The Government is paying the political price for the lack of open policymaking in its reforms to the NHSPosted: October 31, 2012
The NHS is facing significant financial pressure as a result of austerity with smaller increases in spending, which are not keeping pace with demand. This has meant that the NHS has to find £20 billion in efficiency savings by 2015. At the same time the health service is facing one of its biggest upheavals ever, which will result in a greater involvement of private companies in the health services. The reforms to the NHS have been introduced in the face of stiff opposition and in many ways represent the opposite to open policymaking – and the Government is now paying the political price.
The opposition to the Health and Social Care Bill was substantial and included the majority of the main health bodies, many of whom were not invited to attend the infamous Downing Street health summit to discuss the bill earlier in the year. Notable non-attendees included:
- British Medical Association
- Royal College of GPs
- Royal College of Midwives
- Royal College of Nursing
- Chartered Society of Physiotherapists
- Royal College of Pathologists
- Royal College of Radiologists
- Royal College of Psychiatrists
Opposition to the bill was widespread in the workforce of the health service. One survey found overwhelming opposition from hospital doctors, with 9 out of 10 professionals opposed to the bill. Strong opposition to the reforms was also apparent amongst the grassroots of the coalition parties. ConservativeHome came out in opposition to the reforms, arguing that it could cost the Conservatives the next election and would distract from important reforms to welfare and education, whilst Liberal Democrat party members opposed the reforms by 2 to 1.
Much of the opposition about the reforms has centred on how complex and fragmented the new health system will be. Clare Gerada, Chair of the Royal College of GPs, has argued that the move to a market-driven health care system will result in a culture of ‘my disease is more important than your disease’, with GPs at the centre of this trying to balance these competing voices. She has flagged her concerns about the lack of experience of GPs in managing relationships with the charities and lobbyists they will face when commissioning in future.
Andy Burnham, the Shadow Health Secretary, agrees on the point of fragmentation of health care, arguing that “my answer is simple: markets deliver fragmentation; the future demands integration.” He has called for a single system for health and social care which addresses the physical, mental and social needs of the nation. He has argued that central government should decide what health services should be delivered and local government how.
Despite the overwhelming opposition, ministers have been happy to write off the protests as ‘business as usual’ when it comes to NHS reform. Simon Burns, the then Health Minister, stated that the opposition from these ‘vested interests’ was to be expected and scare stories about ‘creeping privatization’ are par for the course. Andrew Lansley, the former Health Secretary and architect of the reforms, argued that the Royal College of Nursing only opposed the reforms because of pension changes, accusing them of being ‘a vested interest indulging in trade union -like behaviour’. The appointment of Jeremy Hunt as the new Health Secretary does not inspire hope about a change of policy course, given that he is seen as a proponent of greater involvement of the private sector in a market-driven health service.
The reforms have now received Royal Assent and the Government seems committed to accelerating the involvement of the private sector in the NHS. Research by the Labour Party using freedom of information requests to NHS primary care trusts found that contracts for almost 400 NHS services worth a quarter of billion pounds were signed in early October, representing the biggest act of privatization ever seen in the NHS. The research found that in a quarter of cases, the primary care trust had not been open about its intention to outsource, resulting in a considerable amount of privatisation by stealth.
The biggest privatisations so far have been in community services – those healthcare services offered outside of hospitals including musculoskeletal services for back pain, adult hearing services in the community, wheelchair services for children and primary care psychological therapies for adults. Children’s health care in Devon is now delivered by Virgin Care, as are GP services in Northampton and sexual health services in Teeside. This week’s Channel 4 Dispatches programme entitled ‘Getting Rich on the NHS’ uncovered poor quality services delivered by Virgin Care and concerns from local residents that their local services have been privatised often with little or no involvement from the community in this decision.
Paul Corrigan, the former Labour health adviser, argued in September that outsourcing of services should go further. He proposed that the private sector should be allowed a greater role in the NHS to ‘save’ failing hospitals. This argument is ironic given that this week it became apparent that the flagship outsourcing of Hinchingbrooke Hospital in Cambridgeshire to the Circle Partnership is not delivering on the initial expectations. The hospital, in private hands, has racked up losses of £4.1 million in the first six months of the contract – £2 million more than was expected. Given that the private sector was involved to save the hospital from financial ruin, the experience so far does not bode well.
