Isabel Hardman: We go too far with the ‘NHS as a religion’ analogy

Isabel Hardman on the history of the NHS, the politics at play and the lessons learned.

12 July 2023

Seventy-five years on from its founding, what can we learn from the NHS's history that could help inform its future? Author and journalist Isabel Hardman returns to Health on the Line to discuss how, from its inception, the NHS has had a unique political undercurrent running alongside its day-to-day challenges. On the launch of her new book on the history of the NHS, she reveals how successive governments and health ministers have approached the challenge of dealing with one of the UK’s most beloved institutions.

Health on the Line

Our podcast series offers fresh perspectives on the healthcare challenges of our time and ways to confront them. Tune in for interviews with the movers and shakers making waves across health and care

  • Matthew Taylor

    Hello and welcome to Health On The Line. I'm speaking to you this morning from the conference offices in Westminster, but last week I had the opportunity to be on the road visiting our members and speaking with our local government partners.

    I joined councillors and officers at the Local Government Association conference in Bournemouth, speaking at three different events and emphasising our commitment in the NHS to integrated work at system and place level. And also, while I was in the south west, I visited Dorset ICB. I spent a fascinating morning learning about their five-point strategy to make Dorset the healthiest place to live. Particularly interesting work they've done in Dorset on data and the use of data to develop plans and to mobilise partners.

    Despite the many challenges facing systems, including coping with swingeing cuts in their running costs, I'm seeing lots of positive developments as I go around the country, and you can soon read all about what we've learned from that first year of system working in our report, State of ICSs: One Year On. Some really interesting stuff in that, so please to look out for it.

    But while systems and places plan for the future, our latest guest on Health On The Line offers us an opportunity to look back and to learn from the last 75 years. Speaking about her new book, Fighting for Life: The 12 Battles That Made our NHS and the Struggles For Its Future, journalist and author Isabel Hardman reminds leaders and policymakers that those who fail to learn from history are often doomed to repeat it.

    So, it's great to welcome Isabel Hardman, journalist, writer, campaigner to Health On The Line. Isabel is the author of several books, including Why We Get the Wrong Politicians and the Natural Health Service: How Nature Can Mend Your Mind. But her new book is Fighting for Life: The 12 Battles That Made Our NHS and the Struggle For Its Future. Isabel, welcome to Health On The Line. How are you?

    Isabel Hardman

    I'm really good. Thank you so much for having me on.

    Matthew Taylor

    It's kind of strange how our worlds have collided really, isn’t it? And I remember discussing the problems of the political classes of the year at the RSA. And then here we are, you're talking about health, and I'm running a health organisation.

    Isabel Hardman

    Just following you around Matthew.

    Matthew Taylor

    I guess my first question is, by the time I think this conversation is broadcast, we’ll have passed the 75th birthday or it'll just be the same day as that birthday, there's a lot of stuff being said and written about that, and clearly the 74th birthday was an opportunity for you in terms of the publication of the book.

    Why did you want a growth opportunity yourself? What was the contribution you wanted to make to what is bound to be a kind of national conversation about the health service?

    Isabel Hardman

    Penguin approached me to write the book, and I think the reason they were interested was because Why We Get The Wrong Politicians had taken a slightly different perspective on another thing that we all like to talk a lot about, which is the failures of parliaments. And that's what really attracted me to writing about the NHS - I am just someone who was fascinated by the way organisations are structured and also their culture and how those two things can be very different, how those two things can go very wrong.

    And with the NHS, the thing that I really find endlessly fascinating is the contrast between its cultural position - we venerate health workers around the world, but in this country, we also venerate our health system, to the extent that we had this in our Olympics; we had Justin Bieber helping an NHS choir get to Christmas number one, a few years ago, which even to Brits can seem a bit weird, but it's people who are just used to their health services being a bit like their education systems or their welfare systems in other countries, you know, just a fact of life, but not something you necessarily go googly-eyed over.

    So, the contrast between that and life inside the NHS, whether it's the way in which its workers talk about feeling undervalued, you know we've seen that one of the outworking of that in the strikes recently. But also patients who are very grateful for the concept of free at the point of access care, but who can sometimes be bitterly disappointed by the way in which that is delivered.

