct victim of Ms Hart's interventions over waiting lists, feel this is a problem? He is tactful: "It will depend on what she is trying to achieve."
The next minister
If the system is being recast in Ms Hart's image, another pitfall could arise when she is replaced by a minister who is less comfortable taking on the minutiae of policy. Those in the service could rightly fear more instability if this happens.
For the Liberal Democrats, Jenny Randerson says the board chair role could be removed without too much trouble. Jonathan Morgan concurs: "I would not chair the NHS, the organisation would be at arm's-length, where we would rely on the talents of those in the NHS to deliver the services."
The three strands behind the restructure - of ideology, personality and practicality of devolution - are hard to disentangle. As the biggest change to the country's health service in three decades, though, it is undoubtedly further proof that the UK's four nations are diverging.
"In one way it is a really interesting experiment to go through, and I hope that between the four different systems we can learn things," says Jo Webber.
Institute for Public Policy Research fellow Katie Schmuecker observes that the different systems are already poaching from each other, citing the introduction of waiting-time targets in Wales: "Despite having legally different powers, actually in practice policy is sometimes constrained by what the public expect. Pressure from the public has sometimes forced convergence on policy."
But whether the latest changes are a matter of politics, practicality or personality, any eastward import of the model can surely be ruled out.
NEW LOOK IN WALES
Eight acute trusts and 22 health boards to be reduced to seven merged regional bodies, combining primary and secondary care
National advisory board composed of appointed experts and chaired by health minister
NHS Wales chief executive to sit on board and lead separate "delivery group" for operational management
Specialist cancer trust Velindre will remain
The role of Health Commission Wales, which commissions specialist care, is being reviewed
Details of the composition, legal form and finances of the new bodies to be published later in the autumn
A consultation on new powers for local community health councils is also expected
Review of access to drugs not approved by the National Institute for Health and Clinical Excellence to report in New Year