This closed approach to policymaking and reform is having a real and significant political impact on the Government. A recent survey by IpsosMORI on which party has the best policies on healthcare found that the Conservative’s ratings are at pre-Cameron levels. Only 16% of voters believe that the Conservatives have the best policies on healthcare and they seem to have lost the battle in convincing the public that the NHS is safe in Tory hands. A further recent poll by IpsosMORI points to a re-toxification of the Conservative brand, with a sharp increase in people who don’t like the Tories since they came into government, which the reforms to the NHS are clearly a part of. The Government is paying the political price for the lack of open policymaking in its reforms to the NHS.
Education Secretary Michael Gove has unveiled “rigorous selection” tests for trainee teachers in a move he claims will improve the status of the profession and raise standards in the classroom. It’s a pity his own approach to policymaking doesn’t live up to the same standards he’s asking of teachers.
Announcing the policy, Michael Gove said: “The evidence from around the world is clear – rigorous selection of trainee teachers is key to raising the quality and standing of the teaching profession.” Despite an apparent inconsistency with previous announcements – in July Gove declared that, like their private counterparts and free schools, academies in England could employ people who are not working towards qualified teacher status (QTS) – at least this policy was based on evidence and developed by a review group of headteachers and education experts. For many of his other reforms, Michael Gove seems to make policy in secret, ignore what teachers and other experts think, and go against the best available evidence.
- Provoking two members of the expert panel recruited to redraft the English primary curriculum to resign; one of them, Andrew Pollard, criticized Gove’s plans for undermining teachers’ professional judgment;
- Repeatedly overruling another expert panel established to advise on selling off school playing fields;
- According to the Deputy Prime Minister, not even telling Number 10 of his plans to scrap GCSEs in favour of the so-called English baccalaureate (EBacc), which less than one in four teachers support, which has been developed without any meaningful input from teachers, parents or young people, and which is unlikely to be properly piloted before being introduced;
- Ignoring that, alongside its academic rigour, the main characteristic of the International Baccalaureate is its inclusion of practical and vocational elements – much like the GCSE dismissed by Gove as ‘dumbed down’;
- Dismissing concerns that a stronger emphasis on exams as opposed to coursework could exclude young people with learning difficulties such as dyslexia;
- Extending academies despite government data showing that local authority schools with a similar pupil intake perform better, without any evaluation of the possible impact on the already highly segregated education system, further divorcing schools from local democratic control and effectively centralising a major tranche of government spending with minimum parliamentary accountability;
- Scrapping the Building Schools of the Future programme because there is ‘no evidence’ that it helps to improve attainment – even though his department knows there is;
- Accepting the lack of transparency of academies and free schools, and awarding half a million pounds of public money to the Free Schools Network (which is not subject to freedom of information requests) to promote his £600 million untested flagship project;
- Abolishing the Educational Maintenance Allowance despite independent evaluations finding that it significantly increased staying-on rates and attainment for young people in education;
- Using secret emails to bypass even his own departmental officials (using the alias ‘Mrs Blurt’);
- Turning a blind eye to his department’s generally poor record on freedom of information and lack of transparency on who actually runs schools and what their status is.
Michael Gove’s colleagues have committed the Government to open policy making as well as open government. The Civil Service Reform White Paper published in June 2012 contained a commitment announced that: “Open policy making will become the default. Whitehall does not have a monopoly on policy making expertise. We will establish a clear model of open policy making.” Our project with The Democratic Society is currently examining how open policy making can be made a reality.
The Government has also promoted the evidence agenda, and is considering the case for new institutions that would perform an advisory role similar to the role that NICE plays for the NHS and the Early Intervention Foundation does for early years, to help ensure commissioners in central or local government do not waste time and money on programmes that are unlikely to be effective.
No-one seems to have told Michael Gove about either of these initiatives. No wonder teachers are starting to make their own education policy.
Is consultation broken – or is it our political system? Consultation seems to have become the lightening rod for general discontents about politics and policymaking. Let’s improve consultation – but let’s also rethink how we do policy and politics at the same time.
In the Open Policy project with the Democratic Society in association with the Cabinet Office, we’re exploring what ‘open policymaking’ means in practice, and how we make it effective and democratic. But we’re starting the project in consultation – what works, what doesn’t, and how it can be improved.
