Hunt stays put - but faces a whole new set of challenges

Jeremy Hunt may be staying, but the political environment for health has shifted. A new prime minister and a new chancellor may well take a different view on health from their predecessors. Jeremy Hunt’s task will be to manage this process.

So what might change? It is worth considering the motivations of the key protagonists in turn. The likelihood that Theresa May and Philip Hammond will assume office understanding that the 2012 reforms ceded large elements of power to NHS England, or that Simon Stevens has established himself as an unelected official with unprecedented autonomy and relationships across Whitehall, is not great.

Jim Mackey leads an organisation that has been hamstrung by organisational turmoil

Politicians are elected to change things and Theresa May will want a shift in the narrative on health. Yet there will be little money to effect change. The Department of Health cupboard is stripped bare; there will be no new money for political initiatives designed to create differentiation.

However, there may well be a realignment in the power hierarchy in the NHS family. The role of Chris Wormald will be significant. He remains relatively new in post and his early months will have been consumed with the Department of Health’s downsizing programme, as well as managing the fallout from a financial year which was challenging to say the least.

A Whitehall high-flyer who many believe is destined for the very top of the civil service, Wormald will be aware that his new role is somewhat diminished from that which is predecessors inherited.

In many ways he is the lesser amongst equals when compared to the big beasts in NHS-land. Do not be surprised if he tries to subtlely rebalance power within the Health/NHS family and also to bolster his position across Whitehall.

Power play

For his part, Simon Stevens is well versed enough in handling political egos to know that he has work to do in both establishing a productive working relationship with Philip Hammond at the Treasury. Hammond, who is known for his respect for structures and processes, is unlikely to strike up the same sort of informal relationship that Stevens enjoyed with George Osborne. He will need to carve out a different sort of relationship.

There is another big beast whose power has hitherto been under acknowledged and perhaps underplayed. Jim Mackey leads an organisation that has been hamstrung by organisational turmoil.

A Whitehall high-flyer who many believe is destined for the very top of the civil service, Wormald will be aware that his new role is somewhat diminished from that which is predecessors inherited

NHS Improvement has rarely been seen as an equal player with NHS England, but it does hold one trump card: it has responsibility for the provider sector. It is hospitals, rather than commissioners, that hold the affection of the public and politicians. When was the last time people marched in the street to save a commissioning organisation? They frequently do for hospitals, irrespective of their quality or safety.

For all the talk about integration, accountable care and erosion of the purchaser-provider split, the provider sector will still want to fight its corner. At a time when hospitals are battered and bruised after years of what they perceive to be attempts by NHS England to artificially depress the tariff in order to balance its books at the expense of hospital deficits, many will be looking for the regulator to adopt a more muscular approach across Whitehall, leveraging the unique connection with the public that hospitals enjoy to reset the level of risk that hospitals are expected to carry.

The Care Quality Commission is likely to be relieved that Jeremy Hunt, its great champion, has survived. Retaining its position at the top table in the face of rapid and probably radical measures to balance the budget will be somewhat easier than it might have been.

One thing that all the disparate elements of the health and NHS ‘family’ will be able to unite on is the need for more money and, with health having played prominently in the referendum, they might well get it this autumn. A new Prime Minister and Chancellor may decide that they don’t want to risk a winter crisis and a repeat of the avalanche of stories about deficits, waiting lists and strikes.

The Department of Health cupboard is stripped bare; there will be no new money for political initiatives designed to create differentiation

However, the task in advocating this may be harder for Jeremy Hunt, given his prominent role in securing and advocating the existing financial settlement. The question will be how much money the NHS might hope for, what May and Hammond might demand in return and which personality in the NHS and health leadership will take the lead in shaping this.

Whenever there is a change it at the very top, there is no such thing as ‘business as usual.’ Personalities and the way people work together matter. Jeremy Hunt will hope for a strong relationship with Number 10, having backed Theresa May early and strongly for the leadership.

Simon Stevens, however, may find a changed relationship with Number 11 and this in turn will impact upon the hierarchy within the Health family. Relations between the houses of Richmond, Skipton and Wellington might be about to get more interesting.

Mike Birtwistle is a founding partner at Incisive Health