    It's this mix of a sort of political miracle almost, or certainly we often tell that story of it being a political miracle. And then the ‘what can be the grinding reality of delivering healthcare and sometimes getting it wrong as well’. And that was just so compelling.

    Matthew Taylor

    And such a strong theme of your book is conflict, that the NHS is born out of conflict, it’s borne out of Bevan’s struggles with Morrison, with the BMA, and then we start to get divisions in the Labour Party about the NHS when charges are first introduced. And then as you go through various chapters in the history of the health service, and it is a compelling story. At each juncture, it feels as though people are always arguing. There's a bit in the book, I think when you talk in particular about Alan Milburn’s tenure, about I think Milburn says or you quote me saying that literally every day when he was secretary of state, he had an argument with somebody.

    Isabel Hardman

    Yeah. And I think he enjoyed it as well. To be fair to Alan Milburn, I don't think he sort of went into health thinking ‘oh, I just want to get on with everyone,’ and you get these pugnacious health secretaries, Bevan being one, albeit being minister of health; Ken Clarke being another. People who enjoy the fight and to a certain extent you have to be up for a fight because there are a lot of people who want to have a fight with you before you've opened your mouth.

    Matthew Taylor

    And do you think that the two things that you talk about as being a contrast are in fact in some way connected? That is to say that the kind of cognitive dissonance which exists between the way that we talk about the NHS as this kind of hallowed venerated institution and the day-to-day realities of the politics? Both the politics of the NHS in the kind of classic sense of its importance to political parties and political communication, but also the internal politics of the NHS, which can be equally kind of conflictual and difficult; that in some ways these two are kind of connected in some sense that that part of the reason that we have this level of conflict is because we're not honest with ourselves about what's really going on in the health service.

    Isabel Hardman

    Yeah, I think that's absolutely right. And politicians, I think to a certain extent insult the public's intelligence on the health service by thinking that all they want to hear about is the NHS being safe and about protecting the NHS and never closing any hospitals ever, and the hospitals point is one that just again was one of those recurring fights throughout the book where you have hospitals that really, in terms of the statistics aren’t any good for the population they're serving.

    Whether it was in the ‘60s when Enoch Powell had his hospital plan or in the early ‘90s when Virginia Bottomley was trying to rationalise the hugely overcrowded London healthcare set- up, or more recently, you would always get people saying, ‘no, no, you can't close our hospital. It's our hospital.’ And politicians going, ‘okay, no, we can't go there.’ You know, Frank Dobson famously saying he didn't want a blue plaque on the door of Barts saying, ‘Opened in the 12th century closed by Frank Dobson.’ So, he reversed that closure, even though the widespread view amongst those who actually understood these things was that this was, in policy terms, a really bad idea.

    And so, you get politicians sort of giving in to that local sort of ‘no, no, don't touch our hospital.’ But you also get them giving in to the sort of wider narrative about NHS privatisation. Think of Andy Burnham in particular, when he was shadow health secretary, banging on about something that is just not happening in the health service and actually, you know, setting up these phantoms to frighten the public at the expense of a debate about, I don't know, workforce or social care, although in fairness to Andy Burnham, he did try to talk about social care.

    So, it's much easier to talk about the sort of caricatures, the phantoms, rather than the actual debate around healthcare provision and the balance of funding and that sort of thing. I do think, though, that sometimes we go a bit far with the NHS as a religion analogy, and that was Nigel Lawson, who famously said that. But there have been lots of other politicians, including Barbara Castle, who cast the NHS in religious terms, talking about it being like a church. I would say that the public are in favour of reforming the health service, they do know that it has problems.

    And also, the idea that the NHS being a religion has stopped that being reform. I mean, there's been so much structural upheaval since the Keith Joseph reorganisation in the ‘70s, but particularly from the late ‘80s, early ‘90s when you had the internal market coming in. From then on, it's been sort of perpetual motion. So, the idea that the NHS is this monolith that no one has touched is just mad. It's had more reorganisations, iterations than probably any other public service.