A widely held view of consultation is that it is a sop – an exercise that governments are legally required to undertake but which rarely changes policies that have already been decided. This might be both broadly true and largely unfair. Consultation is only one mechanism, one particular stage in the policy process; it was never intended as the sole mechanism for engaging ‘the public’, let alone to ensure that policies have a democratic mandate that other parts of the political process have failed to invest in them.
In our previous post for this project we suggested how open policy represents a challenge to consultation. For us, taken to its logical conclusion (to its greatest openness), ‘open policy’ means we need to develop a radically different approach to policy and research. In terms of social policy, this means developing approaches that enable public service practitioners and services users to conduct and engage in research and policy analysis directly. These groups are at the frontline of public services and social issues, and as a result they have practical expertise and experience that could be used to improve social policy, especially to make policy more credible and pragmatic.
Where does this leave today’s approach to consultation? Consultations are often about what government intends to do. It hardly makes sense to complain when government does what it said it intended to (indeed, we commonly criticize government for the opposite). In the case of particularly contentious policies or those that haven’t been sufficiently publicly debated, consultation will never be able to resolve the perceived lack of a public mandate.
As a thought experiment, just imagine a consultation process that was much more ‘open’ – one whereby policy did change dramatically compared to what was originally proposed. The problem immediately becomes apparent: government could in theory find itself in an endless ‘consultation loop’, with each new stage of consultation radically changing the policy in question, to the extent that a new round of consultation would be required to accompany it. Government would never get anything done, and quite rightly this would generate accusations of endless ‘dithering’ and ‘u-turns’ – of being in office but not in power.
In recognition of the devalued nature of consultations and possibly the ‘one-size-fits-all’ manner in which too many consultations are approached, the Government has announced it is moving to a more “proportionate and targeted approach” (this announcement produced what is perhaps the least thrilling headline ever on the BBC News website). The new guidelines recognise the need to “avoid creating unrealistic expectations” by making it clear where policy has been finalised and will not be subject to change as a result of the consultation. This makes sense – much of the criticism directed at consultations stems from unrealistic or inaccurate expectations among respondents. The guidance recommends instead that the objectives of any consultation should be clear, and depend to a great extent on the type of issue and the stage in the policy-making process.
However, the new guidance also risks replicating the current confusion about consultation by advising that: “Engagement should begin early in policy development when the policy is still under consideration and views can genuinely be taken into account.” From a democratic point of view this is unarguable – but the problem is that consultation can’t hope to meet these aspirations. ‘Public consultations’ in most cases aren’t – they don’t reach the public or garner many responses from them. They also aren’t really a form of deliberation; they’re not about policy formulation, rather they are more commonly about policy adjustment. Why be cynical about what should be obvious? Government sometimes makes the mistake of trying to appear as if it is engaged in open policy formulation when it isn’t, but we don’t have to collude in this and then blame government when this turns out not to be the case.
We need new forms of participation for early policy development, and for research, evidence-gathering and analysis. This isn’t and can never be the job of consultation. Unless we create a much clearer distinction between consulting on policies that government intends to enact, and developing new policy agendas where government isn’t sure what should be done, we will see much more of what we call ‘guerilla policy’ – grassroots policy research and development that people and organisations do for themselves without being given ‘permission’ by the policy establishment. There have always been campaigns and protests of course; what’s different now is that people can mobilise, coordinate and share information so much more quickly – including to overturn official policy (or at least severely undermine its credibility). We happen to think that we need more guerilla policy – but we recognise that government might not.
What’s important about this project is that it encompasses how we can improve consultations today, but also how we can develop radical new forms of engagement in policy tomorrow. The extent of the crisis in democratic legitimacy suggests we need to do both. Sorting out which is which will be crucial to our work. So in the spirit of the exercise, let us know your view – are there aspects of consultation we should retain, or does ‘open policy’ require us to start again with a blank sheet of paper? Comment on this site or on the Open Policy forum for open policymaking and better consultation.
We don’t need secret recordings – the policy establishment’s disdain for public service workers is hidden in plain sightPosted: September 24, 2012
“Best you learn your f***ing place. You don’t run this f***ing government. You’re f***ing plebs. I’ll have your f***ing job for this.” So ranted the Government’s Chief Whip Andrew Mitchell to members of SO6, the Diplomatic Protection Group guarding Downing Street, according to the Sun newspaper. Unlike Mitt Romney’s recent remarks we don’t have the secretly-recorded video footage, but whether Mitchell said these exact words doesn’t matter. The policy establishment’s disdain for public service workers is there for all to see – just look at their policies and how they develop them.
