Robert Ede: The Government is right to increase accountability in the NHS

9 Dec

Robert Ede is Head of Health and Social Care at Policy Exchange.

The Health and Care Bill had its second reading in the House of Lords this week.

Till now, its passage has been relatively straightforward – Conservative Home ranked it a modest four out of ten for controversy when investigating this session’s legislation in September. This is not a surprise given an 80-seat majority, and the genesis of the proposals, which resulted from extensive consultation by the NHS over 2018 and 2019. Former NHS Chief (and now Peer) Sir Simon Stevens described the contents as 85 per cent things the NHS has asked for, deflecting the criticism from the Opposition that this is the “wrong bill at the wrong time”. Arguments that the new structures would pave the way for privatisation have been debunked, and now more formally neutered through a Government amendment at third reading in the Commons.

Things will be different in the Lords. The Government lacks a majority and simultaneously faces pressure from the NHS for the Bill to achieve Royal Assent in early 2022 so that the new structures can be formalised by April. These factors together increase the likelihood of compromise.

What is likely to change, and what should remain the same?

There were clues during this week’s debate, with Peers challenging the Government on three areas:

  • Workforce, continuing the campaign led by Jeremy Hunt in the Commons
  • Adult social care, which again faced strong push back after a last-minute Government adjustment to the generosity of the ‘cap and floor’ model
  • Enhanced Ministerial powers to direct the NHS and to intervene in reconfigurations (such as hospital closures).

Whilst there may be grounds for compromise for the first two, it is important that the Government holds its nerve and retains the clauses which strengthen the political accountability of the NHS.

A workable compromise for the workforce?

There are serious issues facing the NHS workforce. Nearly 100,000 vacancies, widespread reports of staff burnout and stress, and a reliance on short term measures to backfill the gaps, such as the recently announced NHS Reserves Programme. All of these are symptomatic of the absence of long-term workforce planning.

The Government has recognised this by introducing a requirement in the Bill for the Secretary of State to report every five years on the system for assessing workforce needs. Many want to see this go further. An amendment tabled by Jeremy Hunt, the chairman of the Health and Social Care Select Committee, for independently verified workforce assessments every two years was backed by 50 representative organisations. In the debate itself 18 Conservative MPs chose to rebel against the Government, cutting its majority by a quarter.

Similar amendments are likely to be brought forward as we enter the Committee stage in the Lords. Encouraging the regular reporting of workforce estimates is sensible; once in every Parliament would be a substantial improvement on current arrangements (the last major healthcare workforce strategy was published in 2003). Introducing bi-annual reporting, with precise modelling by speciality may be a further, justifiable compromise. Much of this work is already undertaken within Whitehall and could be made public. However, the Government must think carefully about the consequences of legally mandated independent assessments.

The elected Government of the day must be free to deliver Manifesto commitments – including for the NHS workforce which now represents 45 per cent of the NHS budget. ‘Independent’ verification of manifestos may not be desirable but is it even achievable? Whilst there is a groundswell of support for more regular workforce planning, there is less likely to be a consensus on how the pie should be precisely carved up. Take radiography as an example, where research has found a divergence in understanding of how AI pattern recognition may re-shape workforce need. Or general practice, where portions of the workforce (which is increasingly female, and part time) may have different views from the BMA on the attractiveness of the current partnership model.

In these examples and others, political judgements are required where consensus cannot be found. Whilst bi-annual reporting and internal modelling would be a positive step forward, it would be unwise to try to de-politicise NHS workforce planning.

Doff the cap?

After the Government chose to bring forward changes to the cap and floor at short notice to make the scheme more financially sustainable, the amendments (which affect the 2014 Care Act) faced a significant rebellion and were narrowly voted through with a majority of just 26.

