Reshuffles rarely lose their capacity to surprise.
The resignation of Sajid Javid will send shockwaves through Whitehall. Whatever the reasons which led to it, it is clear that the Prime Minister will not tolerate a Treasury which does not respond to his beck and call. Treasury officials will be nervous at how this plays out: it was a victory for Sajid Javid to insert fiscal rules into the Conservative manifesto, but it is Number 10’s tendency (and, arguably, part of its job) to want to spend more money. Will we see the Treasury’s defences against social care reform crumble as a result of the move today? We shall see.
With the tumultuousness of the reshuffle, Matt Hancock will be pleased to have escaped with his job intact. In truth, his uber-loyalism will have done enough: he has been wise to take his former boss George Osborne’s advice.
But what now for that other institution which does not respond to Number 10? It is not, after all, the reshuffle today that has given the NHS its most important news over the last week, but the story in The Times last Saturday that – for the NHS too – Number 10 wants to be in charge.
On one level, this is unsurprising. After a decade and more of relatively unstable governments, it is easy to forget that Prime Ministers do like to feel in control of the NHS. When they also feel that promises of building more hospitals and recruiting more nurses won them the last election, and when they fear that deteriorating NHS performance may cost them the next election, they need to be.
The challenge is that, in Simon Stevens, the NHS already has a Chief Executive who is in charge – and he is not a man to keep his head down and diligently implement Number 10’s priorities. Simon is a man interested in condemning quacks, pointing to the faults in social care, picking fights with big pharma, and allowing local experimentation to flourish. He is, essentially, not a NHS Chief Executive but another Secretary of State.
It is easy to see why in Whitehall all the lights are therefore flashing red, and particularly in Number 10 – which only ultimately exercises control through the ministerial appointments they can make. Number 10 are getting jumpy as they realise that one day they will face the electorate on the NHS and that Simon is not in the same boat.
However, the wonderfully technocratic ‘solution’ being offered up is the forthcoming NHS Reform Bill, which promises an opportunity for ministers to exercise a ‘power of direction’ over Simon Stevens. There seems to be no sense of irony that this Bill has been entirely prompted by Simon Stevens, and otherwise implements his plans for the NHS.
But this is a problem because two issues are becoming dangerously confused. The first, that the HSJ is right to point to, is that ministers have an issue with Simon Stevens. The second is that the NHS Commissioning Board has morphed into NHS England which is morphing into the NHS Executive, and officials are concerned that there are no checks and balances on such a monopoly and wish to be able to direct it.
The danger in confusing them is that the Government ends up in a worse situation than the one it started with. There are good reasons why there should be some distance between ministers and the NHS, not least in preventing the kind of ‘NHS Deep Clean’ initiative of yesteryear that wasted time and money because ministers were tasked with coming up with a headline.
But the Government, in responding to the flashing red lights, will probably end up grasping for the far-reaching powers of direction that lead them into back towards this disastrous ministerial micromanagement. And even when they have these powers, they may well find they have left Simon Stevens there, maybe not responding to the missives – and maybe even delighting in explaining why they are short-sighted.
The Government clearly needs to think about what they want from the NHS and if they are happy with who is leading that effort. But it also needs to think, entirely separately, about how much control ministers should have over the NHS, long-term. And now that Matt Hancock is back, these are the things he must help the Government to do.
Matt’s other task, of course, is helping the Government negotiate the future UK-EU relationship. Amidst the turbulence of the reshuffle, the Government published its Medicines and Medical Devices Bill today, with promises of a better future for medicines and medical technologies in the UK post-Brexit. It is optimistic stuff, but accompanied by precious little detail, because – like NHS reform – the Government is not entirely clear what it wants.
Matt will feel lucky to return to Victoria Street. But there is a lot of uncertainty about the future, in the NHS, the wider healthcare sector, and across Whitehall. The EU, the Treasury and soon the NHS are gradually being exposed to the Government’s mantra of taking back control. But exactly why, well, who knows?