Andrew Mitchell claims he actually said: “You guys are supposed to f***ing help us.” Whatever his actual words, Mitchell’s tirade was especially tasteless given that the group of officers he swore at included a female officer, just over 24 hours after the murders of PCs Fiona Bone and Nicola Hughes in Manchester. It’s also pretty special to verbally abuse the people who spend their working lives protecting you. Paul McKeever, chairman of the Police Federation, said it was “hard to fathom how someone who holds the police in such contempt could be allowed to hold a public office.” Unfortunately, it’s not that hard to fathom at all – indeed such attitudes appear to be the driving force behind much public service reform over the past 30 years or so.
Much commentary has focused on the class dimensions of ‘Gate-gate’ (and whether or not Mitchell uttered the apparently politically lethal word ‘plebs’). As the Sun Says: “It is something a smug, fabulously-rich snob might say to belittle his badly-behaved butler. And as such it reinforces the view that millions of ordinary hard- working voters already have …That Britain is run by an upper-class clique — happily slapping VAT on pasties and freezing pensioners’ allowances while handing tax cuts to the super-rich.” Benedict Brogan in the Telegraph wasn’t alone in noting the potential toxicity of the incident to the Tories, but also that such behaviours aren’t unique to one party: “Labour is declaring itself appalled, though frankly that’s a bit rich from the party whose previous leader failed to shake the copper’s hand outside No10 and called an old lady a ‘bigot’.” Such incidents are cock-ups; they also indicate an underlying elitism and detachment prevalent in the political establishment.
Unlike Mitt Romney’s “47 per cent” remarks, we don’t have video footage (yet) of what Mitchell said. But like Romney, what the police offers claim Mitchell said to them represents an essentially dismissive attitude to working people – a worldview described by Paul Krugman in the New York Times this week with reference to the Romney video: “…the modern Republican Party just doesn’t have much respect for people who work for other people, no matter how faithfully and well they do their jobs. All the party’s affection is reserved for “job creators,” aka employers and investors. Leading figures in the party find it hard even to pretend to have any regard for ordinary working families.”
Much the same attitude seems to be prevalent in the policy establishment here regarding public service workers – that they are somehow ‘failures’ for not having had the entrepreneurial zeal to have established their own internet marketing companies (or something equally socially productive), having decided instead to fritter away their time serving others – educating children, treating patients, cleaning streets and so on.
In the case of Mitchell’s outburst, we don’t need to see the video footage from Downing Street’s security cameras, since the policy establishment’s view of public service workers is hidden in plain sight. If the policy establishment had a greater genuine regard for the people who provide public services, they might deign to engage them in working out how public services can be improved, and especially in how policy is developed such that it supports this improvement. Instead, public service workers are more typically regarded as the ‘problem’ to be resolved (and as interests to be battled) – part of the obstructive ‘state monopolies’ that need to be broken up, rather than sources of expertise and insight that should be recognised and respected. This explains why all the main political parties would like to ‘liberate’ public sector workers so that they run their own providing organisations as part of a competitive market in public services – at least then they might join the vaunted ranks of the ‘wealth creators’, albeit at a lowly rank.
The issue then is not so much social class as the types of social occupation now common in the political establishment. It’s probably not a coincidence that both Mitt Romney and Andrew Mitchell have backgrounds in management consultancy – Romney in Boston Consulting before moving to Bain, and Mitchell as a Senior Strategy Advisor for Accenture. In this respect, both are typical of a political establishment that comprises people who have never worked in public services but nonetheless feel they know how services can be ‘made’ to work better by (re-)ordering those who do.
Perhaps then the most helpful reaction to Mitchell’s outburst has been from an unnamed Cabinet minister, who suggested to the Telegraph that he should consider volunteering to work alongside police for a few days as a penance. “It’s what you do in this sort of thing, isn’t it?” the minister said. “A few days in a high-visibility jacket with the cops could be just the thing for Andrew.”
Christopher Hitchens used to evaluate the credibility of any person or organisation by their willingness to cite ‘evidence against interests’, that is, to acknowledge facts that are contrary to their own position. It’s a good test – and one that many policymakers, commentators and think tanks would fail regularly. With this in mind, we should challenge our own view that social policy would be better if it was informed by the people who use and provide public services – after all, doesn’t the Hillsborough cover-up show that we can’t trust bodies such as the police not to put their own interests before the public interest?
