The general view of Wes Streeting's two-year tenure as health secretary hovers at around six or seven out of 10, which – to be fair – is substantially higher than most of his recent predecessors.
Positives include winning more money for the service at a time when other parts of the public sector continued to be squeezed. He offered, through the Darzi Review and 10-year plan, a convincing account of why the National Health Service (NHS) had fallen to its lowest-ever public approval ratings and what needed to change, and made small but important improvements in performance on waiting lists and most aspects of urgent care.
The least positive aspect, given the political capital this adept communicator built up in his early months, was the limited progress on deeper reform. While there was welcome action on some health harms (tobacco and sugar) the much-vaunted whole-Government health mission was quickly and quietly shelved and, as one commentator has put it, Streeting promised reform but delivered restructuring.
Indeed, I suspect new secretary James Murray will have been less than delighted to learn that most of his time and energy will now be taken up stewarding the NHS Modernisation Bill through Parliament, a process which is likely to see controversial moments, particularly around public and patient accountability.
There is broad support for the 10-year plan's three shifts – treatment to prevention, hospital to community, analogue to digital – but national policy lacks clarity and local progress is limited. There are many tensions but the most acute (excuse the pun) is that trusts are incentivised to focus on organisational performance when reform requires them to lean into collaboration with NHS partners, including local government.
The reform the NHS needs, both to improve care and to become financially sustainable, requires a step change in local collaboration and ambition. My conclusions from observing and advising several systems and places suggests some minimum requirements for change.
Which is why one of Streeting's most significant acts might come to be seen as his commitment, in one of his last major speeches, to let Greater Manchester and South Yorkshire drive their own model of integration and prevention. The question is whether this commitment will last and make a difference.
On the one hand, so far there are few signs that NHS England is leaning into greater NHS devolution. Letting go and giving a bigger role to local politicians both go against the deep culture of the organisation. The Department of Health and Social Care (DHSC) has tended to be more respectful to local government but it may not be easy telling a new health secretary that their predecessor has offered to give up control of some of the levers on which he has only just got his hands.
On the other hand, there is Andy Burnham. The Manchester mayor has reasserted his commitment to further devolution. If Burnham ends up Prime Minister, it may not just be the mayors of Manchester and South Yorkshire who are called on to drive health reform.
The reform the NHS needs, both to improve care and to become financially sustainable, requires a step change in local collaboration and ambition. My conclusions from observing and advising several systems and places suggests some minimum requirements for change.
First, a mobilising mission to act as a north star for diverse organisations. At the heart of this should be improving patient experience and outcomes, for that is why we all come to work. Second, collaboration rests on a clear, stable and robust leadership architecture: who is in charge, who is accountable, how authority is devolved and how the different parts of complex change processes are aligned. Third is the need for sufficient change infrastructure. Key elements include evidence, data and fast evaluation, financial modelling, and organisational development capability including the capacity to spot quickly when things go off track, intervene and adapt without losing trust or momentum.
Whether it is the grind of legislation or the ongoing challenges of NHS industrial relations, James Murray's inbox is not hugely appealing. As he takes over the troubled merger of NHSE and DHSC, he might receive some inspiration from asking his officials one critical question: ‘How can I and my new department better empower local change?' Having the answer to that could go down well in future meetings with the Prime Minister.
Matthew Taylor is former chief executive of the NHS Alliance