    Matthew Taylor

    Yeah, and that takes me to, you know, I read the book and you know, gobbled up. It's so well written and fascinating, but it also I kept putting it down and just reflecting on it. And I thought another thing that I felt was that there's kind of a strong ad hominem element to your book. And I don't think that's just because as a good journalist, you're fascinated by individual. It is also the case that this quote I think you attribute to Jeremy Heywood. I think I've heard it attributed to David Nicholson. But this kind of great quote that the NHS is the biggest train set in Europe kind of thing, that politicians come in and they fiddle around with the train set, that in a sense there's a contrast here, which is that every secretary of state or most secretaries of state come in and want to do things differently, and each brings their strengths and weaknesses.

    And if you're lucky, it can make a difference and sometimes a rather surprising ways. So, I'm going to give you a couple of examples of there's good examples. There's a lot that aren't so good, but good examples. So one is that when Patricia Hewitt was secretary of state, which wasn't for that long, I think she was a pretty brave secretary of state. She inherited a department where finances were out of control, where nobody really understood how all the different Blairite reforms actually knitted together and where her predecessor, John Reid, had avoided any difficult hospital closure decisions for several years.

    And I remember sitting in on a cabinet meeting where Patricia basically said to the cabinet, some members of whom were going to protests outside hospitals, protesting against hospital closures. And what Patricia said, I am paraphrasing, was I won't be here for very long. You know, when Tony goes, that will probably be end of my frontline political career. I'm going to have to do some really, really difficult things. But you lot need to just kind of shut up and get behind me because that's what I going to do.

    I think part of the reason Patricia was an effective secretary of state, albeit for not that many years, was in a way, she wasn't searching for personal popularity. She kind of knew she had a hard job, and she was going to do the best with it. Another completely different example is that by the time this is broadcast, we'll have had the long-term NHS workforce plan that we’ve waiting for decades. And that's a really good thing. And part of the reason we've got that unquestionably is just the fortune of the fact that Jeremy Hunt was secretary of state for health when he came out as chair of Health and Social Care Select Committee, he banged on and on and on about the need for a long-term workforce plan. So, when he got to the Treasury, which has always been the department that has blocked a properly costed long-term workforce plan, it was almost too embarrassing for him to go back on that.

    So, he was almost honour bound as chancellor to finally do what the Treasury had always refused to do till now, which is to sign off a long-term workforce plan. So, individuals really do matter. But on the other hand, and sorry, this is the longest question in history, some of the really deep shifts that we need to accomplish in the health service, like, for example, the shift of resources upstream from acute into primary, community, prevention, those things have never happened.

    So, you've got this strange contrast between quite big leaps from one model to another, partly reflecting the individuals in charge, but yet the deeper structural issues don't get addressed.

    Isabel Hardman

    Yeah, and I think if you look at most of the structural upheaval of the past 30 years, it tends to be around commissioning and that is easier to meddle with than, as you say, the overall balance of where the money and attention is going. That train set quote is it was Jeremy Heywood, but it was David Nicholson quoted it to Jeremy Hunt not long after Hunt started as health secretary, because I went back to David Nicholson and said, was it you? And he said, no, it was Jeremy Hayward's. He made that observation. And I think sometimes actually politicians not being associated with the train set ends up being to the benefit of the health service.

    So, Jeremy Hunt being a prime example of that, that David Cameron appointed him health secretary to calm everything down and it was made very clear to him that he could not do anything in terms of legislation or structural reforms. And initially Hunt pushed back against that and had lots of meetings with David Cameron and Craig Oliver saying, you know, but we need to do this, we need to do that. And they were saying, no, we’ve blown things up on the health service. You've got to pick up the pieces.

    But that meant he had to find something else to do and he alighted upon patient safety, which I think was a really, really positive thing for the NHS, to have a politician who was actually not just looking at individual scandals going to the Commons to have to apologise for a failing here, a Mid-Staffs there, but to actually look at how this added up and to realise that part of that was about workforce and that Jeremy Hunt then carried that through, as you say, not just in being House Select Committee chair, but also into the Treasury, where he was very clear from the outset that there were things that he had to do, I think, to maintain his political credibility, but also to live with himself as well.

