NHS England is to have a new chair, albeit the current incumbent Richards Meddings has agreed to stick around until March in line with the government’s tactic of getting the previous administration to ‘own’ a very difficult winter.
But a new chair is only one of the many changes that are coming the way of NHSE.
Those Labour figures who were active in the noughties and are now returning enmasse to help out the new administration have been privately declaring themselves “astonished” by the “degraded” nature of the centre.
They speak of “real difficulty” in getting senior staff in both NHSE and the Department of Health and Social Care to embrace ambitious ideas or to take a positive approach to the service’s future.
Ministers and their advisers, meanwhile, find they cannot get the “reassurance” they desperately want that the service’s problems are being tackled in a timely and correct manner by the DHSC and NHSE.
There is no appetite from the health and social care secretary to scrap NHSE or even to merge it back into DHSC, but that should not be taken as a sign that things are not about to change. They are. A lot.
NHSE’s creation, of course, was a product of the Lansley reforms — the very same set of changes Lord Darzi denounced as his axis of evil influences on the NHS’s performance during the last 14 years.
The defining characteristic of NHSE was that it was “independent” and would be free to fulfil the government’s “mandate” in whatever way it wanted.
For a time, under the leadership of politician supreme Simon Stevens and with the cooperation of Jeremy Hunt, it looked as if that model might work. But with the departure of those two figures, it soon began to show the cracks, which — with hindsight — were always likely to emerge. There is only one Simon Stevens and very few politicians with as admirably well-controlled egos as Jeremy Hunt. Plus, many senior figures in government (and opposition) looked askance at what they saw as an inversion of democratic control.
The tweaked Health and Care Act 2022 placed a shot across NHSE’s bows, which Steve Barclay then turned into a fusillade. In 2024, Wes Streeting arrived, stating he wants NHSE and DHSC to make joint submissions to ministers rather than having the former set out its stall and the department its reaction.
Becoming the “delivery machine”
Discussions taking place with and around Mr Streeting are now coalescing around a number of ideas.
The first is to rationalise and concentrate the centre’s strategy work. NHSE’s direct influence on policy creation is already dwindling. The consultation process for the 10-year plan will launch today, and it is the DHSC (or at least some carefully chosen advisers and officials) that is holding the pen. This is a notable departure from 2014’s Five Year Forward View, 2019’s long-term plan, and even the foundations of the 2022 Act, all of which were effectively produced under the direct control of Lord Stevens.
The eventual result of this trend is likely to be a single strategy unit based within the DHSC, but led by a figure from outside the civil service and staffed by people from across government and the service, including NHS England.
The second area of discussion is how to achieve the reassurance government craves that delivery is being managed closely and effectively. This is highly likely to be NHSE’s primary role, with very clear understanding between it and government about what needs to be done and by when. NHSE would in effect become what one influential policy figure described to HSJ as “a delivery machine”.
The third area of discussion concerns care quality and patient safety. Here the main player is Penny Dash (a good bet to replace Mr Meddings). In the small print of her latest report on the Care Quality Commission, it was revealed she would conduct a wider review of “quality and its governance” in the NHS.
This will embrace NHSE’s lack of alignment with the CQC but also NHSE’s own performance in this area.
One of the trust CEOs at our recent roundtable was particularly critical of NHSE’s record on maternity. We will not name them, as the CEOs’ views expressed during that conversation appear to have produced an explosion of toys from the NHSE pram, which is perhaps the best indicator of an organisation that feels its future is uncertain.
The oversight of quality and safety is the area where the likely solution is most difficult to determine, but it seems NHSE’s influence and responsibility will be lower than in the past.
There are other issues, of course — such as workforce and capital investment — but they will have to wait their turn.
The new chair’s job
All this, and more, will have to be navigated by NHSE’s new chair. They will inherit an organisation still reeling from a huge redundancy programme and, as its own staff survey shows, with little clear sense of its own direction.
Just over a decade since NHSE’s formation, we live a world away from the original concept of the organisation as the unchallenged leader of the service, enjoying a light-touch relationship with government. Its role will now be much more directly influenced by government with all the uncertainty that will bring.
HSJ recently asked a figure with experience of senior roles in both NHSE and the DHSC what was the most important skill the new chair should have. Their answer? “An ability to manage ambiguity.”
