There is no guidebook for new Secretaries of State for Health, and their approaches have often differed markedly. Some have decided to be radical, while others have had to spend time restoring relationships and bringing a period of calm. Sometimes there have been significant policy shifts, even within the same government – such as when Hunt followed the chaos created by Lansley, or the more market-sceptic Reid followed Milburn.
The extent to which Matt Hancock has discretion to choose how he will approach the role is limited. Whether or not it will be quite enough, most of the job of squeezing out more funding for the NHS has been done. A very difficult 2018/19 remains, with major deficits in providers, winter approaching and most targets going in the wrong direction.
There will be an opportunity to shape the 10-year plan for the NHS, but the power to set this has moved to Simon Stevens at NHS England, which has occupied much of the territory of the Department of Health. Even if Mr Hancock wanted to assert control over the process, the evisceration of much of the Department’s policy machinery, partly evidenced by its massively increased spending on consultancy, would prevent it.
What not to do
More to the point there is little room for big new policy ideas. There are strong arguments for not moving away from the current focus on cancer, learning disabilities, mental health and the development of integrated care to tackle the growing burden of non-communicable disease. The recent intent to focus on child and adolescent mental health is very overdue and unarguable. All of these make sense and none have been in place long enough to justify a switch.
There is recognition that the national structure of the NHS is a mess, with confused accountability, and the Prime Minister has indicated there could be legislation to sort some of this out. It would still be a challenge for a new Secretary of State to take this on, even in a much less fractious political environment. Given that, since 1974, the NHS has had a long-running habit of constructing large reorganisations that distract from delivery for up to two years, and which are then declared unfit not long after, he might want to ask some tough questions about this.
Areas where he can make a difference
There are, however, a number of other areas where he can and should act. He has already made comments about needing to value NHS staff, and hopefully he will be able to rebuild some of the bridges that were damaged during the junior doctor dispute. There is an urgent need to deal with serious shortages in hospital and community staffing, as well as burn out and shortages in general practice. Developing an appropriate response to these problems – and the need for a high-quality strategy – is overdue, but we are not seeing enough clear signs of progress. Some of this is in the direct control of one of the Department’s arm’s-length bodies – Health Education England – and this is an area where firm action by the Secretary of State could make a difference.
The most important task Mr Hancock must take up is the painfully overdue need to give England an acceptable system of social care. There are financial and legislative constraints and a need for political bravery to create a long-term solution. Mr Hancock has written about an insurance-based option and the need to press forward with solutions. Whether there is the willingness to deal with this problem, or duck it as has been the case for the last 20 years, remains to be seen.
Mr Hancock has a keen interest in digital technology and this is an area where he could make his mark. The current vogue is for artificial intelligence and patient apps, but he might be better advised to pursue the less eye-catching but more important area of getting the current systems within the NHS to work better together, and dealing with the hurdles that still exist to support the sharing and secondary use of data. Without this basic infrastructure, the more exciting developments will fail.
Rethink how the NHS is managed?
Finally, Mr Hancock might use the change of regime to rethink the way the NHS is managed more generally. The regime of targets and upward reporting mixed with intrusive regulation was the method of choice under Mr Hunt, and seems to have long ago reached the point where the costs outweigh the benefits. Again there seems to be some willingness to look at this.
All of this assumes that he is in place long enough to find his feet and negotiate a difficult role, or that the political turmoil and potential impact of a no-deal Brexit – including the withdrawal of the Prime Minister’s £20 billion funding pledge – doesn’t torpedo what small scope he may have to make a difference.
*This article first appeared in the BMJ on 23 July and is reproduced here with permission. The original version can be found at www.bmj.com/content/362/bmj.k3166
Edwards N (2018) "Matt Hancock must use his time in office wisely", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/matt-hancock-must-use-his-time-in-office-wisely