First of all, a warm welcome back to Tom Smith. Health Policy Today is back for its 2009 run, and can be found here.

And moving swiftly on to the news of a surprising return to front-line policy for former Health Secretary Alan Milburn.

” Modern politics, it seems to me, should be a two-way process where there is more dialogue and less monologue.”
Alan Milburn MP, on www.alanmilburn.co.uk

Even after the return of the prodigal son Lord Mandelson to the Labour cabinet, surely few people expected to see PM Gordon Brown appoint Alan Milburn as an advisor to his new commission on social mobility, as The Observer reported yesterday (www.guardian.co.uk/politics/2009/jan/12/alan-milburn-brown).

As a man who grew up the son of a single mother on a council estate in a north-east mining village, Milburn looks on first sight like a good choice.

Even by Westminister’s high standards, the feud between Milburn and Brown was spectacularly acrimonious. It reached its apotheosis over the 2003 creation of foundation trusts, when Brown insisted on curbing the ability of FTs to borrow from capital markets - one of those decisions that looks fairly savvy just now.

The principled kamikaze
This, along with the other compromises that resulted in the 2003 Health And Social Care Act, prompted Milburn into adopting his “flying fuck strategy” (as in “don’t give a …”) regarding the then-Chancellor Brown.

Having started in government as a junior Treasury minister under Brown in 1997, Milburn will have known that his time at the head of a spending ministry was running out from the time their feud became very public knowledge.

Hence his decision to spend more time with his family.

Legacy systems
Milburn’s single-minded clarity polarised those who considered his legacy at the time. Outgoing BMA chair of council Dr Ian Bogle said that establishing a national target for bowel movements would be a fitting legacy to Milburn.

Others – often senior NHS managers – praised Milburn’s considerable grasp of policy detail. In truth, this was probably something of a testimony to his then-Special Adviser Simon Stevens.

People who worked in the DH under Milburn report that his losses of temper, though spectacular, were not as frequent as was often speculated.

It is however clear that Milburn’s temprament accorded poorly with the mandarin style of the NHS’s then-chief executive Sir Nigel Crisp. If targets were missed, Milburn was known to have a therapeutic shout down the corridor.

What of his willingness to debate policy, to dialogue, as the quote above from his website suggests? One clear memory remains of a debate at the Kings Fund, on the subject of the proposed legislation for Foundation Trusts. Milburn gave his speech. Andrew Wall, a career NHS manager turned academic and author, politely but clearly outlined some drawbacks – a mixture of the policy and the practical – in the ideas outlined.

Milburn flushed, and baldly replied, “I don’t agree with a single thing you’ve said there”. He then repeated various assertions form his speech, but did not present any counter-argument. The chances of “more dialogue and less monologue” ahead? Don’t hold your breath.

The colour of choice
So will Milburn’s return make things plainer sailing for the ship of state? Unlikely. He believes much more strongly than Brown that choice is in and of itself a social good: when Health Secretary, a much-repeated anecdote from his speeches was of coming home as a child to find that the council had repainted all the doors in the street – all the same colour. Milburn was apparently traumatised by tenants’ lack of a choice.

Moreover, Milburn’s alleged popularity with the electorate never seemed very real. As an effective Commons performer and media rebuttal figurehead, he was very popular with the New Labour hierarchy. He had the same skill in debate as his successor in the DH Dr John Reid – likely from the same source, Marxist dialectics in their ideological adolescences.

Comparison with Reid is instructive in another way. Ian Greener of the University of York published a fine paper in my alma mater British Journal of Healthcare Management in March 2004, based on textual analysis of the speeches of Milburn and Reid (only ten of Reid’s – all that were available at the time of writing).

Greener points out that Milburn’s most-used word was ‘person’ – often, Greener notes, in the context of improving care for the elderly. After this, however, the grouping for Milburn includes ‘increase’, ‘choice’, ‘reform’, ‘capacity’, ‘money’ and ‘local’.

The fact that ‘local’ came so high up the list for a man seen as a significant centraliser of the NHS had its strongest roots, according to Greener, in the concept of earned autonomy “rather than allowing managers particular wide-ranging freedoms to run their trusts as they see fit”.

By contrast, Greener found that Reid’s most-used word was “value(s)” –which he observes is notably under-used in Milburn’s speeches of the time. Following these come ‘access’, ‘information’, ‘equity’, and ‘fairness’. Among Reid’s least-used words were ‘reform’, ‘performance’ and ‘standard’.

What will Milburn's return mean? Probably very little. He failed to forge a significant alternative power base, either within New Labour, among Blairite discontents or within the trades union movement (the only possible alternative power base).

Away from the front bench, he has traded on his time at health with lucrative business posts (see below). In practice, he has revealed little evident inclination to promote the social mobility he has enjoyed among others.

One final observation: the 'Breaking Through' programme (now in the NHS Institute - www.institute.nhs.uk/building_capability/breaking_through/breaking_throu...) made a significant effort to improve social mobility among BME staff. It is thoroughly worthwhile. And the person who gave it consistent and generous support was Sir Nigel Crisp, who deserves the credit.

Alan Milburn MP’s extra-Parliamentary roles
(list sourced from www.theyworkforyou.com/mp/alan_milburn/darlington#register)
Member of Lloydspharmacy's Healthcare Advisory Panel. (£25,001-£30,000)
Member of European Advisory Board of Bridgepoint Capital Limited. (£30,001-£35,000)
Member of the Advisory Board of PepsiCo UK. (£20,001-£25,000)
Member of the Advisory Board of Covidien (formerly Tyco Healthcare).