We can expect to see the Lords ask for the Commons to think again. The core criticism: that the revised calculation which will exclude Council contributions and thereby hit poorer people harder is valid. However, the Government is the first to tackle the issue of social care in decades, and as Policy Exchange has argued elsewhere, these reforms must illustrate the first step on a broader journey. Further Parliamentary ping-pong on social care could derail the wider passage of the Bill. Having expended substantial political capital in the Commons, the chances of a further U-turn from the Prime Minister feel remote.

Holding the line on accountability

The Bill proposes four main reforms to increase Ministerial intervention powers. These have proved contentious, with many asking: Why do Ministers want these new powers? How will we avoid the unhelpful politicisation of hospital closures? Should such a general power of direction over the NHS be granted?

These are legitimate questions. On reconfigurations, the case is less clear cut. The current approach – where a contentious service redesign is referred by the local authority to the Secretary of State who then receives impartial advice from the Independent Reconfiguration Panel seems to be functioning reasonably well. Only a few weeks ago, the current Secretary of State chose to approve a much delayed stroke service reconfiguration in Kent following independent advice, despite earlier opposition being raised by three local Conservative MPs. A new power allowing the Secretary of State to intervene sooner, and across a range of reconfigurations, needs a clearer justification. There is no guarantee this will pass into law – Lord Stevens concluded his maiden speech with a stinging critique of this proposed power – and it will be important for further safeguards to be added.

The three other powers; a flexible mandate, the transfer of functions and a power of direction, were cautiously welcomed by Policy Exchange when the White Paper was first published in February. Yet the case is arguably stronger now following the decision to fold NHS Digital, Health Education England and NHSx alongside NHS Improvement into NHS England. An organisation boasting 20,000 employees is a far cry from the ‘thin’ management board envisaged by Andrew Lansley when he created NHS England in 2012. Being able to adapt its structures and objectives to reflect the priorities of an elected government is important – and crucially a view shared by both main political parties. Labour’s most recent National Policy Forum report called for a restoration of accountability in the health service “underpinned by a duty on the secretary of state over health”.

It is possible to see how the new power of direction could be used to deliver against a much bigger agenda. We are increasingly looking beyond the NHS to shape the health of the nation. This requires new forms of partnership to improve people’s environments, housing, and education and employment opportunities. It also requires sustained political buy-in.

The Secretary of State has a unique role in this context; as a fixer who can bring together different Whitehall departments with Local Government and others and create the conditions for change. It is an agenda that many have long advocated for, and there are encouraging signs that the Government is listening, most recently through the decision to revive a Cabinet-Committee for Health Promotion.

The new powers in the Bill would allow cross-Whitehall action to be formalised, for example by requesting to feed into NHS guidance before it is published. Far from a meddling distraction, this type of Ministerial intervention could deliver genuine and positive change.


The NHS is the most important public service and institution in the country. Nearly one quarter of public services expenditure goes towards health. It is also now the beneficiary of additional investment in the form of the Health and Care Levy, a ringfenced discretionary 1.25 per cent increase to National Insurance Contributions. There should therefore always be a debate about the appropriate level of political involvement in the NHS.

If the Lansley reforms argued passionately against political oversight, then the current Bill presents the case for the defence. With a lengthy passage through the House of Lords expected, the Government will face pressure to water down their plans. But whilst sensible compromises may be found on workforce and social care, when it comes to ministerial powers, they must hold their nerve.


Victoria Hewson: The NHS single sex accommodation policy is a dire reflection on how far gender ideology has travelled

13 Aug

Victoria Hewson is a solicitor and co-founder of Radical, a campaign for truth and freedom in the gender recognition debate. She and Rebecca Lowe, her co-founder, alternate authorship of this column on trans, sex and gender issues.

It has been heartening to see some positive developments in the sex and gender debate recently. Prominent and respected individuals like Baroness Jenkin and Nimko Ali have made considered comments questioning gender ideology.

While the inclusion of Laurel Hubbard in the women’s weightlifting competition at the Olympics was regrettable (not least for the young woman whose place at the games was taken by Hubbard) it has prompted a more informed consideration of trans participation in sports by governing bodies and in the media. 

