Will history be kinder than the immediate verdicts on the former health secretary? Niall Dickson puts her in the dock, assesses the evidence and judges that her record is more complex than the jury of public opinion has allowed
In many quarters the immediate verdict on former health secretary Patricia Hewitt has not been favourable. Public perception of the NHS is of a service that is failing to deliver, whose future is in doubt and which has been presided over by a health secretary who has made matters worse.
The British Medical Association expressed no confidence in Ms Hewitt - and as the doctors began to revolt, the other professions were scarcely less hostile. It is a reasonable assumption that managers and Labour politicians, the two main groups coping with the consequences of public and professional discontent, hold a pretty damning view of her legacy too.
Yet Ms Hewitt has departed at a time when the health service is in surplus, with high patient satisfaction rates, falling waiting times and a reform programme that is certainly more coherent than when she arrived. She has renewed and strengthened the top team at the Department of Health, created an organisational structure for the service that is more robust and fit for purpose, and has begun to tackle long-standing failings in financial management and control.
Therein lies the paradox - little or no credit for real achievements and plenty of opprobrium for shortcomings in the service, at least some of which are either overstated or non-existent. Politics, though, is as much about being seen to deliver as delivering, and today's harsh judgements reflect both miscalculations and the near impossibility of leaving one of the most taxing jobs in government with an unblemished record.
The storm clouds were already gathering when the Mr Fixit of Tony Blair's administration, John Reid, marched off to the Ministry of Defence. In spite of three years of unprecedented levels of funding, underlying financial instability in significant tracts of the service had not been tackled and surpluses in some areas were being used to bail out and cover up deep-rooted problems in others.
It was not until after the new health secretary arrived in 2005 that the seriousness of the financial position was realised.
That said Ms Hewitt's decision, within weeks of taking over, to embark on a major reorganisation was bound to make the ensuing 18 months even more tumultuous.
Commissioning a Patient-led NHS was released on an unsuspecting health service in July 2005, just as many of those who would be expected to enact its wide-ranging orders headed off on holiday. In effect, this document abolished and reinvented the two main organisational tiers of the NHS and instructed primary care trusts to divest themselves, in an unspecified way, of a quarter of a million community staff.
Timing all wrong
The strategy itself, in part prompted by the apparent lack of financial control, had much to commend it. The PCTs and strategic health authorities created by Alan Milburn were too small and numerous to be effective or to attract the quality of senior management required. Commissioning was clearly not working as it should, or as it would need to do in a reformed system, and it made sense for PCTs to concentrate on that rather than be distracted by the conflicting demands of being a significant provider of community services.
It was the timing and the manner of implementation that were all wrong. The most obvious error was that Ms Hewitt herself had not taken on board the implications of casting thousands of nurses, midwives and allied health professionals into organisational oblivion. There was, it seems, very little discussion of this before the document was published.
How this happened remains a mystery. Some of the key players say that the clear demand that PCTs divest themselves of their provider function appeared in the document without them knowing; others blame the sudden release on a naive decision by officials to brief a large number of key figures without even a rudimentary communication plan in place. Whatever the sequence of events, the politicians themselves should have anticipated the fall-out from such a crass move.
The result was rapid climbdown: having appeared single-minded and decisive, the still-new health secretary was faced with a judicial review from the Royal College of Nursing and was forced to apologise for a policy that made a lot of sense but had been ineptly handled.
The damage was done. Nurses and others who were already grumbling at the failure of the Agenda for Change pay strategy to meet their expectations would not forgive her, and many community staff remain suspicious of any moves towards reform. Ironically, some believe that the delegates at the RCN congress may have saved the health secretary from being moved last year by booing her on stage: prime minister Tony Blair's reshuffle, not long after, could not be seen to reward such behaviour.
Her decision to intervene in the debate over the cancer drug Herceptin is arguably another example of diving in too quickly. Hewitt believes she was misrepresented and insists she never instructed North Stoke PCT to pay for the drug, as some have alleged.
Nor did she. But she did intervene personally rather than leave it to the National Institute for Health and Clinical Excellence; state that she was 'very concerned' at the PCT's decision; tell PCTs in general they should not reject the drug on cost alone; and demand a meeting with those in North Stoke who had taken the decision to refuse.
All this for a drug that was not yet licensed for use on women with early-stage breast cancer (Roche had not even submitted an application) and which was very far from being the miracle remedy peddled by the popular press.
In one sense Ms Hewitt was vindicated in that NICE eventually approved the drugs but it was an intervention that clouded lines of accountability and created an unfortunate precedent. It alienated many senior figures in the service, who regarded it as playing politics in what will always be an emotionally charged and very difficult area.
In the public's mind, the failure to deal with MRSA and Clostridium difficile was even more critical. Again, perception is all important - the public's view of hospitals as dangerous and unclean may have been unfair or overstated but if Ms Hewitt was to take the credit for shorter waiting and more responsive services, she also had to accept responsibility for a service that had done too little too late to stem the rise of hospital-acquired infection.
One of her biggest failures - by no means confined to this health secretary - was the inability to take staff with her on the reform journey. An HSJ poll of staff morale revealed an angry and disillusioned workforce, and that matters, partly because it represents such a huge part of the electorate, partly because it is difficult to see how reform can be embedded with staff who feel so alienated from the process.
However, perhaps her greatest weakness was one of style, not substance. She has few supporters among those who do not know her personally or have not seen her in action. The common charge is that she appeared supercilious and patronising, a know-all who did not listen. This is unfair. Of all the politicians at this level I have known over the years, my impression is that she was genuinely interested in ideas and more prepared to listen than most.
Part of the problem may be a degree of misogyny, and the difficulty bright and capable women have of conveying authority without sounding like a man. When she was health secretary, Virginia Bottomley suffered from almost identical unkind and unjustified criticism.
Many of the issues Hewitt had to confront during her two years in office were inherited or were decisions for which it would be unreasonable to hold her responsible. She did not approve the large pay awards for doctors or reduced hours for GPs, nor did she devise Agenda for Change. She has carried the can for the serious errors made in the junior doctor recruitment fiasco but, as her supporters point out, this was a system designed by doctors and run by doctors - not something often reflected in coverage of the issue.
And her achievements are real. Landed with a silly and convoluted manifesto commitment to restrict but not ban smoking in public places, at first she went along with the party line but then changed tack as it became clear that it would be defeated. Her own instincts were always for a ban, and this may well prove to be the most significant public health measure of this administration.
The white paper Our Health, Our Care, Our Say was quickly eclipsed by the financial woes of the service but in time it may come to be regarded as a seminal document that signalled the beginning of new understanding of how care out of hospital can be developed and services re-engineered and personalised.
She must take some credit too for beginning to sort out the financial mess she inherited and for replacing a top team which, whatever its earlier achievements, was regarded as dysfunctional.
She certainly fought hard for a better comprehensive spending review settlement in both health and social care.
So how should we assess this secretary of state? Immediate verdicts are often harsh, and history can be a kinder, more reflective judge. On her own admission Hewitt lost the battle for hearts and minds and that is a significant failing. But much of her time was spent clearing up messes not of her own making and, in spite of gaffes along the way, she persevered with complex and challenging reforms, which have the potential to deliver a better service. For that too we should be thankful.
According to the secretary of state herself, the past 12 months have been very difficult and bruising; she may not be as sorry to have left as you might think.
Niall Dickson is chief executive of the King's Fund.