Addressing the mess

By Matthew Taylor | 03 October 2023

To have any chance of addressing the deepening problems of our country we need radical reform to our systems of governance. This has long been apparent to local government leaders, but it is equally true for the National Health Service.

Lying recently on the beach provided an opportunity to catch up on things I have been meaning to read. One is an article by my former Downing Street colleague Geoff Mulgan [‘Can democracies afford incompetent politicians….’ at]. In it he bemoans the limited skills and relevant experience of politicians on taking up office. He points to how other jurisdictions – from Australia to some American mayors – have sought better to prepare political hopefuls and encourages the British political class to overcome its outdated amateurism.

Mulgan is not alone. Many commentators agree key aspects of our system are broken. Also, given the country’s economic plight and the limited scope for extra spending, this is an area where radical improvement could be pursued without a massive bill attached.

Beyond training and support for ministers and developing the strategic and operational capacity of the civil service, a shortlist of changes could include electoral and House of Lords reform, making greater use of participative democracy and forms of digital engagement. Wider institutional reform might include outcome-based forms of regulation, the development of alternative models of organisational control, particularly forms of mutualism and community ownership, and the mainstreaming of funding models oriented to longer-term solutions, like impact investment.

Imagine the impact on our jaded public of a Government pursuing substantial change in all these areas with the intention not only of catching other countries but surpassing them?

But what has all this to do with health? Health policy, implementation and regulation in England suffers from an administrative double-whammy. On the one hand, as is often recognised, the NHS is highly centralised and overly politicised. An obvious result is chronic short-termism and a tilting of priorities to newsworthy sectors, problems and targets. Equally corrosively, it also fosters a brittle culture in which intimidated leaders feel obliged to spend time looking up to national bosses and not enough looking out (challenge and support from other leaders) and down (engaging with patients, carers, communities and local partners).

There is a second problem; while the geography of English governance is centralised, decision making within Whitehall is more fragmented than in other countries. The power of departments and the Treasury and the strategic weakness of the Prime Minister’s office helps to explain the lack of joining up in policy. This has malign consequences in areas ranging from spending on prevention to capital investment.

It also helps to explain the repeated failure of attempts to develop health strategies that reach beyond the Department of Health and Social Care and encompass the social determinants of health and well-being. This problem is connected to the first. When central government is responsible for so much the energies of the PM’s office have to be spread too thin, seeking to manage every problem rather than focusing on strategic cross-Governmental priorities.

By working with the Local Government Association to support Integrated Care Partnerships and place bodies (often led by local government) and by reaching out across Whitehall to make connections between health leaders and departments ranging from the Department for Levelling Up, Housing and Communities and the Department for Work and Pensions to Education and the Cabinet Office, the NHS Confederation is trying to model a different model of governance; more geographically devolved but more joined up nationally and locally.

Labour’s commitment to democratic reform and to a small number of cross Governmental missions – including health – is promising. The party has also pledged greater decentralisation. However, as Geoff Mulgan and I can testify, it is one thing to make such commitments in opposition, another entirely to act on them in Government. The combination of the temptations (and illusions) of ministerial power, the pressure of events and the media and civil service resistance are all likely to reinforce the status quo.

Political strategists argue not only does governance policy fail to win votes it can suggest to the electorate politicians are focused on matters irrelevant to voters’ day to day lives. But the deep inadequacies of our institutions, processes and governing norms are a huge part of the mess we are in. Addressing them is essential to national renewal.

Matthew Taylor is a public policy expert, former adviser to Tony Blair while Prime Minister and currently chief executive of the NHS Confederation

X – @ConfedMatthew

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