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Editorial Friday 12 February 2021: Waiting for the Bill means Big Speculation

It's been a fairly lively week.

After publishing the text of the Health And Care White Paper, and writing this piece on what it all means on here, I've been explaining it for BMJ readers as well as putting it into broader context of the big, real problems facing the NHS in the HSJ column.

The national media have been excellent about acknowledging Health Policy Insight as having got hold of the White Paper first: a courtesy which I appreciate.

Yesterday, I got an unexpected name-check in the House of Commons from Labour's Shadow Health lead Jonathan Ashworth, which made it into Hansard, and also recorded a short piece for BBC Newsnight (19 mins 30 in) alongside the splendid Helen Buckingham of the Nuffield Trust.

Waiting for the Bill
Now we only have the White Paper so far (the text of which was given a few obligatory tweaks). We need to actually get the Bill. That is where the wording will clarify the power shifts being proposed.

The language is always important.

There have been some ill-advised commentaries trying to suggest that this White Paper will not effectively undo the Lansley reforms and does not represent a big power-grab by the Secretary Of State For Health But Social Care.

Those takes will not age gracefully.

Longstanding readers know that I was the first person to see and state what NHS Commissioning Board CE and Sun King Of Skipton House Sir Simon Stevens was doing with the Five-Years Forward View in 2014.

It was 'a subtle subversion' of the 2012 Health And Social Care Act.

When the Five-Year Forward View was launched, I wrote, "the message behind the FYFV is ‘we're going to be doing this. And we’re going to deliberately, blatantly ignore key parts of the 2012 legislation, and you're not going to stop us, because we know that you know that it's already overspent chaos in the NHS, and it’s going to get worse as the money goes ‘ping!’ That OK with you? Splendid'.

"It doesn’t engage with the 2012 Act’s legacy of a leaderless system, which has often left NHS providers and indeed commissioners unhelpfully uncertain of who is supposed to be in charge.

"It goes beyond simply ignoring the 2012 Act, promising 'meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied'."

It took too many people in the field of health policy and politics years to catch up with this: a fact that reminds me of Kingsley Amis' suggestion for the title of a new edition of Robert Conquest's classic book 'The Great Terror'.

Eventually, the penny dropped that I was right in observing that the Conservative Government had offshored health policy to Sir Simon Stevens, who was ignoring the shit out of the Lansley reforms, because a) he could, and b) he needed to, to prevent the financial derailing from being too high-speed.

Sir Simon's political rule as absolute monarch over the NHS was also something I observed long before others did.

Major changes in health policy and politics were happening, and most people did not discuss them.


I wrote in February 2015 that in an NHS circled by a galaxy of regulatory Death Stars, that had run out of money and wasn't going to be running back into it any time soon, the market mechanisms of the Lansley reforms were the highest-maintenance imaginary boy/girlfriend ever. The theory might be willing, but the practice is weak.

Another piece from 2015 which strongly bears re-reading is this lecture by the former NHS Comrade-In-Chief, Sir David Nicholson, which posed the question 'Is the Government still ignoring the NHS's financial problem?'

You can probably guess the answer, but the analysis remains valuable.

Big reputation
In the words of health policy guru Taylor Swift, NHS Commissioning Board boss Sir Simon Stevens has a "big reputation".

Inevitably, if you are such a Big Beast in health policy and politics, then once word about your departure is set in motion - back in June 2019 - the speculation gets under way.

Firstly, when are you off?

Secondly, who's replacing you?

As political parlour games go, it's up there with picking a future Cabinet. I mean, imagine having predicted in October 2017 that Boris Johnson would be Prime Minister and Priti Patel Home Secretary ... oh.

Sir Simon Stevens, NHS Dowager-General?
(Um, no)
The speculation game got a particularly poor entry this week, with this piece in the Guardian suggesting that Sir Simon Stevens will be transitioned into a sort of NHS Dowager-General role.

The piece alleges that ministers are discussing offering Sir Simon "a new role as an international ambassador for the NHS".

Reading this, I laughed until I stopped. This idea of an ornamental, in-out hybrid role would be ridiculous on so many levels.

The NHSCB leadership job becomes un-do-able at any level if there is an obvious 'King Over the Water' figure of such a kind, both backseat driver and aide-memoire.

Just think about it. Shit Kremlinology would know no boundaries. The narrative shifts from 'when's Simon off?' to 'when's Simon coming back?'

Still, it's given ex-Comrade-in-Chief Sir David Nicholson and the rest of us a pretty good laugh this morning.