Health Policy InsightEditorial Tuesday 9 March 2021: The separation of Church and State (and Treasury)
My latest HSJ column is here, and latest bits for BMJ are here, on the Budget and here on publishing Government data for the unlocking.
This morning's Health Select Committee had evidence from NHS Commissioning Board boss Sir Simon Stevens.
Watching Sir Simon doing his 'Bartleby the Scrivener' act is always entertaining. Those Melville fans among you will already know that Bartleby, when asked to do something he doesn't want to do, replies "I would prefer not to".
Sir Simon doesn't actually say that out loud, but his clarity levels vary depending on the questions he enjoys and those he does not wish to address.
He most certainly did want to talk about money: specifically, the Budget comedy of the non-allocation of extra monies to deal with the impact of Covid19 in 2021-22. (The public health grant for 21-22 has also not been announced, but post-Lansley, this is not Sir Simon's direct problem.)
I'm grateful for the Independent's Shaun Lintern for getting these quotes down.
Sir Simon was slightly forthcoming on the 1% pay offer: “Coming out of the past year, and everything that NHS staff have been through, proper recognition for that is entirely right and I think goes with the grain of what the public would want to see.
"At the time (2019), the working assumption was that there would be available 2.1 per cent for the costs of the Agenda For Change pay group in 2021-22, together with the overhang from the 2021 elements of the multi-year Agenda For Change pay deal.
“In a publicly funded, democratically accountable health service, the government of the day gets to decide what NHS pay should be, but you would expect me as the head of the health service to obviously want to see properly rewarded NHS staff, particularly given everything that the service has been through and they've been through, over the course of the last year.”
Conflicts of ministerial interference
Sir Simon also observed that Matt Hancocks's recent intervention in a local NHS reconfiguration owing to Chorley Hospital's A&E being in Speaker Lindsay Hoyle's seat created potential conflicts of political interest under the new proposals for legislation.
If the CQC is to start looking at ICS's performance, Stevens suggested that "it should review against mandate plan and goals that the system is set" to ensure alignment. If CQC is making calls on safety of reconfiguration, as HSJ's Dave West observed, then it needs to be clear if DHSC is making these calls, and not the ICS.
Show me the money
Sir Simon will not have reinstated himself on the 11 Downing Street Christmas Card list by his comments on the lack of announced funding to deal with the still-ongoing pandemic and its consequences.
Answering chair Jeremy Hunt's observations on the OBR's spotting of the NHS funding that wasn't there, Sir Simon replied, "for the year we're about to go into beginning on the 1 April, we have the previously-agreed NHS long term funding settlement.
"Over and above that, in the November spending review the Chancellor provided additional funding to make a start on catching up on the backlogs of care that have arisen as a result of Covid, including on waiting list operations, and for new needs that have arisen for mental health services.
“During the course of this past year, as you say, the NHS has been provided with the extra costs of looking after Covid patients and all of the indirect consequences for Covid care. The majority of Covid hospitalised patients that we've been looking after have actually been admitted since that November spending review: we've obviously had an incredibly tough December, January and February across the health service.
“There are going to be continuing Covid-related needs and costs spilling into the new financial year. And so, the expectation is that the NHS will receive additional funding to cover those unavoidable Covid costs ... there is obviously an urgent need now to give that funding certainty to hospitals, to local frontline services ... the beginning of the financial year is hoving into view, so we do expect that that will be resolved very shortly".
In other words, 'your move, Chancellor. Now move, eh?'
Our dear friends the Treasury Munchkins will really, really hate being spotlit about the missing money for Covid19. It's a tough old life, eh?
Stevens vs HM Treasury, round 17,351: seconds out. It's what he does rather well.
'More Matt Hancock' - checks and balances
Sir Simon also threw some light onto the plans for the Secretary For State For Health But Social Care to start 'taking back control' over the Commissioning Board next April, telling the committee that he anticipated safeguards of a clear, written and published SOS direction to over-rule the NHS Commissioning Board's decisions, combined with a public interest test.
An obvious read-out of that would be that Sir Simon doesn't anticipate being out the door quite as soon as some people may think he will be.
There was some interesting, although inconclusive, discussion about social care, too. Plus ça change, plus c'est la meme chose ...
What it means
This was yet another Stevens Masterclass in focused, highly-briefed selective responding.
The NHS Commissioning Board is far from perfect, but it has achieved durable and important checks and balances, and separation of Church (NHS) and State.
All of which matters, A Lot.
That's why the 'more Matt Hancock' hypothesis about the new Bill proposals matters.
It remains fascinatingly hard to judge the NHS Commissioning Board’s independence as a thing in and of itself, given the two leaders to date - Sir David Nicholson and now Sir Simon Stevens - have been political Big Beasts prior to taking on the NHSCB's leadership.
But I’m unaware of anyone else in the public sector in recent times with comparable influence and weight.
There could, as HSJ editor Alastair McLellan observed, have been a case for comparison with Mark Carney at the Bank of England.
When it comes to the NHS, the current separation of Church and State (and Treasury) involves some interesting political architecture.