We’ve argued previously against the view, promoted in particular by right-wing think tanks and commentators but implicitly taken up by much of thinktankland, that public sector workers and ‘user groups’ need to be largely ignored in policy development because they are inevitably self-interested and self-serving. Our view is that social policy would be better if it was informed by the expertise, experience and insight from the frontline.
In the case of Hillsborough, as the publication last week of the report of the Independent Panel confirmed, the police engaged in an extensive and coordinated cover-up of the truth. This went all the way to the top of the South Yorkshire Police. Chief Constable Peter Wright authorised the alteration of police statements to delete words like ‘chaos’, ‘fear’, and ‘confusion’ in criticism of the police operation, in order to enable the police and others to blame Liverpool supporters for the disaster. 164 police statements were altered in the wake of the disaster, and 116 of these received substantial changes to remove comments “unhelpful to the force’s case.”
The coroner also took blood alcohol levels from all of the deceased, including children, to try to draw a link between the late arrival of fans and heavy drinking. Perhaps most sickeningly of all, police officers carried out computer checks on those who had died in an attempt to impugn their reputations. As one comment on the Liverpool Echo‘s website asked last week: “How could such a cover up have happened? So many different authorities getting away with lies. And to get away with it for so long is simply astonishing. They must know the hurt and the pain that they have caused for so long. And still they continued to hide behind the lies, carrying on with their own lives and careers.”
This type of behaviour is not confined to the police of course. NHS staff have abused and neglected patients, and hospitals have tried to cover it up and threaten whistle blowers. Charities have mistreated and ignored the vulnerable adults and children they claim to care for. Public sector trade unions have bullied their own members and failed to represent their real views and interests; they have also stopped managers from dealing with poorly performing employees or from improving services for the public. Given this, why should we listen to the people who provide services? Won’t they always represent their own interests first?
The problem is institutions, not individuals. There will always be some people who act badly and harm others, including inevitably in public services. But only badly led and managed organisations can effectively legitimize such behaviour and try to silence those who challenge it. When we argue that the people who provide public services should have a greater role in policy, we don’t mean a stronger role for those organisations such as large charities or trade unions that can already promote their views to policymakers, rather we’re talking about the individuals on the frontline who are ignored not only by policymakers but also sometimes by the organisations that claim to represent them.
Could the Hillsborough cover-up ever happen again? Some columnists have suggested that the ‘forensic transparency’ now offered by mobile phones and Twitter would make it much more difficult and that there is a danger of over-reacting to scandals such as the Hillsborough cover-up by not trusting any public institutions. But the best mainstream media article of the week for me was by Philip Johnston in the Daily Telegraph, who recognised the broader implications:
“Over the years, the police have been one British institution that has proudly stood comparison with the very best in the world: unarmed (though less so than they used to be), impartial, independent and largely incorruptible. Perhaps that was always a naive caricature; but it was a view so deeply ingrained in our national psyche that we were unwilling to give credence to powerful evidence that suggested otherwise. However, it was not only the police who let down the Hillsborough families: the very institutions that most of us trust to get to the bottom of things – the courts, the media and Parliament – were all culpable.”
This is perhaps a rather middle class view – many working class communities have always had a less trusting view of the police – but it’s a strange week when the Guardian tells us to ‘go easy’ on the establishment and the Telegraph reminds us to be ever-watchful of those in power.
Surely the Hillsborough cover-up demonstrates that policy can’t be left to the establishment – that arrogance and remoteness breeds bad policy and leads to tragedy (as Daniel Taylor argued in the Observer yesterday). It reinforces the importance of the individuals who provide public services having a much greater voice in policy, so that they can speak freely and honestly outside of institutional interests and constraints.
Perhaps what’s most frightening about institutional power is not its ability to make evil decisions but its collective capacity for ignorance regarding of the effects of those decisions. The answer to the question from the commentator on the Liverpool Echo site is that such ignorance comes most easily to those remain safely distant from the consequences – another reason why we should listen more closely to those at the frontline, both service users and providers, rather than the policy establishment. As C. S. Lewis wrote:
“I live in the Managerial Age, in a world of Admin. The greatest evil is not now done in those sordid dens of crime that Dickens loved to paint. It is not done even in concentration camps and labour camps. In those we see the final result. But it is conceived and ordered (moved, seconded, carried, and minuted) in clean, carpeted, warmed, and well-lighted offices, by quiet men with white collars and cut fingernails and smooth-shaven cheeks who do not need to raise their voice. Hence, naturally enough, my symbol for Hell is something like the bureaucracy of a police state or the offices of a thoroughly nasty business concern.”
