Cowper's Cut: Why Ian Dalton and Matthew Swindells really got the bullet

It’s not been a week with a deficit of news.

First, we had the joint board meeting of NHS Engroovement-Improveland setting out its shopping list for legislative change to abolish “the NHS’s own internal market” (in the 2017 Conservative manifesto’s memorable phrase).

And then on Friday, HSJ broke the news that Simon Stevens is taking over as the leader of both organisations.

Ian Dalton, the NHS Improvement/Monitor/NHS Trust Development Authority chief executive is leaving. The now (almost) fully combined NHSE and I leadership will have a new chief operating officer, who will report to Simon Stevens. Matthew Swindells’ role as NHS England’s deputy chief executive is being abolished.

Those are the facts. So, what do they mean?

Games of Thrones and legal fictions

The signals sent out to senior managers by the defenestration of Ian Dalton and the likely ditching of Mr Swindells are not terribly heart-warming.

Imperial’s board must be spitting feathers over having had their CEO extracted after just four months in post, only to see things ending like this, and the new NHSE/I regional directors, who signed up to work for two chief executives, might be more than a little unamused to find themselves shunted down a tier. 

So, why has this consolidation of NHS Engroovement-Improveland happened now?

(There is a beautiful irony here for future NHS historians, a legally fictional body NHS England is taking over another legally fictional body NHS Improvement. At least they bothered to formally fold the Trust Development Authority into Monitor.)

In the months before Mr Dalton was appointed in the autumn of 2017, many suggested exactly the approach now being adopted as the solution to bringing NHSE and I together. The two bodies and Jeremy Hunt were consistent in their views that – while that might be desirable – it was not possible under the current legislation.

Hilariously, it is now being suggested by many of those same people that this structure has always been possible (by designating the COO as NHSI chief executive), but that the two organisations were too dysfunctional and at odds with each other at that time to make it a sensible move.

(Strange, then, that it was apparently a surprise for Mr Dalton to learn on his return from a recent holiday that the integration of the two bodies had moved so fast that his role was no longer required.)

The simple fact was that back in 2017 Mr Hunt did not want to hand Mr Stevens any more power – and the NHSE and I chairs were, respectively, too demob happy and too new to make him see sense.

All that changed when Lord David Prior arrived at NHSE and Baroness Dido Harding got into her stride.

The wrong kind of behaviour

Lord Prior has form for a certain kind backstairs political street fighting, and evidently feels free to say whatever the hell he fancies. As I noted a fortnight ago, Prior has previous.

As we saw with her recent intervention about regulators encouraging the wrong kind of behaviours, Baroness Harding is on that point of the learning curve where she wants to start seizing some of the agenda.

She is a strongly-connected figure on the moderate-ish (ie sane-ish) wing of the Conservative Party. She is close to Mr Hunt, now foreign secretary, and goes horse riding with ’Appless Matt ’Ancock. The evident politicking she has been involved in over this announcement, in which Mr Swindells has been thrown to the roadside, has been a blatant attempt to present this news as “not an NHS England takeover”.

Baroness Harding is relatively young and obviously still very ambitious. Her experience as a chief executive of a major organisation (TalkTalk) ended badly, and she may believe she has something to prove in terms of execution – hence her chairing the joint NHSE/I delivery, quality and performance committee.

Taking hilarity to new heights – it is now being suggested that separate chairs are still required because of – you’ve guessed it – the legislation. Lord Prior has found himself on the wrong side of a determined woman before. He probably shouldn’t get too comfortable.

Shuffling the pack in the house of cards

The decision to name a single ‘leader’ across NHSE and I confirms Simon Stevens is the first among unequals of NHS leaders. It also gives him a very different job from the one he accepted in 2013.

(As an aside – what are we going to call Stevens now? Not technically chief executive of NHS England and Improvement – so president emperor, his holiness?)

It has been an interesting trajectory for Mr Stevens – comfortably the most able politician of this Legoland era. He was brought back to run the NHS from a comfortable global job with UnitedHealth in the US by memoirist and failed prime minister David Cameron and Standard editor and failed chancellor George Osborne.

The CamBorne Supremacy, chronically traumatised by the Lansley legislative fiasco, offshored NHS policy wholesale to Mr Stevens and were glad to do so.

It wasn’t plain sailing. Mr Stevens (and the rest of us) saw The Stevens Ask disappear with the lost 2016 EU/Brexit referendum ending the CamBorne Supremacy and delivering us the delights of Theresa May’s premiership.

A lesser figure would have been floored by that loss of political capital and ambled off in a measured way back to another big international job after a further respectable nine-12 months.

Instead, Mr Stevens handed his antagonists (both those advising Mrs May and in the Treasury Munchkin community) their ineffective backsides on plates, while steadily manufacturing consent for the necessary if not sufficient NHS longer-term funding boost announced last summer.

Mr Stevens has his critics. Some feel and think that his undeniable analytical and political talents do not connect with the serious cultural challenges evident within the NHS and the arms’-length body/bodies, and shown within the latest version of the NHS staff survey. Bullying remains a problem, as Richard Taunt ably pointed out.

There is also discontent within and about both the organisations Mr Stevens now runs, NHSE and NHSI. At one level, this would be surprising if it were otherwise: the uncertainty over their slow-motion merger puts pressure on staff (and there is still much to do below board level).

The change matrix seems to have some fascinating mathematics at work with the 196 very senior managers currently in posts being mapped across to 225 new very senior manager jobs proposed: a promised 20 per cent reduction in management in the same way that the Lansley reforms replacing 150 primary care trusts with 218 clinical commissioning groups was a reduction in bureaucracy.

Realism about this critique is required. Problems in the NHS’s centralised culture, including bullying, did not start with Mr Stevens: they have long, cultural and structural roots, and will not be dug out overnight.

The real task the NHS has faced, in an era of demographic and technological demand rising further and faster than resources, is not complex: it was to minimise the impact of the crash as far as possible. That has required huge efforts by staff across all levels of the NHS, where significant praise is due.

Equally, systems need leaders who can make and marshal the case for investment and reform. There has been little serious challenge to the vision of a better-integrated service set out in the Five Year Forward View and the NHS long-term plan.

And it would be hard to argue reasonably that Mr Stevens could have done much more to try to refocus attention on the significant impact that the crisis in social care is having on the NHS, and indeed more broadly.

This de facto abolition of the purchaser-provider split in contracting as we have traditionally understood it over the past three decades will not, of course, end the requirement for tracking the relationship between funding and resource inputs and activity and outcomes.

It would be welcome to see a radical move towards greater transparency on all this data, but that will require real investment in management and training at a time when the NHS long-term plan proposes cuts.

Moreover, the tradition of getting the NHS to lie about its deficits so as not to lose incentive funding allocations will unambiguously now come home to roost.

As if that were not enough for Mr Stevens to be taking on, he will have to anticipate and create narratives to deal with the possibility that the move to get legislative change actually gains ground; and, rather more plausibly, that it fails due to the internal uncivil wars of the Conservative and Labour parties.

I almost got my wish to write a whole column without mentioning anything stupid that ’Appless Matt ’Ancock, the poor man’s Chris Grayling with a PC World loyalty card had done this week. Then I saw him on Channel 4 News on Friday night, extolling the strategic political genius of, erm, Chris Grayling.

And the government. Because giving Eurotunnel £33m of taxpayers’ money is about ensuring continuity of medicines and not at all about being wildly ineptly politically incompetent. Phew. (It’s 1 minute 45 seconds into this film, fellow ’Ancock aficionados!)