Cowper’s Cut: The politics and the problem

I’m a cross party consensus Royal Commission on the future funding and sustainability of the NHS: I go on and on for ages, and the government basically ignores me.

I’m broadly sceptical about Royal Commissions and cross party consensus positions on the NHS. However, politics has moved on radically since I  last wrote that I thought such a thing was unlikely to happen, two years ago. Many of my assumptions about what were the fixed points in politics were wrong.

I think it’s still quite unlikely, but far less so. Writing in January 2016, I suggested that “a cross party funding commission on health and social care might get traction if funding issues represented an imminent and significant political challenge to the government.

“Thanks to The Fixed Term Parliaments Act and the tacit, uncivil war within the Labour party, this does not seem likely.

“Not yet, anyway”.

A lot has changed in politics since then: Brexit, the general election. Yet even with current performance issues, it still feels as if the NHS is not quite urgent for the government, with Brexit sucking all the political oxygen out of the room.

On the money

The issue of future NHS funding was pushed back up the agenda this week by two significant sources: one formerly close to thinking in the Treasury (its ex-chief civil servant Nick Macpherson), and the other to prime minister Theresa May (her special advisor Nick Timothy).

Speculation is also rampant that by the time you’re reading this, a Cabinet reshuffle will be under way. Despite his less than subtle manoeuvres in sounding out a possible post Theresa leadership bid, health secretary Jeremy Hunt is strongly tipped to replace Damian Green as first secretary of state and/or minister for the Cabinet office: a role analogous to the deputy prime minister.

It’s a brave or slow learning person who makes predictions about politics these days. I’m still trying to work out which of the two I am (or in what proportions I am both). So here goes.

Takes May to know Hunt

Theresa May and Jeremy Hunt were both “remain” campaigners, who now claim to be converts to the virtues of Brexit. They may even mean it: who knows?

They are dutiful, uninspired home counties Oxbridge educated Conservative MPs: one senses that both got their Conservative politics more by default than by thought.

Neither is likely to win any awards for social ease, but both have proved remarkably resilient in challenging circumstances. Both have perhaps been saved by the lack of any obviously better alternative.

If you want to believe there is a Mayism or a Huntism (in the way that there was a Thatcherism and a Blairism), there is a big, obvious gap between the well intended rhetoric and the reality. Think of Mrs May’s speech on the steps of Downing Street; Mr Hunt’s on patient safety, duty of candour and the NHS as a learning organisation - and of the distance between those warm words and what each does in practice.

The cognitive dissonance between Mr Hunt’s speeches and statements about learning, candour and openness and his Monday morning phone calls on performance to, oh, pretty much everybody; not to mention his more recent insistence on chief executives’ heads rolling seems to be lost on nobody except him.

I don’t know whether Theresa May likes Jeremy Hunt, but she can almost certainly see or sense some of herself in him. (Perversely, as prime minister, Mrs May’s weakness is probably the main thing keeping her in the job. She is weak enough for both the ultra Brexiteers and the liberal, One Nation wing to push around. Brexit will probably be the death of the Conservative And Unionist party, in not too many years’ time.)

For that reason, I think Mrs May will set Mr Hunt free from the Department of Health. Mr Hunt has delighted us long enough as secretary of state for health. He is sufficiently associated with the current NHS crisis and its roots to provide six to nine months’ political air cover for his successor – after that time, people will be focusing on nothing but the impending chaotic realities of a fast approaching Brexit of as yet uncertain flaccidity.

So by moving Mr Hunt mid crisis, the Conservative government buys itself a temporary firewall on the NHS crisis. So far, so “Machiavelli For Dummies”.

But that won’t put out the fires currently burning in the service.

The politician is not the problem

Is removing Mr Hunt now the right move anyway?

It probably is. The snarking of the Hunt on Twitter (which has been snowballing over the past year) indicates that he has come to see himself as a martyr to NHS transparency reform that is in practice being sent into reverse by the current mismatch between demand pressures and available workforce and resources.

The politician is not the problem.

The NHS as a “bottomless pit for money” is not the problem, either. 

We know what the problem is.

The mismatch between demand and funding and workforce availability and skill mix is the problem. Culture is also the problem. So are primary care, competent operational management, and learning from best practice. They are the problem too.

Whether it’s Anne Milton or Philip Lee, the NHS needs a politician who is going to listen with an open mind.

‘Doing an AJ’

That is what the service needs. However, A Big Problem will arise if Mrs May decides that what the government needs is someone who can “do an AJ” – get NHS issues reported as a “news in brief” item on page eight of the nationals, as Alan Johnson so successfully did for Gordon Brown, back in the Era Of Money. 

“Doing an AJ” won’t be possible in today’s NHS, but if Mr Hunt is moved (as I suspect), his successor will have to learn that lesson the hard way. We could well go from the longest serving health secretary ever to the shortest serving one. Sackings give a prime minister control of the news cycle for 24 hours or so.

The choke point

If there is to be progress, then it will need some level of political consensus, such as Lib Dems leader Norman Lamb has been suggesting for some time.

Maybe we need to asset lock and mutualise the NHS on the lines of the Wine Society (my favourite mutual); maybe the model is the BBC licence fee. 

If the funding power remains with Westminster politics, then the choke point does too. And it chokes both the NHS and the politicians.