    Having, you know, he wrote a whole book on this stuff and you can't write a book and then just say, ‘oh, I’ve got a new job. I don't stand by any of that.’ So, I think we were fortunate he couldn't do anything else, and he had to find something to occupy his time that wasn't moving bits of branch lines in the NHS around.

    But yeah, it is a very difficult job being health secretary and that's really interesting Patricia Hewitt's observation to you. I think also actually it can be one of those graveyard jobs where you do it and then you say, I've had enough of this. I mean, going all the way back to the Thatcher years, one of Thatcher's quite forgotten health secretaries, John Moore, came to the end of his job and said that it had completely broken him doing that job. So, it's not always the case that it's a springboard to greater things, including the Treasury.

    Matthew Taylor

    Well, this takes me to the next thing I wanted to talk about as well, which is this question of, as it were, political interference. So I think that one of the conclusions that one could draw from the book and in fact, I think, you know, recently I interviewed you as part of a group on the Times Health Commission, and I think one of the things you said there was that having written the book, that political interference probably was one of the biggest problems for the health service. But also on a number of occasions in the book, you say that any attempt to move away from that, any attempt to suggest that somehow politicians can evade responsibility for what goes on in health service is naive because whether it's the press or just the national public expectations, are that you can hold politicians responsible for what goes wrong in any in any hospital or any part of the health service.

    So, is there any way of addressing this conundrum? I've heard people from other countries, I was chatting to someone from France a few weeks ago, and they said, look, there are lots of problems in the French health service, but people don't assume that anything that goes wrong in the health service, some unfortunate experience they have means that it's the responsibility of President Macron. They see it in more in the way that we might see local government, that there's variability in service. And you need to try to get accountability at the local level. But it doesn't all end up in the kind of in the cradle of national politics.

    Isabel Hardman

    Yeah, I think just the way the NHS was set up means it's always going to be political and it's always going to be the case that the secretary of state for health is going to end up answering questions on something that technically is not his or her responsibility because NHS England is a separate entity and so on. It's just not going to be the case that you can palm people off with ‘oh well, that's a question to an organisation headed by someone who's not elected.’ Bevan, when he set up the health service, said that he would be the, I think it was that the chief receiver of complaints and that's part of his point about the sound of a bedpan dropping at one end of the country echoing in Westminster.

    But he knew that from then on, basically he'd probably get more negativity about the NHS than he did congratulation, although he did tend to congratulate himself quite a lot on it as well. But it is, you know, it's a political health system. It's not one that has sort of a bit of government involvement in terms of ensuring that there's, you know, insurance coverage or, you know, ensuring regulation standards, and so on.

    It is one whereby necessity in 1948, the allocation of resources had to be decided centrally because provision was so patchy. General practice, you had GPs who were working in leafy areas but not wanting to go into the more deprived areas. And so, the same with the hospitals. When you looked at the hospital surveys that were done before and after the Second World War, there were these big gaps in coverage.

    And so that central control, I think, had to be there from the start. And has just ended up being part of, I guess, our relationship with the NHS, that it is always going to be a very political relationship, far more so even than schools, however, they're responsible or accountable, whether it's through local authorities or the secretary of state or whatever, we do have a very political relationship to our NHS and I can't really see how that's going to change.

    In terms of the rebalancing of resources from acute to preventive and community, I think that's the big vogue at the moment, isn't it? We've heard West Streeting talking about it; Steve Barclay, he's been announcing, you know better preventive work on lung cancer, for instance, he’s very interested in social prescribing. But my worry is that, as you've alluded to, it's very difficult to actually do it. It's either you can announce a bit here and there, but when I gave evidence to your health commission, I was really struck by the point from the King's Fund, which was that actually you won't be taking resources away from hospitals because they're running too hot at the moment. You'd be giving more resources to preventative and community services.

    Now, I obviously have a lot of sympathy with that, having written a book on the NHS, I understood better than I did before quite how stretched it can be in terms of funding and how under-resourced it is compared to other health systems. And you know, we had a King's Fund report recently pointing that out.