But a quick scan of relevant stories from the past couple of weeks shows that troubling policies and lobbying are still widespread. 

The Telegraph reported that hospitals across England accommodate patients on wards on the basis of gender (including self-identified gender) rather than sex. This has led to males, including sex offenders, being treated on women-only wards 

Looking back at the origin of the legally binding commitment to single sex wards, it is clear that Andrew Lansley, the Health Secretary at the time, was unequivocal that patients would be separated based on biological sex, for reasons of privacy and dignity, as well as safety.

This seems obvious when one considers the vulnerable state of many people being treated in hospital, including the elderly and those who are in mental health wards, who often unable to leave.

The applicable NHS guidance on meeting the commitment is indeed unequivocal on single sex sleeping, bathing and toilet facilities. Until it comes to the Annex on trans patients and gender-variant children. Which undermines the entire policy by mandating that ‘Trans people should be accommodated according to their presentation: the way they dress, and the name and pronouns they currently use’ – even if they have not legally changed their name or gender and even if their transition is only temporary.

Moreover, ‘Non-binary individuals, who do not identify as being male or female, should also be asked discreetly about their preferences, and allocated to the male or female ward according to their choice.’ Transgender-identifying children are also to be accommodated in line with their gender identity, even if the parents disagree: ‘the child’s preference should prevail even if the child is not Gillick competent.’ 

The guidance claims that the NHS is required to manage wards in this way, and can only carry out risk assessments to exclude transwomen from female wards on a case by case basis. This is, of course, the preferred interpretation of the Equality Act put forward by Stonewall and other activists, and it fundamentally undermines the premise of single sex wards when any man can simply assert that they identify as a woman and must be taken at their word.

Carrying out individual risk assessments on trans patients would entail a significant burden on clinical staff and ward managers, and it is unclear what risks are to be assessed, if fears and threats to the personal dignity of fellow patients who do not wish to sleep and undergo medical and care procedures alongside members of the opposite sex are effectively excluded as a consideration. As with the case of prisons, if this is truly what the Equality Act requires, it is surely time for the law to be changed. 

We have written in this column before about the disproportionate influence that LGBT charity Stonewall seems to exert, in both public and private sectors. The deference to its legal advice and guidance was criticised by barrister Akua Reindorf in her report to the University of Essex on the ‘no platforming’ of certain speakers at the university.

A number of organisations have subsequently distanced themselves from the charity. Now research by the Taxpayers’ Alliance has revealed that over just a three year period, Stonewall received at least £3,105,877 from 327 public sector organisations for its Diversity Champions scheme, conferences, events and training programmes. This included almost half a million pounds from the NHS.

The TPA has rightly noted that Stonewall’s privileged (and well-funded) position has allowed it to lobby and campaign at the taxpayers’ expense. The TPA has called for this taxpayer-funded lobbying to come to an end so that public money is not being used to distort political decision making and to advance policy positions which many taxpayers may seriously disagree with. 

The vision of gender identity activists has been allowed to infiltrate public life for a generation, either because politicians and activists did not understand the implications of phasing out references to ‘sex’ to replace them with ‘gender’, or because they thought it was the right thing to do to support transgender people. In either case, the practical consequences for women and girls and for fairness and accountability in public services have not been properly considered.

Unwinding these consequences seems likely to be the work of a generation too, and greater transparency about the relevant policies in bodies like the NHS and the pernicious influence of Stonewall is essential for that purpose. We await with interest the outcome of current Health Secretary Sajid Javid’s review of the NHS single sex accommodation policy. 

David Davis: The Covid public inquiry should open in October, be held in two stages – and prepare for the unexpected

26 Mar

David Davis is a former Secretary of State for Exiting the European Union, and is MP for Haltemprice and Howden.

