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The amateur ethos that informs British public life long ago completed its mutation from endearing national quirk to debilitating madness. Entire departments of state, budgeted to the tune of tens of billions of pounds, are run by ministers with zero expertise in their portfolio and no experience of managing anything either. Just as they acquire a little of both, they are “reshuffled” to another branch of government. Helping them is a civil service of variable talent and jaw-dropping unaccountability, designed in the Victorian age when government ran almost nothing and spent a negligible amount of money.
The antithesis of all this cheery fumbling is Simon Stevens, one of the world’s superstar technocrats, who took over as chief executive of the National Health Service last week. He made his luminous reputation as Tony Blair’s healthcare adviser and, at the turn of the millennium, drew up the former prime minister’s market-based reforms of the NHS.
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These began a process, more or less uninterrupted since, of slowly loosening up a command-and-control system founded on the giddy collectivism and rationalist naivety of the post-1945 years. Power was devolved from Whitehall, non-state providers were ushered in and Britons were treated to a morsel of the information and choice that patients in other countries take for granted. All of this was fought tenaciously by public-sector vested interests and ideologues in the Labour party. When Mr Blair spoke mysteriously of the “scars on my back”, he was thinking of these assailants. His successor but one, David Cameron, got his own war wounds when he attempted similar changes to the NHS in recent years.
In 2007, Mr Stevens moved to America to run UnitedHealth Group, a company that serves more people than there are in the UK. His return, which entailed a pay cut, testifies to his ardour for the NHS but also to its desperation for outside help. Extreme cases of shoddy care and callous neglect of patients, hard to read about without feeling queasy, are sapping the NHS’s reputation.
Even if these problems are fixed, the organisation faces a future of rising drug costs and an ageing population. These inflationary forces must be absorbed without anything like the lavish budget increases the NHS grew used to in the boom years, when spending in England doubled in real terms over a decade. The NHS will have to do more with less. Its recent record of productivity offers no cause to be sanguine.
Mr Stevens was galvanised by his American experience. He is said to be more taken than ever by the potential of data – about the performance of doctors, the effectiveness of treatments, the cost of everything – to empower patients and reduce waste. He is open to the incendiary idea of local pay variations as a way of cutting the share of the NHS budget taken up by wages. And he is keen for providers to compete for patients as long as access to treatment remains universal. Some in Westminster balked when Mr Cameron, a Tory, went out of his way to headhunt Mr Stevens, but the surprising thing is that so many were surprised. There is a zone of the British political spectrum where New Labour, Conservative modernisers and “Orange Book” Liberal Democrats overlap. They all want to shake up public services conceived in a bygone age of bureaucracy and deference. That zone is where Mr Stevens and the prime minister both live.
Mr Stevens will not want for assistance. Although healthcare has quietly fallen in salience as a political issue, Mr Cameron knows that failures on his watch – such as a crisis of capacity in the winter – could undo him at next year’s general election. He also knows that voters have never really shaken their mistrust of his party on healthcare. So he keeps a hawkish eye on the NHS, acting at times like a supplementary secretary of state. The man who holds that official title, Jeremy Hunt, was appointed despite a brush with scandal precisely because Downing Street rates him above almost every other cabinet member for sheer executive competence.
The destiny of the NHS is not for the chief executive to determine by himself. The biggest decision is for elected politicians: how much is to be spent on healthcare? And what blend of tax rises and spending cuts elsewhere will pay for it? Once those terms are set, even the business of reform will be as much democratic as technocratic. When nurses protest against changing pay scales, when GPs resist being ranked according to performance, when the NHS gives up on some areas of care for reasons of cost, it is the government of the day that must withstand voters’ wrath.
Within these constraints, however, Mr Stevens will have vast and solemn power over people’s lives. He will help to decide what treatments the NHS says no to at a time of scarce resources. He will bear the burden of eradicating the kind of maltreatment exposed in recent years. He will oversee 1.7m employees. With such sway over matters of life and death, the appointment of Mr Stevens might turn out to be more important than the appointment of Mark Carney as governor of the Bank of England.
Even the most advanced societies have taboos – untouchable areas of public life that only brave or foolhardy politicians go near. In America, social security and the right to bear arms are examples. In France, it is the labour laws. In Germany, it is the assertion of national interests abroad. In Britain, it is the NHS. Any reform is interpreted by unions and voters as privatisation in drag. On the part of the unions, this is perfectly natural self-interest. But the public’s sensitivity lurks deeper in the soul and goes back to those years when a nation enervated and almost beggared by the second world war was moved to be “given” something for “free”. It is that searing folk memory that puts what passes for discourse about the NHS beyond the realm of reason.
The NHS is said to be the closest thing the British have to a national religion. If so, it must be led by a nonconformist, someone who believes in the core tenet of universal care but dissents from the surrounding theology of dirigisme. In Mr Stevens, the government has found the most suitable of priests.
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