The vaccine rollout could set the future terms for health service accountability

Jan 19, 2021

There is hope. As many of us sit through another lockdown and our healthcare staff work as hard as ever to keep us safe, an end to the nightmare of Covid is in sight. The rapid development of new vaccines is a remarkable achievement (as my colleague Rob Ede and I noted on this blog last week).  The task of now deploying them as quickly as possible is well underway.

The roll-out though begins with concerns and tensions about whether the NHS can deliver what is required. Government Life Science Tsar John Bell caused ripples last weekend when he said ‘the NHS could deliver the vaccine in five days if it was better motivated.” This drew a strong rebuke from former NHS Chief Executive David Nicholson.

Simon Stevens the current NHS Chief Executive was notably front and centre at a recent Downing Street press conference alongside the Prime Minister and Brigadier Prosser to update the public on the vaccine ambitions. Last Monday, when publishing the vaccine plan, Secretary of State Matt Hancock was asked whether he was confident about hitting the target of 2 million vaccinations a week by the end of January. The Secretary of State was clear he was, and then turned to NHS England Medical Director Steve Powis and simply said ‘confident?’. Behind the scenes there are reports (publicly denied) that tensions between Government and the NHS are rising. The stakes here are high, with some even arguing that the Prime Minister’s legacy is in the hands of the NHS England leader.

The Government, scientist back and forth in 2020, which reached a crescendo in the run-up to November’s lockdown is, until March, at least less of an issue. The catastrophic impact of the new variant of the virus on public health and the NHS means that even the most ardent lock down sceptics have been neutered for now. Focus has instead changed to the quickest way out of the cycle of lockdowns and getting as many jabs into arms as quickly as possible.

The operational responsibility for this sits with the NHS, with support from the military, but it is Ministers who will ultimately be accountable to the public for any successes or failures.

The Government’s approach to holding the NHS to account is two fold; pull them in closely and publish a plan with clear targets. This explains the higher profile joint media conference appearances, the appointment of a specific Minister, Nadhim Zahawi to oversee the process, a clear vaccine rollout plan and the publication of daily vaccine uptake figures. These set of measures combined with sufficient funding are aimed at ensuring the NHS delivers what it has promised.

This approach to accountability, may give us some wider clues into how the NHS is managed in the months beyond the pandemic. Before Covid hit, rumours swirled through Westminster that the Government wanted greater political direction over the system in future legislation. The system recoiled fearing another top down re-organisation and a return to command and control from Victoria Street and Downing Street, but a full re-ordering is unlikely.

Instead officials have been exploring what powers and levers could be strengthened to ensure the NHS is more responsive and carries out the priorities of the elected Government, whilst maintaining degrees of NHS operational independence for delivering them (and the many other services it provides). Indeed it is the wide range of challenges and items that the system faces and is being asked to deliver that is the biggest difficulty. NHS Providers Chief Executive Chris Hopson stated at a Westminster Health Forum last week that between the manifesto, long term plan and Covid recovery some things would have to give. The set of issues are not mutually exclusive of course – tackling waiting times is a priority across all three – but a looming prioritisation of what matters to the NHS post Covid is coming.

With resources unable to stretch, Whitehall will fragment. Number 10 and the Department will want the manifesto delivered, the NHS will want to get on with the long term plan and moves to integrated care systems, the Treasury will want all parties to slim down and prioritise.

For a Government who made the NHS a cornerstone of its election campaign in 2019, the post pandemic world will see an urgent desire to run hard at the promises made and want no barriers to delivering on them. The level of independence of NHS England and Improvement from Government does not sit comfortably against this politically charged backdrop.

Whilst all former Secretaries of State historian Nick Timmins has spoken to say that political day to day decision making of the NHS is neither practical or desirable; the issue of an independent NHS board has long divided politicians.

The late Frank Dobson called a statutorily independent commissioning board: ‘bollocks’, adding that “I think the person who takes the decisions should carry the can and the person who carries the can should take the decisions.” Jeremy Hunt has said that he did not feel the mechanics of the 2012 Act were any barrier to him intervening in NHS matters. Hunt was (and continues to be) relentless in his pursuit of patient safety, delivering notable results. His ‘Monday meetings’ were notorious for the officials involved many of whom spent weekends mocking up slides for their update meetings.
Both Hunt and the current Secretary of State have shown no great interest in the formal 2012 levers of the Mandate and outcomes frameworks as means to hold the system to account. This is mainly because they do not see them as effective.

Which brings us back to the vaccine roll-out. The importance of the programme has generated a Government/NHS policy making structure that combines sufficient funding, joint agreed plans, direct oversight and clear measurable, transparent targets that could underpin a better and clearer way forward than what exists today.

It is neither politically or practically desirable for Government to ‘take back control’ of NHS England and Improvement. But there is also a democratic deficit if politicians do not or are unable to deliver their political mandates. The vaccine rollout may show us a model for how a new approach to health service accountability, underpinned by new levers in legislation, will provide stronger political oversight whilst maintaining day to day NHS operational independence in the future.

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