    But I think even Jeremy Hunt in his most pro-NHS guise would struggle to do that in the Treasury and that's why it hasn’t happened. I'm just a bit wary that we could end up in the same position as we have with mental health, where everyone talks about the need for better resources in mental health, but if you talk to people who are actually delivering the care or who are receiving that care, they say that all that has changed is that politicians like to talk about it. It's not actually the case that now we've reached parity of esteem by any stretch of the imagination.

    Matthew Taylor

    Well, I mean, there's so much there is Isabel, I'll just pick out a couple of things. My sense is that there is a commitment, it's not universal. And I think there are important bits of the health service which aren't part of the consensus. But I think there is a broad consensus behind the principles of system working, of collaborative system working, a working better between the different bits of the health service, but also critically between the health service and local government and other agencies.

    So, I think there is a kind of commitment to that. But I think there's also a recognition that with the general election 18 months ahead, it will then in Malcolm X's famous phrase be ‘the hinge that squeaks that gets the grease’, and the hinge that squeaks is access, is A&E waiting times, elective waiting times, GP access, and that's where the focus will be.

    And I think it's kind of widely known that while Steve Barclay says good things actually about his support for systems and whilst he's to be absolutely commended for his role in getting this long-term workforce plan over the line that he is also, like other secretaries of state before him, like Alan Milburn, for example, very, very focused on managing towards those key targets that the Prime Minister wants him to deliver in time for the next election.

    So, the sense I get is that we need to work at system and place level and through organisations like the Confederation on that consensus around a different model of health and care, whilst recognising the political realities of what's likely to happen in the next 18 months.

    If I can be a bit kind of nerdy with you, which I know I can because you, like me, are a policy nerd, I wonder whether - and maybe you'll tell me I'm being naive about this - but I wonder whether there is hope… I remember when Labour was in power, local government was subject to very, very high levels of supervision. You know, the audit commission I remember, every local authority in the country, you remember, had a score that was out of 35 or something.

    And then basically what happened after 2010 was - I know this is very simplistic - but basically the deal was to local government, you're not going to have any money, but you can do what you like. You know, we're not going to measure what you do anymore. Because you've got no money you can't really do any harm. Now, actually in the last few months has been a bit more focus on trying to get to reintroduce some elements of local government regulation, not least because you've got councils like Thurrock and Woking going hopelessly bankrupt.

    But nevertheless, generally speaking, we have seen a significant shift and if the Conservatives lost power tomorrow and someone said to me, what did they accomplish? I would say, well, you know, they genuinely did accomplish quite a lot of devolution. I mean, yes, no money. But the combined authorities, the mayors, there really has been a bit of a shift. Now, with health working now more closely with local government, with integrated care partnerships, the bodies that oversee integrated care systems, often being chaired by local authorities, health leaders generally being in a minority on those integrated care partnerships, there is something quite significant happening at the system level or at the place level that genuinely is a situation in which health is having to collaborate much more richly with, particularly with, the local government.

    And I wonder whether that's where a bit of hope might lie for a future in which the centre is more strategic, more focused, more consistent, less micromanaging, less likely to interfere and lurch from one thing to another. Because in a sense, the health service has become so entwined in its work with local government that a greater level of devolution is inevitable. Is that hopelessly naive?

    Isabel Hardman

    No, I don't think it is. I think it's interesting though because I think you're being too kind to the conservatives on the ‘we're going to leave you alone, there's no money’. I think my view of their relationship to local government over the past 13 years has been that they've seen it as such an under-scrutinised area, that it's just so easy to cut the fat from it, not even the fat, to cut whatever from it, and then blame local authorities for the impossible task of allocating resources they don't have.

    I find that very frustrating as a housing journalist, and that was at the start of the past decade in Britain as conservative government. I think, the way in which spending pots were devolved but also shrunk at the same time was very cynical and, I think I said this to you when I was giving evidence to the Health Commission, if I really want to punish myself, I'd love to do a history of local government, and when has it ever fully been taken seriously in this country, because it certainly wasn't at the founding of the NHS. I mean, that was a big fight between Bevin and Morris, wasn't it? That Bevin basically said local government's not ready to take on this kind of responsibility around health.

