Cameron wants to reform the NHS. But it was his government that handed over the levers

The labyrinthine management structures of the NHS and BBC stymie change

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The ideas that shape both the NHS and the BBC are timeless and compelling.

Patients have no need to worry about money when they fall ill. Viewers and listeners enjoy uninterrupted output every day of the year with no adverts. The funding is raised and distributed centrally. The services are delivered free at the point of use.

Some on the right argue with a patronising disdain that the British are sentimental about the NHS and the BBC. It is only an irrational attachment that explains the enduring support for these two publicly funded bodies. This is nonsense. The default position of British voters, to a dangerous extent, is cynicism about all aspects of public life. If they approve of the NHS and the BBC it is because they recognise the virtues of systems where the level of funding is addressed centrally in order to provide national services that bind a country and to some extent define it.

Nonetheless parts of the NHS and the BBC are less than compelling in practice, and for the same reason in both cases, a lack of control or clear lines of accountability are in evidence. The recent Public Accounts Committee hearing with senior BBC figures was one of the great emblematic encounters of our times. The brilliantly persistent chair, Margaret Hodge, asked repeatedly in relation to the scandalous pay-offs of senior BBC managers “Who was culpable?” She got no clear answer.

This is partly because there is no clear answer. The Chair of the BBC Trust, Chris Patten, was right to point out that control of such matters was not within his remit. Patten is proving to be the Gorbachev of the BBC. He has made mistakes but instead of choosing the easy life he has posed some tough questions of the BBC management.

Yet he lacks the power to follow through. Nowhere are there any clear lines of control. Ministers cannot interfere when they see public money being wasted on excessive pay-offs to managers heading off for other jobs, although they will do so by imposing a punitive license fee settlement next time. Patten cannot micro-manage the management because the BBC Trust has no remit to do so. The management micro-manages the management, or does so until things go wrong and then no one is culpable, as Hodge discovered.

The NHS is different to the BBC in the sense that ministers can intervene and often have done. But in a highly significant twist, David Cameron and the Health Secretary, Jeremy Hunt, seek to pull levers when they discover more about the poor performance of some hospitals – only to discover they no longer have the powers to do so. They have given the powers away. Indeed, following Andrew Lansley’s original reforms they have created a structure in the NHS quite similar to the one that malfunctions at the BBC. Much of the power lies in the hands of the new giant quango NHS England. In No 10 they have noted the irony. Suddenly they want to do much to raise standards and cannot do so because of their own legislation.

The consequence for the NHS is an even greater degree of incoherence than is usual in terms of accountability and control. Rightly it is Cameron and Hunt who have sought to take the lead in response to the various revelations of poor management and delivery in hospitals. They want to get a grip. Cameron chose to deliver the Commons statement in response to the various scandals in Mid Staffordshire. Hunt has spoken at length this week about poor performance exposed in some other parts of the country.

Together they have proposed a series of measures – the need for greater transparency, protection for whistleblowers, zero tolerance of poor nursing, the removal of bad managers. More specifically, Hunt has called in emergency task forces to sort out the underperforming hospitals. He plans – separately – Ofsted-style inspections of GPs, who have suddenly acquired substantial powers themselves.

In terms of policy their responses have been measured and justified. Their problem, as they are discovering, is that earlier in this parliament they advocated a series of reforms from the bottom that contradict what they are trying to do now. Who is in charge? Cameron and Hunt? NHS England? The GPs who are viewed with a degree of wariness and are soon to be inspected?

The answer is that in the end Cameron and Hunt are accountable as elected figures who raise the money for the NHS from taxpayers. While that dynamic remains in place they will have no choice but to accept responsibility, yet at times they will declare, as Patten did truthfully, that they have no powers to sort it out.

Tony Blair distorted the complex debate on the NHS by posing a banality. Blair argued that the choice was between “reform and anti-reform”, as if the only set of reforms was his partly innovative and partly incoherent attempts to encourage greater local freedoms for hospitals. The Coalition made an even bigger leap with the Lansley reforms, at first removing even the principle that the elected government had any responsibility for the NHS.

Now Cameron and Hunt propose a series of standards-raising measures that are worthy of support and come from the centre. This is unavoidable, but becomes incredibly messy when ministers hand over the levers as they seek to pull them. It becomes messier still at a time when spending in real terms is being cut in the NHS.

Better resources do lead to improvements. Some argue that virtually all spending on the NHS is a waste, but finding the money to meet the growing demand is vital. This debate is not even taking place at the moment. It is all about structures, at a time when the layers of responsibility are unclear.

In relation to any organisation, the following question is pivotal: “Who is responsible for what?” If the answer begins, “Well, it’s all a bit complicated...”, that organisation is in trouble. We need the NHS and the BBC more than ever in this fractured country, but they are organisations in trouble. The answer in both cases is not more devolution of power but the need for strong leadership at the top and a clearer sense of who the leaders are.

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