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Editorial Monday 29 June 2015: Under what circumstances would Jeremy Hunt unleash his Johnson?

This  Local Government Chronicle story by David Paice, cross-posted on HSJ, shows why the health policy universe needs to understand the circumstances in which health secretary Jeremy Hunt would unleash his Johnson.

Readers are advised against making the Freudian slip of seeing a double-entendre at play where none exists: this is a reference to a tale confirmed by the excellent Nicholas Timmins' 'Glaziers and Window-Breakers' book on past health secretaries for the Health Foundation.

At the peak of the Mid-Staffs news becoming a national news story, the then-health secretary Alan Johnson had the system leaders of that era in his office. As Johnson was agreeing with NHS CE Sir David Nicholson that Mid-Staffs chair and chief executive would have to go with immediate effect, executive chair of Monitor Bill Moyes piped up "under what legal authority, Secretary Of State, are you going to do that?"

Mid-Staffs was of course an FT, and Moyes was rightly pointing out that Monitor was the body with the legal ability to dismiss their board. Timmins recounts that Johnson replied "Look, this is what we are going to do. I’ve spoken to the prime minister about it. I’m up in the House tomorrow answering questions about it. I am the Secretary of State for Health. And I’m responsible. And that’s what we are going to do. I don’t give a damn what the legislation says".

Johnson's retelling of the story in his interview with Timmins summarised it more concisely: "piss off: I'm dealing with this".

A health secretary is unleashing their Johnson when they ignore the law in favour of the realpolitik.

A little devolution is a dangerous thing
Back to Paice's story, which covers a House of Lords Committee discussion of the Communities and Local Government Devolution Bill.

The government's spokesman Baroness Williams (a former leader of Trafford Council) was responding to queries about circumstances in which the health secretary could intervene in the Devo-Manc arrangements.

HPI has already observed that the Devo-Manc proposals are a limited devolution of power to agree to share budgets and self-regulate with the 'help' of existing system regulators. This experiment is worth trying, albeit the amount we can disaggregate the learning from the factors driven by general NHS demand and finance pressures is wide open to question.

Asked by Labour peer (of sorts) Lord Warner about the decision to take hundreds of acute beds out of the Manchester health economy, Baroness Williams suggested that the health secretary “would have something to say about it” if he thought “all of them collectively were making the wrong decision”.

She added: “I was not saying that the secretary of state would overrule them for overruling’s sake, but if it was fundamentally a wrong decision, I am sure that he would have the power to intervene”. She added that the government “cannot have a situation where there is unfettered ability for people to do things without any checks and balances”.

What is a “bad decision”?

Baroness Williams hazarded the definition that an intervention-triggeringly bad decision would be one which had “negative” consequences for patients and service users: “the secretary of state would have to intervene or call into question the decision of the collective bodies that had made it in partnership”.

This is as clear as the "exceptional circumstances" in which (under the 2012 Act which disestablished and denationalised the NHS in the name of liberating it) the secretary of state for health can intervene in the operational management of the NHS.

Which is to say it is not clear at all. It essentially says, 'here are some very important rules which we can break whenever that is the more politically convenient option'.

Mr Hunt's view on when to 'do a Johnson'
I had the opportunity to ask Jeremy Hunt about circumstances in which he might 'do a Johnson' when he spoke at the Kings Fund's leadership event recently.

Mr Hunt acknowledged that it was a case of balancing a desire to be properly accountable to Parliament with the desire to give the NHS time and space to resolve things for itself.

In the event of a bad news week or weeks, Mr Hunt added, it's right for the secretary of state to be accountable to parliament and the media, but that accountability mustn't mean that the health secretary should get sucked into operational day-to-day management.

Mr Hunt was inclined to defend Alan Johnson's response: the legislation and structures are right for the NHS, but as health secretary he also felt that he must look at the bigger picture and represent the voice of the public. When something significant has gone wrong in the system and has to be sorted out quickly, Mr Hunt suggested that the priority is to get to the right answer and hold NHS managers as system leaders to account.

Mr Hunt concluded that he recognised the tension between competing pressures here and its impact on the system's culture.

All of these points are reasonable ones. And they amplify one clear message: the facts of NHS life are political.

Not only that: they are highly contingent on the individual politician in the secretary of state's role at the time, whatever the law may say.

UPDATED: HSJ's splendid news editor Dave West points me to a continuation of the debate, in which Baroness Williams demonstrates that when she is in a hole, her instinct is to keep digging vigorously.

Baroness Williams is unable to answer the simple question of who the accountable officer will be for the Devo-Manc consortium. (It will remain all the individual AOs of the member organisations). It seems that the right hand does not know what the further right hand is doing.