    Now, I think there are areas of extraordinary practice, such as Greater Manchester, which is always cited and has always had a very strong municipal culture. My anxiety is that local government is probably in as bad, if not worse, state as it was postwar, because you actually have politicians, I think actively undermining it really, and you know that the bankruptcies in Woking for instance one example, but actually you go across the country there are other large areas of local government where it's just really bad quality and there isn't the local accountability either from a functioning opposition party or from the local press, which as you know, for its own reasons, really, really struggled and isn't doing full coverage of councils and other local institutions.

    So, my kind of anxiety about devolution is it's a way of masking something else rather than full trust. I'm sure lots of people involved in devo bank and so on would disagree with me on that. But certainly when I talk to local conservatives in Manchester, they are still furious with George Osborne for ever coming up with the idea of giving Andy Burnham more powers because they sort of see that as being that the point at which the Conservatives lost all hope of ever doing anything in Manchester, even though George Osborne saw it in entirely opposite terms.

    Matthew Taylor

    Isabel, I could talk to you for hours, but our time is running short. So let me just connect this point to a final question I want to ask you. Just to carry on being nerdy, one of the things that really fascinates me at the moment is that we've got now a set of institutions which kind of exist in an accountability and support vacuum. And I've never really seen this before. So integrated care partnerships, because they're truly partnership bodies and place bodies, which are mini versions of ICPs - these are the bodies that oversee kind of health and care collaboration at a place level, generally a kind of upper tier local authority or single tier or unitary local authority level. These bodies can't be held accountable by NHS England because they involve local government. They can't even really be held accountable by the DHSE.

    We, the Confed, have a police body, you know, we bring together leaders of places, but there's nowhere else for them to report into. So, I've had conversations with DLUP colleagues in the levelling up unit, they’re kind of really interested in place, but they're not clear it's really within their remit to engage with it. You know, we're having conversations of DWP about the work they're doing to try and get people back into the labour force.

    So, there's something rather peculiar, which is that we've created integrated care partnerships and we've created place bodies, but they're not really accountable to anybody and no one's responsible for… there's literally no one in government I can see who has a remit for place bodies, even though they are of growing importance in terms of the day-to-day kind of coordination, collaboration around care.

    Now that leads into a question which is - the bookmakers would say Labour's going to win the next election - do you feel that Wes Streeting, who's obviously a very thoughtful person, he will know, he will read your book I'm absolutely sure, I'm sure he'll talk to you about it, do you get the sense that he and maybe even Keir Starmer and possibly there are bits of this in the health mission, do understand some of these pathologies you're describing and would like to try and do it differently, or do you think that they will just repeat the mistakes of the past?

    And as I'm fond of pointing out now, I pointed out to both of them, actually, the last time we had a change in political party in government, 1997 and 2010, we both then saw huge-scale reorganisations. In Frank Dobson's case, abolishing things which were then just recreated years later, the internal market. And in Andrew Lindsay's case, well, we all know what kind of went wrong there, and you tell that tale very eloquently. One ends up feeling very sorry for Andrew Lansley, reading your account of it in the book.

    Isabel Hardman

    Oh dear!

    Matthew Taylor

    So, do you have hope that maybe Labour will learn the lessons and will come in with a new way of working and in particular a more intelligent way of thinking about the role of the centre?

    Isabel Hardman

    I know actually Wes Streeting went to a bookshop and bought my book, which was nice.

    Matthew Taylor

    Very flattering for you.

    Isabel Hardman

    Normally I just send them copies of the book, saying: ‘Please, can you read this?’ Hopefully he intends to read it as well as just owning it. But yeah, I mean, I think he is a very thoughtful politician. It's also really interesting who he talks to. I know that he's had a lot of advice from Alan Johnson, from Alan Milburn, from Tony Blair, you wouldn’t be surprised by any of those names.

    And I think you can see in some of the things that he's announced or tried to push Labour towards, there are some unfinished battles from Milburn and Johnson particularly, I think GPs. It was very interesting that he has done so much on GP contracts and so on. But another interesting person who I know he's talked to a lot is Sajid Javid, who obviously was one of the many Conservative health secretaries who has been doing his own work on health reform and is very keen to work cross-party on this now because he felt from his time as health secretary that there was a lot of the NHS that was wrongly untouchable and so again, I think the GP's plan that Sajid Javid had, we've seen quite a lot of that coming out of Wes Streeting's mouth as well. And so, he is somebody who is prepared to listen, not just to his political heroes in the sort of Blair era, but other figures with different perspectives.