While the dedicated staff of our NHS and public services have managed superbly under extreme pressure, it is clear that mistakes have been made during the Coronavirus crisis.

No, let me rephrase that piece of Blairite prose. We have made mistakes. The whole British ruling class. Government, advisers (scientific and otherwise), Whitehall, the lot. And not just this Government, the previous one, and the ones before that.

So it is essential that lessons are learnt. Not just by this Government, but by future governments as well.

So we must establish a public inquiry on the handling of the pandemic.

Needless to say, the architects of our strategy throughout the crisis are nervous about the implications for them, and unsurprisingly they are saying “Yes, but not yet.” Not before the next election, or not before they retire, or move on to their next job.

Unfortunately, that will not do. The principal aim of the public inquiry is not recrimination about the past, it is preparation for the future. Pandemics come out of an apparently clear blue sky, or seem to. They are a peculiar class of threat, one whose eventual arrival is certain, but whose timing is entirely unpredictable.

The sloppy thinkers in Whitehall tend to imagine that if it is going to happen in the next 20 years, the most likely time is in about ten, so we have time to prepare for the next one. They are wrong. There is an approximately equal chance of a new pandemic in every year. There are “wet-market” style interfaces between wildlife and urban populations in Asia, Africa, and South America, and as the urban populations expand there are new opportunities for zoonotic pathogens jumping species all the time.

As public health services expand, depending too much on antibiotics, the risk of new drug resistant bacteria continues. It is probably only a limited time before we have a really virulent strain of multi-drug resistant tuberculosis, for example. We do not know whether the next threat will be bacterial, viral or fungal. We do not know whether it will be transmitted by air, by touch, or in our food. All we know is that there will be another pandemic at some entirely unspecified time in the future.

So we need to get a move on with the inquiry, and start as soon as possible. Of course the inquiry must be thorough, and must thoroughly review what went right and what went wrong in the Government’s handling of the pandemic. The public will expect it, and the Opposition will demand it. But the most important thing is that we learn the lessons and develop the template for the next crisis as soon as possible.

What is different from other inquiries is that there is a vast amount of data to design this rapid template for pandemic management, and most of it comes from abroad. Although we have had a spectacular success with our vaccination programme, and a lesser but important success with the RECOVERY programme (that delivered dexamethasone as a valuable therapy), the majority of the most successful strategies were in other countries, most obviously in East Asia.

There is a vast amount of data to evaluate all the national strategies and operational arrangements. There are reasonably accurate data on mortality, infection, recovery and excess other deaths on a daily basis for virtually every country in the world. Similarly there are accurate economic impact assessments available. Along with the genetic mutation data this allows us to track very accurately how the disease travelled, grew, was suppressed and was treated, and assess the effectiveness of dozens of different preventive and therapeutic approaches.

This argues for a two-stage inquiry. The first stage, which could start in October, should report on what the best template is within one year, giving us the best possible chance of dealing with another pandemic whenever it appears. The second stage can (and will) take years, and should review what we did right and what we did wrong.

While such inquiries are normally run by judges, the first stage of the inquiry might be better led by a leading scientist, possibly a past President of the Royal Society or some similarly recognised intellect. What it should not be is chaired by anybody who was an adviser to the Government in the crisis.

So this week the Health Secretary – Matt Hancock – announced that his Department will be setting out plans for a new UK Health Security Agency. The Agency will plan for, prevent and respond to external health threats, such as pandemics.

This is a welcome development to better protect the UK, our population, and communities from future external health hazards.

However, the Government has chosen Jenny Harries, Deputy Chief Medical Officer, to head up the Agency. I am not at all sure that this is wise. This is not a reflection on Harries, who may be brilliant. However the Prime Minister himself accepts that there were a number of missteps in the crisis.

These missteps taken by the Government were often based on questionable advice provided by the very same medical advisers who are now being handed the job of looking at what went wrong.