We have a new secretary of state for health – but not apparently a new policy for health, or a change in the way that health policy is made. The way to improve the NHS is apparently the same as it was before Andrew Lansley was sacked – more outsourcing and competition. Jeremy Hunt has been appointed to implement this policy by being a ‘better communicator.’ But the Government’s reforms are unpopular not because of how they have been presented, but because of how the policy was developed – including the fact that no-one voted for them.
Under Any Qualified Provider, private health providers are likely to profit because, in contrast to existing NHS services, they can offer worse terms and conditions for staff, they will not be subject to the same regulations of transparency and accountability as NHS providers or bound by the same financial regime. AQP is a not about establishing a ‘level playing field’, or even about extending proper choice (since patients will not be told who owns providers including whether they are profit-making). Rather, it’s a programme to turn the NHS into a ‘trojan brand’ for private health provision, paid for by the public, while NHS providers lose income and some will have to close – so making the NHS as a whole less sustainable.
Whether you think these are the right reforms or not, they are not a popular because the public has never voted for them and haven’t been involved in developing them. These policies are not completely new of course – many of these ideas are shared across the main political parties, and this particular policy has already been applied in elective care. But this only reinforces the point. AQP is a classic example of the ‘Whitehall consensus’ – the shared view about the obvious rightness of outsourcing held by the policy establishment in the political parties, most Westminster-centric commentators and think tanks – that ignores what the majority of people who use and provide public services including the NHS actually think and want.
Andrew Lansley’s real problem was that he epitomized this approach to policy-making. The issue wasn’t his personal style or language, more that as a member of the Whitehall consensus he assumed that outsourcing is obviously better than ‘monopoly provision.’ It’s this that explains one of his most famous quotes, to nurses at a Royal College of Nursing conference, that: “I am sorry if what I’m setting out to do hasn’t communicated itself.” He thought the case for outsourcing was so obvious that he didn’t really understand why it had to be made at all.
As befits a former senior civil servant and head of the Conservative Research Department, Lansley’s approach reflected the way that policy wonks often approach public services. They seem to assume that institutions such as the NHS can be re-engineered according to blueprints, rather than respecting them as collective institutions with complex cultural as well as organisational histories. Hiring the like-minded (and self-interested) from management consultants such as McKinsey to sketch out massive structural changes reinforces this blinkered thinking, at the expense of any real world, practical engagement with improving how the health service operates, how patients are treated, and how resources are spent and saved.
In the name of greater efficiency, Lansley’s reforms have already wasted hundreds of millions of pounds and distracted health staff from the day-to-day business of improving services. But the point of hiring McKinsey is that they ‘get it’ – they share the view that the (lack of) evidence for outsourcing doesn’t need to be put before the people because they too assume that private provision must be better than public. This outsourcing of policy to the like-minded, even though they are likely to benefit from the policies they help to develop, is the same reason that parts of public health policy under Lansley were effectively outsourced to fast food companies.
This closed and cosy approach will continue as long as the political class is largely drawn from the same old PPE-think tank-commentator axis which pays the greatest respect to an elegant argument and a nicely designed slide deck, but which lacks any real experience of public services, or indeed any broader experience of life outside the Whitehall consensus. The lack of public engagement, and public mandate, for the Government’s health reforms further erodes public confidence and trust in policy-making. The greatest irony of all is that the reforms were supposed to be about devolving power and enabling shared decision-making between GPs and patients. At the heart of these policies, however, is a fundamental lack of accountability – at the level of some (privately-provided) individual services but also for the reforms as a whole.
What’s worrying about the appointment of Jeremy Hunt is not his lack of knowledge of health services – after all, Andrew Lansley held the health brief for many years, and look what happened. It’s that in his time at the Department for Culture, Media and Sport he adopted a similar behind-the-scenes, and way-too-close, relationship with corporate interests against a loved and largely respected but inevitably imperfect public institution (in this case, the BBC). The NHS is still – just about – a public institution. Its future should be deliberated, developed and determined publicly.