The DHSC is a Lovesome Thing, God Wot

If the Department of Health and Social Care (DHSC) had been around at the time, the Victorian poet Tom Browne would surely have described its structure as “a lovesome thing”.  He would have recognised the tangles, the plots and the “fern’d grot”.  He might have struggled, however, to connect its re-structuring gyrations, which we are witnessing this week, with seeing “more patients benefit from the best possible care, with the right staff in place to meet patients’ needs.”  You and I might have been thinking that was a question of getting more doctors and nurses, if not now, then sometime. It seems Hancock’s MBPR (management by press release) is still with us. We are not hiring the doctors and nurses we need, but merging quangos which is, in fairness, also something we need.  My grumble is that the two are being confused. 

When Hancock was trying to ease Dido Harding into the NHS CEO job, he put her at the helm of the quango “NHS Improvement” and, in 2019, semi-merged the two.  They are now, supposedly, a single organisation, NSE/I, but they still have separate boards, each with executive and non-executive directors and objectives.  One may wonder why the business of improving NHS (England) was ever seen as distinct from the management of NHS (England) but we are getting there.  NHS England is simultaneously part of government and independent from government (it is a “non-departmental public body”).  It does not have charge of primary health care (GPs own and run their own practices as contractors to the NHS) nor of secondary care (hospitals are answerable and not answerable, see below, to NHS Improvement) and since it does not yet have charge of its staff development, IT, business or legal services (NHS Litigation Authority), not to mention half a dozen other quangos which are regulatory in nature. Nor most of health which almost every other government department, local and national, deals with. Not to mention the Health Foundation, which is independent of government, but, in 2020, spent £50M on promoting health and has plenty to say on the subject.  Parliament may approve this integration in 2022 so, technically, the status quo remains until then. 

Then again, the major hospitals are supposedly independent trusts and only voluntary members of “NHS Providers”, the “organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.”  With all of her main responsibilities farmed out, it is amazing that Amanda Pritchard, the new CEO of NHS England, finds anything to do. 

The good news this week is the announcement that three of these quangos, that should never have been outside the control of NHS England, are now being integrated with it. One is Health Education England (HEE) which “exists for one reason only: to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place.” It refers to itself as “part of the NHS” but is actually an independent executive non-departmental public body which is why it now needs an Act of Parliament to merge it with NHS England. According to its 2020/21 Annual Report, 2,432 staff were employed at a cost of £187M and the whole caboodle cost £4.4bn. Never mind merging it with NHS England, with no savings, since HEE’s function manifestly duplicates that of NHS England itself, would it not have been better simply to abolish it? It appears to add no value.  

NHS England’s IT operations are provided by NHS Digital and NHSX.  The former “is an executive non-departmental public body, sponsored by the Department of Health and Social Care.”  In other words, it is not answerable to anyone, and certainly not to the CEO of NHS England, but it is jolly good that it has a sponsor. Ironically perhaps, it has not had time to publish a 2020/21 annual report but the 2019/20 one (published July 2020) showed a cost of £180M.

NHSX is also now being merged with NHS England although it was only created two years ago. In theory, it sets “the strategic, policy, and delivery objectives for digital transformation throughout the NHS and adult social care sectors” but as adult social care does not have any overall digital transformation, the Cinderella of the DHSC will not be affected. It did, however, deliver 11,000 iPads to care homes.  NHSX cost a mere £1bn in the last financial year. 

Amanda Pritchard is probably right to absorb just the quangos discussed above and leave business services, litigation and health matters to another day. The NHS Business Services Authority is “independent of the DHSC but can [sic] be subject to Ministerial direction.” It does not appear to have lodged an annual report since 2018/19 and, since that reported the disbursement of £36.4bn of taxpayer money, it might be good to know what they have been up to since. Most of the expenditure (£22.3bn.) went to NHS pensions which one would have expected to have been included in the NHS accounts. £11.6bn. went on prescriptions for GP surgeries (presumably the elderly and those on income support) and only £2.4bn. on the Authority’s projects including £200M operating costs. 

NHS Resolution is, like its sibling Business Services Authority, a “special health authority” and thus both independent and, in the manner of this sector of government, not independent of the DHSC. The transfer of liabilities from two medical defence firms caused staff numbers to rise from 328 to 400 (£26M) over the 2020/21 year. NHS Resolution is, in effect, an insurance company for the NHS and should therefore not be part of it.  The pandemic brought new challenges, e.g. “state cover for employer’s liability and public liability to fill gaps where Covid-19 positive patients have been discharged from the NHS into designated care home settings which have been unable to secure sufficient private insurance cover.” Like any private insurance, the annual charges to hospital trusts take claims history “into account meaning that members with fewer, less costly claims pay less in contributions.” The value for money of NHS Resolution should be tested every 10 years or so by inviting private sector insurance companies to tender.  Beyond that, no structural change is recommended here. 

Finally, we come to the issue of whether the NHS should focus just on treatment and cure or whether it should also address general health, i.e. prevention. Ministers like to proclaim that marketing health saves the NHS money, e.g. reducing obesity, but there is no evidence for that.  Furthermore, other public bodies, both national and local, have those responsibilities.  It makes little sense to the writer of this blog to have waiting lists at record lengths and yet divert doctors to lecturing their patients about their (the patients’, that is) poor health habits. The NHS should focus exclusively on treatment and cure until its waiting lists cease to exist and ambulances are no longer queued outside A&E. 

To summarise, the Secretary of State and Amanda Pritchard are right to complete the NHE/I merger and integrate Digital, NHSX and HEE but they should be more radical and look for greater savings.  NHS Providers should be integrated too. The extensive anomalies of arm’s length bodies being both independent and not independent, should be sorted out one way or the other.  The NHS should be focused on patient treatment and cure but let us not pretend, please, that rearranging the furniture on the upper decks will bring that about.