These public inquiries must be led in an unfettered way by an independent actor who is not consciously or unconsciously committed to the strategies that have failed in the past.

In due course the inquiry will review the errors that have plagued some of our Covid strategy. Before the current Government gets too nervous it should realise that many of the errors are rooted in the past, long before the current Prime Minister came to power, and often before the Conservative/Liberal Democrat government government took over in 2010.

So the advisory arrangements – SAGE et al – date back to the Blair years. They were first activated for the H1N1 swine flu outbreak in 2009. They frankly do not work very well. The idea of dumping all scientific advice into one committee is a bit bizarre, the sort of thing that liberal arts dominated Whitehall might do. It can often become dominated by a single strong character with a speciality that is beyond many of the members, as happened with Neil Ferguson and his poorly constructed and opaque mathematical model at the beginning of the crisis.

Similarly the Whitehall structures that are supposed to cope with crises are pretty poor too. The best demonstrator of this was the Operation Cygnus pandemic preparation exercise that was run a few years ago. This so-called command post-exercise was positively harmful, because it persuaded Whitehall that it was ready for a pandemic when all it rehearsed were the coping mechanisms – how many body bags you need, and should you have a mass mortuary in Hyde Park – rather than what you would actually do to minimise deaths. This is a generic problem, not just applicable to pandemics. Their “worst case” Brexit preparation was pretty poor too.

Some of the deep-rooted problems come a little later. The Public Health England structures were largely a product of the Lansley reforms, and they too were visibly not fit for purpose. It was their poor leadership that meant that we failed to hit the target of 10,000 test a day before the end of March, while Germany comfortably hit 15,000 a day in mid March. That incompetence denied the Government the strategies that worked so well for Germany in the first wave.

Then of course there were many decisions made on the fly during 2020. Obviously many of these were wrong, notwithstanding Matt Hancock’s cheerfully optimistic gloss earlier this week. But the public, and frankly anybody with any sense, knows that any government was making decisions based as much on guesswork as on hard data, and the public are very tolerant of that.

The primary area where an inquiry’s criticism is likely to fall is poor strategic management in, for example, the upper levels of NHS management. While their staff were doing a brilliant job, I am not too sure that the decisions on, for example, the deployment of the Nightingales and the private sector hospitals were entirely sensible.

These are the sort of things that will be unpicked over a few years by the second stage of the inquiry. The data will be complex and sometimes hard to establish, so it will take a significant time to resolve. Since it may be commenting on the decisions of individuals it is right that it takes its time. But that is all the more reason to start soon.

So my message to Boris Johnson is do not fear this inquiry: grasp this nettle soon, get the actionable insights quickly, reform and prepare accordingly, and then allow the commission to take its time doing a detailed inquiry over several years. History will judge you well for doing the right thing on this.

Nick Hoile: The tide is beginning to turn on Covid. Ministers should act now to prevent a winter flu crisis.

17 Feb

Nick Hoile is a health policy specialist and a Senior Director at MHP Communications.

After making it through the most gruelling January in its history, there is a light at the end of the tunnel for the NHS. The number of people in hospital with Coronavirus is slowly falling, as the lockdown pays off by reducing transmission and the vaccination programme now reaching over 500,000 people a day. With spring around the corner, ministers will surely be tempted to move the story on from “winter pressures” and focus on the Government’s recovery strategy.

But winter is always coming, and it pays to be prepared. Despite dire predictions, there was no “twindemic” of Covid and seasonal flu this year. In fact, the number of people suffering from flu fell by more than 95 per cent compared to the previous year. Social distancing, mask wearing, hand washing, lockdowns, and an enhanced influenza vaccination programme all contributed to reduced transmission. Next year, we may not be so lucky.

Seasonal flu has the potential to come back with a vengeance, as Coronavirus restrictions lift and the public begins to “tune out” after 18 months of persistent public health messaging. Ministers and health systems leaders may struggle to find the bandwidth to focus on flu, as they work flat out to deal with the backlog of patients waiting for routine care, implement new NHS legislation, and establish new public health structures.

