The DHSC is Structural Lunacy
The Department of Health and Social Care (DHSC) has three responsibilities: personal health treatment and care (the NHS), public health and adult social care. One of its 15 (or so) arm’s length bodies (ALBs or quangos) addresses public health. Local authorities also have responsibility for public health which works well but Covid exposed problems with the DHSC messing up, for example, “Test and Trace” activities which local authorities could have done better. None of the quangos, apart from some quality control via the Care Quality Commission (CQC), address adult social care. That is funded by the Department for Levelling Up, Housing and Communities. In other words, all bar one of the 15 DHSC quangos are focused on the NHS.
That may explain a lack of balance in the attention given by the DHSC. For example, the Health and Social Care Levy Act was packaged for PR purposes as being for both but in reality the extra £12bn, or what was left after HMRC have first helped themselves, will all go to the NHS and social care will get none of it. The Prime Minister’s claim that the money was “hypothecated” in this way is a similar nonsense as HM Treasury does not hypothecate taxes – they all go in the general spending pot. It sounded good though.
The NHS has a voracious appetite for the taxpayer’s hard earned money. “In 2018/19 prices, health expenditure in England increased from £30.2 billion in 1979/80 to £130.3 billion in 2018/19”, i.e. by 4.3 times in real terms. The King's Fund predicts it will grow by another £32.4bn in real terms in the further four years to 2022/3 and that is just in England. The simple truth is that NHS expenditure is out of control and the Prime Minister thinks he can win the next election by throwing ever more money at it.
The NHS is thought to be the fifth largest employer in the world and, with 1.2M staff in England, by far the largest in this country. Only about half are clinical staff, e.g. doctors or nurses. In fact, the CEO of NHS England has just 9,877 staff reporting to her (December 2021 data). That is because both the secondary (hospitals and consultants) and primary care (GPs and their surgeries) service providers are independent contractors, at least in theory. Secondary care is mostly provided by 223 trusts, mainly hospitals, each of which has layers of boards and management.
Almost all organisations have two types of structure reporting to the CEO: line and staff. The line executives are responsible for achieving the organisation’s goals and the staff functions, such as legal, IT, human resources, support the line. In the DHSC, however, there are 12 quangos that should be staff functions within NHS England or the CQC or merged or abolished: Health & Social Care Information Centre (IT department), Health Education England (training department), Health Research Authority (duplicates Medical Research Council), the Medicines & Healthcare Products Regulatory Agency and the National Institute for Health and Care Excellence should merge (essentially the buying department, checking efficacy, maximising value for money and rationing to meet budgetary concerns), the Human Tissue Authority and NHS Blood & Transplant should merge (spare parts department), Human Fertilisation & Embryology Authority (merge with CQC – why should the regulation of this set of treatments be treated differently?).
Monitor and the NHS Trust Development Authority became part of NHS Improvement in April 2016 but no one seems to have told its respective 82 and 1,583 employees (December 2021 data). NHS Improvement was merged with NHS England on 1st April 2019 and are supposedly one organisation, but each still has a separate board, chairman and non-executive directors.
NHS Litigation Authority is the legal department and should report to the CEO of NHS England. It is a clear guide to the standards and competence of primary and secondary care. NHS Business Services Authority is the “everything else” department which, apart from central buying (probably its key role) provides a wide variety of other functions, most of them probably unnecessary. They must be very busy as its 3,660 staff have not been able to produce an annual report since 2018/19 and the 3,502 DHSC staff have also been too busy to notice.
Frankly, the DHSC quangos are a shambles. The above listing is based on the December 2021 payroll but other lists they publish differ, e.g. the list updated to 10th February 2022, the same week as the payroll data used above. Is the Health & Social Care Information Centre (3,987 staff) the same as NHS Digital and NHSX? They certainly manage to mess up every major IT project they handle. Contracting the work out must be a better option. The payroll listing of quangos failed to mention that the NHS Counter Fraud Authority (NHSCFA - internal audit) has 166 employees. £54M was saved against a target of £50M, clearly a good result especially in the context of the complexity of the quango. Finding thieves and banging them up is not a complex business (I write as someone who became a Chartered Accountant 59 years ago) but the 130 page NHSCFA 2020/21 annual report certainly makes it look that way.
Rationalising the quangos and turning NHS England into a conventional organisational structure driven by medical professionals apart, there is one further key transformation needed. The NHS thinks it needs ever more money to do ever more things. Pursuing that strategy will make it unaffordable. It needs to focus on what only it can do and leave the rest to others who can do it better (and cheaper). Essentially the NHS hospitals should concentrate only on personal treatment and cure. It does not need to serve as a hospice where death is inevitable nor mess with public health which other parts of the DHSC and local authorities handle.
It needs to turn over responsibility for the middle sector, i.e. between primary and secondary (major hospital) care, to social care, supported as needed by the primary sector. For example, births, convalescence, minor operations and the things that cottage hospitals used to do and some still do. Given a choice between three days in our local cottage hospital and in the major acute hospital 25 miles away, most of us opt for the local unit. The point, of course, is that the cost per stay in a medically supported nursing home is far lower than that in an acute hospital. This is not just a matter of bed unblocking, though that would benefit too, but of tailoring the NHS to maximise value for money.
Anyway, the point of this post is that NHS England is too complex and needs to be streamlined. That conclusion may surprise no one but here are a few actions to take:
We do not need the 15 or so ALBs currently reporting to the DHSC. NHS England, a new body to monitor, improve and represent adult social care together with the Health Security Agency and CQC, i.e. four in total, would suffice and help the DHSC do a better job. That would remove over 150 of the current 213 ALB directors.
With the work all being done by the ALBs, the 3,502 DNSC civil servants could be reduced to about 30% of that number.
There would seem to be little to gain from further messing about with the primary sector. They have had enough of that recently.
The 223 trusts are another matter. Each of them has layers of boards and management. Obviously, these units need managers but they do not need all the modern bureaucracy associated with independent corporate bodies. The reality is that they are part of the NHS, not independent, and do not need all the paraphernalia the government now loads onto commercial companies and partnerships. A commercial company does need to be driven top down but health services should be provided by the clinical staff with managers helping them with what they need and can afford. In other words, the secondary needs to be driven bottom up with minimal management and bureaucracy.
Finally, the DHSC should develop the medically supported nursing home sector to relieve pressure and costs on hospitals which should focus on treatment and cure. This would materially improve the value for money of, and patient satisfaction with, the NHS.