Reflections from the inside: how to improve decision-making on health and care

Please note that views expressed in guest articles on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.

When I first went into government, I saw greater political control over the NHS as an answer to some of its problems. Two years later I have changed my mind. Not that political accountability isn’t important; it clearly is. But as the NHS has expanded, both in terms of the things it does and the people it employs, attempts to over-centralise and then “grip” (an awful phrase, beloved of Whitehall officials) are becoming impossible. Or at least, in our efforts to do so we risk entering a death spiral where the system becomes less functional, with clinicians and managers on the front line less empowered and trusted to deliver.

This feels important in the context of the arrival of a new government and a Secretary of State who has said that he thinks the NHS is “broken” and who will be under great pressure to fix it.

The investigation he commissioned Lord Darzi to conduct will be published shortly, but it will be at the Spending Review next spring when the central questions on funding and reform will crystalise. In the shorter term, I think we can achieve marginal improvement in how the NHS is run if we are prepared to change how we approach making decisions.

To understand why my views evolved, it’s probably worth explaining how decisions in DHSC (and wider government) are currently made.

The red box of submissions

Every working day (and most weekends), the Secretary of State receives a red box of submissions – commonly two pages with annexes. A typical 'box' might contain between 10 and 30 submissions. Each requires a decision, ranging from the routine (Do you approve the salary of [Trust Chief Executive]?) to the politically sensitive (A set of options for seeking to resolve industrial action). Submissions are developed by teams in the Department, typically with input from arm’s-length bodies such as NHS England, going through private office and special advisers for comments before reaching the Secretary of State. Significant decisions require cross-government agreement, achieved through ‘the centre’ (HM Treasury and Number 10) or cabinet committee write-rounds.

The workflow is immense. During my time as a SpAd, I learned to make a judgement call between scrutinising something closely versus trusting in the recommendation of officials. Choosing to interrogate every submission, equally, all the time was not possible – there were not enough hours in the day. 

Even with this strategy in place, bottlenecks were common. While most of the time the consequences were limited, in others you could see how a slow decision would impact on execution. This was almost never the fault of the two secretaries of states I worked for; instead, it was the cumulative impact of too many different (and often conflicting) layers of approval and process across NHS England, the Department, HM Treasury and No10 before the final decision was arrived at. Individually bright, conscientious policy professionals would add their layer of scrutiny – playing their part in the process – but pulling operational teams into another round of meetings, negotiation and eventual resolution before the circus moved onto the next issue.

The obsession with process was brought home to me when I accompanied the Secretary of State on a visit to a new 150-bed mental health inpatient unit in Greater Manchester. We had finished the tour and were about to leave the site when I saw the government-approved procurement process map tacked to the office wall (see the image below). The mapping of the 80+ stages involved in construction of the new site showed that the team was organised and meticulous. That was not the surprise; walking through the site we were blown away by the quality of the construction. The real surprise was seeing in black and white (or blue and magenta) just how many hoops we ask people to jump through to get anything built in the NHS – with most to be completed before a single digger went into the ground.

The P22 Process Journey Map (taken by author)

The need to declutter

I am not arguing that we need to get rid of procurement frameworks, or Treasury business cases. These things exist for a reason. I’m sure a procurement expert would tell me that inadequate consultation, or rushed business case development, is worse in the long run. But from my vantage point, I also saw too many instances of where policies were decided, money was announced, and yet 12 months on we were still going through business case approval. The pendulum seems to have swung too far one way. I am now convinced that we need to find a way of decluttering our system if we want to get on and achieve stuff for the patients we serve.

How do we go about doing that? There are obvious wrinkles in the relationship between NHS England and the Department which add to the collective workload and would benefit from being ironed out. We kicked this work off when I was in the Department, bringing in co-location of teams to deepen relationships, and joining finance and communications functions closer together. In the final months, we asked for all ministerial submissions to come jointly from DHSC and NHSE – a practice the new government has now formalised.

This was always designed to help streamline decision-making. Yet in a siloed system, many saw unification as a threat. We need to find a way of overcoming our protectionist tendencies. The new government must get the tone right too, including in how it establishes and runs the dedicated mission on the NHS. My experience taught me that initiatives to improve cross-government working are badly needed. But there is a risk that in the desire to signal that health is a priority for No10, mission-led government becomes another layer of sign-off and challenge in the system, when the value added will be in sorting out things which the Department cannot.

Ultimately though, decluttering decision-making will come down to relationships and trust. When I was pressed for time and had a stack of submissions to get through, I would ask myself if I trusted whether the official named on the advice had adequately surfaced the risks. But individual relationships are always tricky to legislate for, and it is no secret that during the last parliament there were periods of strained relations between the NHS, the civil service and political leadership. The fault lay on all sides. Some inaccurate information or advice might be given to ministers (often in genuine error), which then eroded political faith in the system and fed a desire to grip things more tightly. When things did go wrong, I was surprised by the lack of serious consequences, with officials often quietly shuffled sideways. In a building where thousands work, risk and accountability felt stacked onto a small number of elected ministers.

Amid the difficulties, there were also successes. On some areas – including medicines policy – teams in NHSE and the Department collaborated effectively. We also found ways to speed things up. One enterprising minister discovered that by inviting himself to the official-led DHSC investment committee, he reduced the approval time for capital projects by six weeks in a single stroke. The system will need to embrace such challenge if we want to take this kind of anecdote and make it a theory of change that can be applied more universally.

If we can rebuild trust and agree to hold more risk in other parts of the system, it will open new possibilities. Local managers may feel more able to take calculated risks. Decisions will be made more quickly.

All sounds great, right. So how do we get there? I think we need to find a way of evolving the foundation trust model of autonomy for the era of integrated care. I am not naïve to think it will be easy to pull off. Most ICBs are in deficit and, being blunt, too many currently lack the confidence of the centre. Provider collaboratives are exciting but their place in the landscape never felt clear, with a risk the model sucks the marginal resource to acutes. Autonomy will need to be a gradual, earned process. And yes, it will take investment. The Hewitt Review, while not perfect, did kickstart this thinking. Things inevitably will go wrong as experimentation fails. But one thing I learned in government is that no policy decision is consequence free.

Another, parochial side effect of this model will be freeing up ministers (and their advisers) to have space to think. This might sound trite; surely leaders should already have the ability to create their own space for long-term thinking? Well, that mantra rarely survives contact with reality.

The need to think long term

Thinking time is valuable because of the unique role that our politicians play. If we are to solve the totemic challenges in health and social care (around funding, prevention, an ageing society and multimorbidity), we will need committed politicians to take the long-term view. My two years in government have taught me that you can’t subcontract these decisions to an apolitical committee. As the issue gets bigger, the politics becomes more important, not less. Take the long term workforce plan, or the decision to bring forward legislation to create a smokefree generation. Both carried limited short-term benefit and had tricky handling in parliament and the media. The reason we got them off the ground was because individual politicians gave their backing from the start.

So in summary, I think there are five organising principles that can help drive better decision-making in health and care in the 2020s. These aren’t revelatory and, in many ways, apply irrespective of whether we are working at a national, regional or local area. We need to:

• Accept that centralisation has limitations.
• Be determined to rebuild trust.
• Allow risk and accountability to be held in more parts of the system.
• Focus less on process and more on timely outcomes.
• And, finally, we must protect political space to think.

Robert Ede was a Special Adviser to the Secretary of State for Health and Social Care from November 2022 until July 2024. He has written this blog in a personal capacity.

Please note that views expressed in guest articles on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.