If Sir Simon Stevens moves on from NHS England this year, as he is expected to do, we may enter the next flu season with new NHS leadership in place. The result could be a “perfect storm” for the NHS, with swamped GP practices, full hospitals and longer waits for care causing a severe headache for the Government. It would be an open goal for Labour’s effective shadow health team.

So, what can ministers do to avoid a health and political crisis next flu season? Thankfully, they already have one of the most powerful tools for protecting public health and reducing pressure on the NHS at their disposal: seasonal flu vaccines. There are several steps ministers should consider now to help ensure the vaccines reach people at risk of flu and its complications.

First, they should build on the success of the 2020/21 flu vaccination programme – the most effective there has ever been. The successful rollout of a national “call and recall” system, which encouraged people to get vaccinated, should be fine-tuned, and the expansion of the programme to include people aged 50 and over should be retained for another year which evidence is collected on its impact.

Second, ministers should seize the opportunity of the new NHS legislation to establish clear leadership and accountability for vaccination programmes. As a result of the Lansley reforms introduced by the Health & Social Care Act 2012, responsibility for flu vaccination is currently spread across several different NHS and public health organisations. Against this backdrop, it is no surprise that England has consistently missed the World Health Organization’s target for flu vaccination uptake among over 65s and at-risk groups in recent years.

A more rational structure, with clear safeguards to prevent vaccine programmes falling in and out of fashion once politicians have a stronger grip on the NHS, would undoubtedly focus minds. As Nadhim Zahawi’s appointment as minister with responsibility for the rollout of the Covid vaccine has shown, accountability is often critical to the successful rollout of government programmes.

Third, the NHS’s complex system of payments and incentives to drive uptake of the flu vaccine should be reformed as part of the Government’s planned vaccines strategy for England. Providing flu vaccination clinics can be lucrative for GP practices – and rightly so, given their importance. However, this can cause GP practices to compete, rather than collaborate, with other health services like community pharmacies, which may be more convenient for some patients to visit.

A review into payment systems has already been conducted, and the emphasis on collaboration rather than competition in the forthcoming NHS legislation sounds like a step in the right direction.

In addition to fostering collaboration, the payment system could also be adjusted to provide a greater reward for vaccinating “at-risk” groups of working age adults with conditions like cancer or diabetes that make them particularly vulnerable to flu.

These groups have historically been harder to reach than the over 65s. In 2020/21 only 52 per cent of “at-risk” groups took up the offer of a flu vaccine, compared to 81 per cent of the over 65s. These numbers need to increase if we are to protect the vulnerable and reduce pressure on the NHS next flu season.

Fourth, there is an opportunity for ministers to do more to encourage best practice sharing across the NHS. The uptake of the flu vaccine can vary significantly across the country, with local areas facing different challenges based on their geography and demographics.

The size and scale of the NHS means that, whatever the challenge, there will always be one local area that has developed an innovative solution. In advance of the next flu season, the National Immunisation Network annual meeting could be relaunched and expanded in light of the forthcoming health reforms and new vaccine infrastructure.

Fifth, ministers should consider running a large-scale public information campaigns to raise awareness of seasonal flu. After eighteen months of public health messages about viruses, hand washing, and vaccines, ennui may have set into the public mind.

Some at-risks groups may conclude that, when compared to Covid, seasonal flu is nothing to worry about. A hard-hitting campaign that helps people understand how serious flu can be, with a focus on working age adults who are particularly vulnerable, may help change this mindset.

With a concerted effort now, ministers can help prevent a resurgence of flu next season and cement the UK’s reputation for world-leading vaccination programmes. There is no need to be caught off guard.

Lastly, every one of us can do our bit to save lives and protect the NHS. If you’re contacted by your GP this autumn and offered a flu vaccine – say yes.