After a tumultuous and often bloody couple of years, the Department of Health has a new ministerial team. Jeremy Hunt, Norman Lamb, Anna Soubry and Dan Poulter are the new faces, with the widely respected Freddie Howe the only returner.
From encyclopaedia to unwritten book
For Jeremy Hunt, this will be a foray into an area of policy with which he is not familiar. Perhaps he is best known for spearheading the successful and widely acclaimed Save the Royal Surrey Campaign (alongside Anne Milton, who departs the Department of Health). This campaign undoubtedly won him kudos as a campaigner and contributed to his promotion to the Shadow Cabinet in 2007, but should not be seen as evidence of a deep engagement in health policy. If Andrew Lansley was an encyclopaedia on the NHS, then Mr Hunt is more of an unwritten book. For some stakeholders, frustrated by the dogmatic attitude of his predecessor to health issues, this may well make a refreshing change.
This move – an undoubted promotion – has long been touted, with perhaps even Mr Hunt talking up his chances of making the move to Richmond House. However, the scandal earlier this year about links between Jeremy Hunt’s office and BSkyB threw this – and his wider career – into doubt. Presumably the Prime Minister is confident that Lord Leveson, when he reports, will not criticise the erstwhile Secretary of State for Culture, Media and Sport. It remains to be seen whether journalists, angered by perceived leaks to their rivals, are prepared to give the new Secretary of State the same leeway as he gets to grips with his new brief.
Jeremy Hunt’s team may be new to the Department of Health, but it does contain experience on health and social care issues. Norman Lamb returns to a policy area he shadowed in the last parliament and intervened very publically during the ‘pause.’ Dan Poulter is a practising doctor who has served on the Health Select Committee and spoken out in favour of abortion rights – an issue on which he may be at odds with his new boss. He also resigned from the BMA over its industrial action on pensions. Anna Soubry has witnessed many of the battles on health reform first hand, serving as Simon Burns’ Parliamentary Private Secretary.
Downing Street’s hope in moving Jeremy Hunt to Health will be that he is able to communicate the reforms and defend the Government’s record on the NHS more effectively than his predecessor, who was an awkward media performer and often spoke in terms which meant more to policy wonks than they did to patients. Hunt is unlikely to face the same issue. However, Number 10 will be sorely mistaken if it thinks that the Coalition’s challenges on health are as simple as improving its communications.
A difficult in-tray
Hunt will also inherit a difficult in-tray. When he has had time to read his ‘to do’ list, he may well not thank the Prime Minister for handing him his new job at this point in time. Although the legislation underpinning the reforms may be successfully through Parliament, substantial amounts of politically tricky business remain to attend to. There was in fact a strong political and communications case to be made for leaving Andrew Lansley – familiar with the territory and already politically tarnished – in place to act as a lightning rod for the inevitable controversy and unpopularity these will cause. However the political decision has been made that now is the time for a new face, and so it falls to Jeremy Hunt and team to make what they can of the challenging hand they have been dealt.
So what of the hand? It is important to note is that the job description is very different from that of Jeremy Hunt’s predecessors. As a result of the Health and Social Care Act 2012, the new incumbent will find themselves with far less room for manoeuvre in establishing themselves. Gone are the days when a secretary of state could simply announce an operational change as a way of demonstrating what they cared about and showing that they meant business (think hospital car parking charges or hospital ‘deep cleans’). Instead, the primary formal influencing mechanism will be the Mandate – a complex and longer term policy instrument which the Department of Health and the NHS Commissioning Board are only just coming to terms with. Working out how to co-exist with the Board will be no easy task, particularly given that the Board has yet to begin making the case for change which logically should now be its responsibility.
Mandate for what?
The most immediate challenge facing Jeremy Hunt will be handling the agreement of the Mandate itself. He will need to tread a fine line between the political demands of Downing Street, which will want to see a highly prescriptive document setting out a wide range of politically attractive measures, and those of the NHS Commissioning Board, which wants to see a more general document, creating unprecedented amounts of operational freedom. These are two fundamentally different visions which are not compatible.
The new Secretary of State, and the Department of Health, will inevitably be caught between these competing tensions. Expect this to be an immediate issue for Jeremy Hunt to deal with. Lansley could use his experience to negotiate a course, protecting the freedoms which are meant to be at the heart of his reforms. Hunt will need to draw on other skills. How he handles this will set the tone for his tenure in Richmond House.
Dealing with failure
The primary political issue facing the Department of Health is one which voters care far more about than the intricacies of reform. And it is not one which can be reshuffled away. How to deal with failing hospitals, either in a financial or clinical sense (or both) is an issue which has bedevilled many a secretary of state. Yet the issues are now more pressing. The special administration process at South London Healthcare NHS Trust is now on a legal pathway which should resolve itself this autumn without political intervention. Although politicians may be excluded from the process, they will not be protected from the fallout.
It is inescapable that South London has two large PFI contracts, which will need to be serviced irrespective of the outcome of the administration process. This is not as simple as bailing out the Trust, which has already received additional assistance from the Department of Health. The likely outcome is that services will have to be transferred from financially and clinically viable trusts to fill space in PFI buildings – surely the opposite of how competition should work, with successful providers expanding. This will be a difficult one to communicate and will be politically very messy.
Of course South London is not the only provider in distress. Tough decisions, potentially including special administration, will need to be taken at a number of other providers as well. Look out for Mid Yorkshire Hospitals NHS Trust to be amongst the next providers where difficult decisions will be need to be made. This won’t get any easier and it will be interesting to see how a new Secretary of State whose main experience has been fighting to save services will approach this.
The Francis Report is also expected this autumn. Jeremy Hunt will find his ability respond to its findings will be limited by the strong desire across Whitehall for no more health legislation in this parliament. However, as well as finding a way to respond to Francis’ recommendations, Jeremy Hunt will need to work out what to do with Mid Staffs as a trust. Put simply, the Trust’s reputation has been damaged to such an extent that it can’t recruit and is bleeding money through agency fees. The situation is unsustainable (either financially or clinically), but intervention will not be simple. Given the reputational hit the hospital has (rightly) taken, how can it be turned around?
Social care funding and value-based pricing
On top of all this, social care funding reform and implementing a system of value-based pricing for drugs remain unfinished business. Both are superficially attractive but could have unforeseen consequences and will be difficult to navigate with stakeholders. Again, the devil will be in the detail and the new Secretary of State will need to get up to speed rapidly.
The passage of the Health and Social Care Act was indeed a milestone, but it was far from the end of the Government’s political difficulties on health, no matter what Downing Street may have hoped. Jeremy Hunt and team are about to find out just how challenging the health portfolio it can get.