Wes Streeting set out his “radical” but “thoughtful” approach to reform in a two-hour session with MPs this week focused on the NHS England-Department of Health and Social Care merger.
Offering lots of imagery, Streeting explained to the Health and Social Care Committee how his thinking had changed in his first six months as health secretary, going from thinking structural reform would likely be a waste of time to believing it to be a necessary upheaval.
Here are CSW’s highlights from the session.
‘Some meetings felt like West Side Story’: Experience in office
In January, Streeting told Health Service Journal that abolishing NHS England would mean he would “spend a hell of a lot of time in parliament and a hell of a lot of taxpayers’ money changing some job titles, TUPEing over staff and changing some email addresses and not make a single difference to the patient interest”.
Asked by Labour MP Ben Coleman what had made him change his mind, Streeting said: “Experience in office, bluntly.”
Streeting said he was, “even as someone who has paid close attention to how this system is run and led as shadow health and social care secretary”, surprised at the extent of the duplication that exists between the department and NHS England.
And he was “taken aback” by the extent to which policy and strategy, which he assumed had always sat with the department, had become “part and parcel of life over at NHS England”.
Streeting said this “blurred form and function”, and has led to “litigation and relitigation of decisions that democratically elected governments…have wanted to take”.
Asked if there was a straw that broke the camel’s back, Streeting said “not particularly” but that some meetings involving NHS England and DHSC had felt like the musical West Side Story.
Streeting said he had, alongside the then-NHS England chief executive Amanda Pritchard, sought to build a “one team” culture from day one as health secretary, and that this had “to the credit of people working in both organisations, already begun to bear some fruit”.
But, he added: “I think about some of the teams that sit around my table in the department. The best meetings are where you can't distinguish who's in the department, who's in NHS England. Some of the worst meetings are when it's blindingly obvious who’s sat on which side, which sometimes resembles West Side Story, albeit a very polite version and less musical. I don’t think that's really a good way of working for anyone.”
Streeting also said that one of his metrics for success from the merger will be whether, a few years down the line, “you still have…people still referring to themselves and their job functions based on where they used to work”.
“It is not unusual to find people who say, ‘Oh, yes, I was with HEE’, even though that's been abolished,” he said. “And I think those are signs that the culture of team working and one organisation hasn't always been achieved in previous mergers, and that's something I'm mindful of as we embark on this process.”
Duplication was like ‘Mr. Messy’
When Streeting outlined the plans to abolish NHS England on 13 March, he said the country has been “left with two large organisations doing the same roles, with an enormous amount of duplication”.
Asked to explain where the duplication is in further detail, Streeting said that, alongside there being two HR departments, two finance departments, two communications departments, and duplication of policy and strategy functions, there are also issues further down the system.
“You look at NHS regions, you look at [Integrated Care Boards], and then you look at the different regulators and the regulatory landscape, and your lines of accountability and focus of work begin to look either blurred, or worse still, like Mr. Messy in terms of the kind of the number of lines of accountability and the amount of duplication.”
Asked why he thinks duplication has been allowed to happen historically, Streeting said there has been “quite a lot of what I call man marking going on between the department and NHS England”.
Streeting said the organisations’ elective care teams had been set up for NHS England to deliver elective performance and elective recovery and for the department to “man mark” but that he has, through the “one team” approach, got the two teams “working much more effectively” by turning them all into “doers.. rather than a team of doers and a team of checkers”.
Streeting added that he thinks there is a “a natural tendency” to “expansion in the state” and “empire building”.
“In the broader regulatory landscape, if there's a problem, you introduce a new regulation. When that doesn't work, you introduce some more regulation. And when that hasn't worked, you might not only introduce a new regulation, you might even introduce a new regulator. And if you look at the way in which, over more than a decade, the health and social care landscape has evolved, we've got far too much duplication. We need to call time on it.”
Restructure comms ‘not ideal’
Streeting said the manner in which the abolition of NHS England was communicated was “not ideal” due to the public nature of political restructures.
“In any organisation I've ever worked in where I've either been part of a restructure or led a restructure, you would never have handled the process in a way that in government you inevitably have to,” he said.
“In an ideal world, we would have embarked on this process with a change management plan already in place, with an organisational structure in place and new job descriptions, organograms ready to go when you start briefing staff about changes. But of course, the moment we started to do that work, which is now well underway, we would have been reading about it in the HSJ long before the prime minister announced it or parliament was informed.
He added: “So, I appreciate that for people who are on the receiving end of some of these changes, this has been a really difficult and challenging time, but the prime minister and I have sought to make sure we've handled announcements in the right way, and now that we're clear about the direction of travel, we will be keeping regular internal communication up with staff whose jobs are affected.“
'Radical but thoughtful’ cuts
Streeting has said he wants to reduce the headcount of the central health system by 50%, which reports suggest could equate to around 9,000 jobs.
Asked how that number was calculated, Streeting said the department took into account duplication, where it intends to devolve more powers, and the need to “demonstrate…the seriousness of our intent and purpose”.
Streeting said he was not wedded to an exact figure of cuts. “Whether or not we land on 46% reduction or 52%, we will do so through careful design and deliberation and consultation with staff,” he said.
He said the exact number of cuts will not be known until DHSC confirms “what the ultimate size and shape of the organisation will be”.
The health secretary said the change would be a “radical reduction of the centre” but that the department is “proceeding in a considered and thoughtful way about how we execute that”.
Asked if the cuts might cost around £1bn in redundancy packages, Streeting said: “I didn’t think that was an unreasonable ballpark figure.”
‘It boils my blood’ – Streeting on criticism of the amount the merger will save
Streeting has said the abolition of NHS England will save the government hundreds of millions of pounds per year which will be reinvested in frontline services.
Questioned on what impact the savings will have on the frontline given this amount is relatively small in terms of the department’s overall spend, Streeting said: “It really boils my blood when people say, ‘Oh, but it's only hundreds of millions of pounds of savings. Is it really worth it?’”
Streeting said he thinks “one of the cultural problems with the NHS and…with the department that has a budget of the size that we do now, in excess of £200bn, is there is a risk that, because we deal so often in the billions, that we lose sight of the hundreds of millions and the millions”.
Less top-down diktat, more test-and-learn
As well as generating more money for the frontline through the reforms, Streeting has said he views the merger as an opportunity to devolve more responsibilities.
Speaking to the committee, Streeting told MPs that the department will take a “test and learn approach” to this, giving “more freedom, more flexibility, more powers to the front line”.
“If it's always top down command and control, we will fail,” Streeting said. “And the more we get that pressure from below and that hunger to change, I think the more we will be succeeding, whether that is system leaders in [Integrated Care Partnerships] or frontline clinical teams who are changing the way they do their elective surgery, for example, and having support executive leaders to do that.
Learning lessons from previous reforms
Asked what lessons he has learnt from previous reforms, Streeting said: “Proceed carefully even if you’re acting radically.”
“[Former health secretary Andrew] Lansley did a huge amount of work in opposition. Came in with ready-made reorganisation and steamrolled through,” he added. “We’ve done a different approach. Consult, engage extremely widely. And in terms of the department and NHS England change that’s been done after consideration of seeing how things are working in practice.“
He was also asked if the reorganisation would be a distraction. Streeting said the “public will be pleased to see we’re going after bureaucracy and putting more money into frontline” and that it is “disruptive certainly” but not “necessarily a distraction”.