A guest briefing from Health Service Journal’s editor Alastair Mclellan.
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Today, Jeremy Hunt passes Norman Fowler’s record and becomes the longest serving political boss of the NHS (Bevan was left choking dust back in February). What a long, strange trip it is has been.
When commenting, Health Service Journal has always taken Patti Smith’s advice on prioritising the future over the past. However, it is worth pausing for a moment to consider Mr Hunt’s time in office.
The best way to rapidly do this is to locate an electronic copy of Nick Timmins’ wonderful and recently published brief history of the NHS between 2012 and the present day. Stick ‘Jeremy Hunt’ into the search box and follow the health and social care secretary’s changing strategy and views through the years. It is fascinating.
Mr Hunt comes out pretty well. Mr Timmins claims “neither the media nor the opposition [have] managed to lay a glove on him” despite his tenure covering a period of significant austerity and a series of “crises” that would have seen off many predecessors.
He did what only the sainted Aneurin had done before and defeated the British Medical Association through placing them in a position where its next move would have seen it lose the public support it craves.
He convinced the prime minister not to move him even though it would make her look even weaker; and then persuaded her that supporting the NHS through extra funding was the right thing to do both morally and politically.
He has formed an effective partnership with Simon Stevens, allowing the NHS England chief executive free rein as he tries to sort out the mess left by Andrew Lansley.
Mr Hunt’s most significant contribution to the sector is the Care Quality Commission. Very few in the NHS are going to love an inspectorate (nor indeed, any Conservative health secretary), but quality and especially patient safety are now higher on the agenda than they have ever been.
At first, Mr Hunt opted for the usual levers of regulation, criminalisation and command. But unlike most previous health secretaries, he also opened his department to harmed families. Post Mid Staffs he has met many of them, often against civil service advice, and never sought publicity for it. It may have started as a ploy, but the experience clearly influenced him.
He has been captured by his brief and even many cynical NHS leaders accept his genuine commitment to improving safety, and that his years in the job have brought him useful perspective.
Mr Hunt now recognises cultural issues have the greatest influence on harm, and that tackling it requires a long-term commitment to transparency and systems thinking, rather than new laws.
There have been notable missteps – unsurprising given his time in office.
Mr Hunt was slow in starting to push for an NHS funding uplift and his lack of interest in the NHS’s financial position was recognised even by his bosses who appointed a series of junior ministers to make sure things did not get out of control. He micro-managed too much at the beginning of his remit (as Mr Timmins forensically reveals).
His stubbornness helped create and prolong the strife over the junior’s doctors contract (though it ultimately helped him settle it too).
But enough looking back, what does the future hold for Mr Hunt?
The money is his first test. HSJ has already predicted this year will see a welcome funding boost, but one which will fall short of what all independent analysis argues is required. Mr Hunt must, therefore, make sure it arrives at the right time (ie frontloaded) and without the kind of robbing Peter to pay Paul games of recent years.
…and then he must work together with Simon Stevens to prepare the case for a more substantive funding settlement at the turn of the decade, as the election looms.
The easy job over, Mr Hunt can turn his attention to the reform of social care – starting with the promised green paper. This is where his legacy lies (whether he likes it or not) and where his bravery and political nous will really be tested.
Of course, Mr Hunt also has not one but two era defining political problems to wrestle with.
Brexit poses an existential threat to the NHS – EU staff are leaving and their compatriots are not arriving in anything like the necessary numbers. Workforce shortages could yet produce the kind of scandal that Mr Hunt as patient champion pledged to avoid after the Francis inquiry.
If that does happen, the health secretary will be partly at fault for being too relaxed about staffing numbers early in his tenure, and overseeing a dispute with junior doctors, which left a generation of medics bruised and discontent.
The health and social care secretary has made it very clear that qualified and experienced healthcare staff from overseas are still welcome in the NHS but, to date, it is not working. More UK trained staff are on their way, but Mr Hunt must still find a way to give overseas clinicians the confidence that their careers can flourish in the UK.
Technology is one of the few areas, along with patient safety, where Mr Hunt pushes harder than Mr Stevens – he is by far the most tech-savvy individual to occupy the service’s top political job.
Time has come to turn the rhetoric, which first found voice in his 2015 HSJ lecture, into action, and give the service cover to introduce the kind of disruptive and in the short term disturbing change other sectors have already seen.
Then there’s the small matter of finally and formally committing much of the Lansley legislation to the dustbin of history – something Mr Hunt first floated in HSJ 18 months ago.
Far from being a new idea, as portrayed in some media last week, the proposal to give legislative backing to new care models and potentially scrap the internal market was included – presented as an offer to the NHS – in the 2017 Tory Party manifesto.
Can the health secretary use his new political capital to squeeze in effective legislation among the Brexit-inspired torrent; and take it through a precariously balanced Parliament, which would likely choose to refight the battles of the past?
Mr Hunt may well spend a decade as health secretary – an astonishing length of time. If that happens he will have been given one of the greatest opportunities in British public life, for the longer you are in post the better your ability to embed meaningful change.
If the health secretary were to be “inspected” today against the CQC’s six domains, how would he fare? He would do relatively well on “caring”, “well-led”, “safety” and “effective”, but the inspectors might be less impressed when examining “responsive” and “use of resources”.
Whether that makes him “good” or “requires improvement” overall would depend how much personal responsibility they decided he carried for Brexit and, especially, public sector austerity.
But such is the scale and nature of the challenges ahead of him that Mr Hunt could yet end his time judged either “outstanding” or “inadequate”.
By Alastair Mclellan, editor of Health Service Journal