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Guest editorial Friday 21 October 2011: Why the Secretary Of State role change matters

This guest editorial from Irwin Brown of the Socialist Health Association considers the historical context of the Secretary Of State For Health's role in providing or securing provision of NHS healthcare.

The debate about the role of the Secretary of State for Health is significant, but in many ways only symbolic.

The role of the Secretary of State is a proxy for the kind of NHS we have.


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Choosing a social model
In its way the kind of NHS we have is a proxy for the kind of society we want, altruistic or consumerist.

The debate in the Lords on the issue is also the final test for the LibDems a last chance for them to show any real resistance to a Bill which will destroy the NHS as we know it – by design.

The role of the SoS in health is unique. In other public services, there are very different structures ;usually with a strong involvement of elected local authorities – social care and education as the best examples.

Originally in the 1946 model we had a SoS attuned to the sound of falling bed-pans. The SoS presided over the whole of an NHS delivered by public bodies.  This was something of an illusion, as from day one significant areas of the NHS were in fact delivered outside the public sector.  The public view was of a publicly owned, publicly delivered NHS.

For decades, we have had a different model - in the sense that we had a managed system and some separation between planning and delivery or as it became between commissioning and provision.

There are still those, especially in Wales, who see the apartheid-style separation between planning and providing as unhelpful.  In England, alongside this separation ran the related theme that providers could be drawn more widely from private providers.

From providing to securing
The role of SoS thus shifted from being provider to securing the provision.

The idea that the SoS secures provision is now established and (until recently) was common ground, in England.  Using non-public providers to increase capacity or to fill gaps, or using third sector providers to add expertise, is generally acceptable.  

What was not in doubt was that it was down to the SoS to ensure that services were provided, with powers to intervene if this was not the case.

Alongside plurality of providers, we saw the emergence of ‘commissioning’ and to some extent its devolution.

The idea of enabling local clinicians to lead local commissioning is hardly new.  But here is the big distinction - until this Bill came along, it was a shared understanding that the devolution was about delegation downwards of the powers of the SoS, most recently from SoS to the PCTs and then to PBC groups.

That allowed the reality of a SoS in control of the whole system through commissioning; through powers to direct commissioners and powers to intervene.

FTs: a limited liberation
The SoS has to some extent given up the power to direct and intervene in providers.  The emergence of Foundation Trusts (FTs) brought in some hybrid form of provider; both NHS and independent.

Some of the independence was a myth, as the control over commissioning and control over the terms of the contract FTs had to sign meant they were not all that free.

But as of today, the SoS sits at the top of a managed system; accountable not only to Parliament for the system performance, but recognised by the public as accountable – no matter how free or not some of the components of the system might have been.

And in the view of the Health Select Committee, the SoS will always be politically accountable – until we get to a fully-privatised regulated utility model – and maybe even then!

Separating commissioning
Nobody, up till now, had envisaged making commissioning separate from the SoS.  This is what the Bill sets out to do, and this is why it is absolutely farcical to suggest this Bill is in any sense a continuation of previous policies.

Only by changing this part of the role of the SoS can the way be cleared for increasing marketisation and eventually a full, regulated market as with the utilities.  This adds to the Bill provisions which bring in the principle of “autonomy”; remove the power to set prices and contracting rules; and many other changes - all of which further weaken any SoS powers of intervention.

All these enable the freedoms necessary for the market.  This is what the Bill is for, even if the LibDems have not noticed.

It takes the rest of the Bill to create the architecture to break up our NHS and turn it into something we do not want and for which we never voted.  Changing the role of the SoS is necessary but not in any way sufficient to make this possible.  It may be a proxy argument, but it is an important one.

It’s an argument the Lib Dems are afraid to have.