    I do, though, think if you look at the way in which Labour at the moment is in opposition operating, so much of what they talk about and so much of the contrast with the Tories is we would do this better and you know, that's Keir Starmer's big thing really sort of because ‘You know, I've run a public service for five years’ and then talks about how things could be more effective. And I don't get any sense from that pitch that Labour is saying we're going to let go. I very much think that logically, if you follow all of the complaints they make about the government having no control over things, not caring that you would see - perhaps you disagree with this characterisation that I have, Matthew, having been much closer to it than I have - a possible return to Blair control -freakery? I mean, I thought that the fascinating contradiction from the Blair years was Alan Milburn, and then John Reid, wanted to set hospital chief executives free three foundation trusts. But also, particularly Alan Milburn spent a lot of time on the side shouting at them, which is sort of strange version of control-freakery.

    So, I don't get the sense that there is a sort of, ‘Oh, yes, we must decentralise’ here. My suspicion would be with Labour that they might argue that things are so broken that they have to get a grip on things from the centre first. I think that would be their instincts.

    The thing about West Streeting as well is that he's a brilliant campaigner. We know that because that's been his career. We don't actually know what he's like in terms of an executive role because he's never done that. Opposition MP are still campaigners really, so he's very untested in terms of the way that he would make decisions, interact with the NHS and so on. As the Blair government was, I guess in ‘97.

    Matthew Taylor

    But this brings me, Isabel, to a conclusion that I feel like you and I should, should kind of write something and nail it to the doors of the Department of Health. And that conclusion is surely this: The issue is not central control versus devolution. It's about the effectiveness of the centre. And the point is this: the way for the centre to be more effective is not to micromanage and to do more; the way for the centre to be more effective is to be more strategic, more focused, more consistent.

    It is great we've now got a long-term workforce plan. I mean, maybe that will be a kind of model. That's what we want from a centre, a centre that sorts out the really big, difficult issues like workforce, like capital investment, like how do we shift resources upstream and genuinely leaves the operational stuff, first to NHS England to arm's length and the NHS England themselves use a similar kind of notion of how you most effectively lead from the centre by devolving as much as they can to systems and trust.

    So, the tragedy here is politicians and officials who think that the best way to make a change in the health service is to micromanage it. It isn't. It's an illusion. It is micromanagement that leaves the big issues unsolved. Should we this write this up? Shall we nail it to the doors of the Department of Health?

    Isabel Hardman

    Let's have a march on the Department of Health. Let's do that and see how well that goes. I mean, look, the current culture in the Department of Health has got Steve Barclay playing with the sort of control tower of screens and the ministers sitting in the middle of civil servants so they can work together or sort of keep an eye on them in making NHS England figures co-work in the Department of Health space as well.

    So, you could say that's collaboration or you could say it's control. But I really think that the DNA of the NHS lends itself to controlling politicians and so we would have to do more to nail some articles to the door, unfortunately, before, in practice, we got that change.

    Matthew Taylor

    Well, I guess all I can say is that Confed as a whole organisation is committed to a better-balanced health service with a centre that is, as I say, more strategic-focused and consistent. So, we'll do more than they'll things to do. We will go on about it at great length, even when it makes us unpopular with our colleagues in the Department of Health or NHS England or anywhere else.

    Isabel, absolutely great to talk to you. I can recommend Fighting for Life incredibly strongly because opens up all the issues that Isabel and I've been talking about, but it's also just an incredibly good read. I read it in four train journeys, and if it wasn't for the fact that I was going to King's Cross, so the train terminated there, I'm sure that I would have ended up going somewhere else.

    As it was, I nearly failed to get off the train yesterday as I was reading the last chapter. So, Isabel thank you so much for the book and thank you so much for joining me on Health On The Line.

    Isabel Hardman

    Thank you so much.


Free to listen, every fortnight. Subscribe for new episodes.

Subscribe Arrow pointing right