4 October 2022: Expert Group on Public Health and Administration - A

It was Day 2 of the Expert Group (EG) on Public Health and Administration. It had been dubbed the “Expert Group on Cover-ups” and it was hoped to see some action in that regard. It was worth noting that there are other people on the EG who did not appear to give oral evidence.

(The Chair announced that the evidence set for Wednesday, involving the Statistics Expert Group, would not be able to happen as scheduled due to Covid-19. It will be re-scheduled for some time in November.)

The evidence for Public Health and Administration picked up on the problems or weaknesses of decision-making about health policy. A key problem seems to be a lack of long-term planning, in part due to the turnover of personnel. Long-term planning by Government was been recognised as possible when it wants to do it. However, the example of the longer-term ideological plan to break up the NHS as proof of this capacity was not fully supported by at least one other EG member. The guru civil servant on the EG said the civil service values policy over delivery, then spoke in self-admittedly boring management terms to exhaust any remaining energy left in the topic. It was felt that the civil servants should not be blamed for problems developing because the major negative changes have been down to political will, facilitated by (usually young) management consultants with no expertise or commitment to the results of their inputs and outputs.

Often the issue is that the short-term problems are so pressing that the best staff are devoted to solving these immediate issues, so the necessary longer-term planning is side-lined. The short-term fixes are usually demanded by the politicians. The only solution is to have a Prime Minister who believes in the longer-term objective and ensures people stay in role for long enough. It was  suggested that it takes about 15 months for a new person to get to grips with their brief. Newer people are more open to be being “manipulated” by civil servants who may have their own preferences about what should be done. It was also pointed out that the annual funding cycle of local Trusts similarly results in short-termism in decision-making, and this negatively affects longer-term activities such as training or cancer referral processes which would have great benefits, but not immediately.

It was suggested that the current structures of integrated care boards and the foundation trusts are all in competition with each other which diminishes the focus on the local health needs as they build their own empires. (This writer notes, not for the first time, how heavily skewed the evidence is to the English system, with no or rare reference to the conditions in the devolved administrations.)

The Cumberlege review was cited by Counsel, as it was in the EG report, concerning monitoring systems on devices and medications, to the extend of it not being fully known what actual devices and what actual medications were in use in any given place. The concern is to recognise a “disjointed, siloed, unresponsive, and defensive” health service with the result that it doesn’t realise how “patients are it’s raison d’etre”. It was admitted that the “patient first” assertion was very hard to achieve. A “patient-centred approach” has been written about but has not yet changed what is still a generally “top-down approach”. Patients want longevity (staying alive) and quality of life (which is much harder to define), but sometimes these two dimensions clash, for example, when a clinician wants to encourage their patient to improve their lifestyle choices so that they hopefully live longer but doing that means their everyday life is not so much fun. Reference was made to the local health councils which, when they worked well (and not all did), they had much more access to decision-makers than is possible nowadays. There was a plea for the health system not to be completely characterised as depersonalising and just an uncaring bureaucracy, because many of the people involved are clearly very committed to healthcare and the welfare of patients over all else.

Counsel moved to the topic of devolution. Since 1948 there were three systems: England and Wales together, Scotland, and Northern Ireland. Later there was greater delegation for Wales after devolution. These have undergone shifts in the nature of the devolution, being somewhere between political devolution or administrative devolution. The first part of the discussion was about how things were done before devolution. For example, the Secretaries of State for Scotland were responsible for Health in Scotland, not answerable to the Department of Health in Westminster. In this case these roles have never been integrated. There were differences for Wales where the policies had been Whitehall controlled. In Wales, devolution was seen as a process and not an event as it gradually moved to be mote like the case in Scotland. Northern Ireland was intended to have greater autonomy, but this has been occasionally disrupted by the collapse of the Assembly.

Counsel pointed out the dearth of documentary evidence from Wales and Northern Ireland in relation to the topics of interest to the Inquiry, whereas in Scotland there has been a relative plethora of paperwork. The EG report noted how common it was for English-originated policy to be copied in whole or part by the devolved nations. This was mainly out of convenience and the situations when the same political party was in power across the piece. (This writer would suggest that things have shifted in Scotland since the rise of the SNP with its elemental focus on “independence”; as both a political objective and as a philosophical approach.)

The EG had considered both the advantages and disadvantages of devolution with respect to Health; for example, the potential to achieve a “tailored” approach. Other advantages included local accountability, agile decision-making, scope for learning, etc. Disadvantages included the lack of funding in the Barnett Formula. It led to a mini-masterclass on Barnett, such as what counted as England-only activity and what had to be adjusted when the simple population apportionment was an inadequate tool for determining amounts of money needed. A further disadvantage happens when there are major political differences, such as free personal care in Scotland which is not the case in England. The joint ministerial council was meant to be a way of better coordinating things, but it didn’t meet often at the start and at one stage did not meet for 20 years. The aim had included the desire to achieve the civil servant mantra of “no surprises”. Obviously, that did not always happen in relation to the Contaminated Blood Scandal, such as with the HIV Litigation settlement arrangements. This was considered less likely to have happened the way it did in a pre-devolution world. It seemed clear that devolution had been viewed as a messier way of doing government by officials due to their having to recognise and allow for four systems to operate and not the simplicity of one. It has highlighted how the issue of having a central government in England as well as national Parliaments would lead to accusations of people in power having an Anglo-centric mind-set.

It was noted how health was low on the agenda of intergovernmental relations activity, maybe until the Covid situation, at least. The period of the 1970s and 1980s was still very much a case of England taking the lead. This was partially explained by the much greater human resources available in Westminster where people could be specialists, compared to the numbers of people in the other nations where individuals would be covering much wider remits. The expertise was easier to see in London since it is much harder to shine if you are being pulled in so many directions at the same time. It was noted how political rivalry could be a potentially detrimental factor in some policy areas, and the EG report noted how issues such as safety and public health should be above party politics. The example of Covid was cited as a demonstration of people recognising the need to act together, although it did become a bit of a competition on issues such as the timing of reducing restrictions.

The Chair wanted to focus in on the situation of the 1940s when there was a need to freeze-dry blood for soldiers on the battlefield, and where this happened in Cambridge and Edinburgh. By the 1960s the Scottish plant was servicing “up North” for blood services. He expanded his rehearsal into the 1970s, including how it began to bump into questions about where the funding came from and how oversight was achieved. This was added to in complexity by the David Owen aim of achieving self-sufficiency. The Chair invited the EG members to provide insights on the local-national arrangements which may have contributed positively or negatively on, particularly, patient safety in the context of contaminated blood. The first response was to mention how there was, for so long, no national blood transfusion service either for the UK as a whole or one for Scotland and one for England and Wales (Northern Ireland didn’t get a mention). It became a discussion about the Centre versus the local regions, particularly on the matter of “top-slicing” of funding. This tension was made more difficult by devolution. There was also an issue of what was decided to be devolved and what was reserved (considered better to be managed centrally). Pushing things out to the regions is not always simply about allowing more localism in decision-making, but also of spreading the funding catchment. The central-local dilemma also affected the dynamic between a centralised standard care model and the issue of clinical independence of a doctor to opt for a bespoke treatment regimen for a specific patient who they know well and who may not easily fit a one-size-fits-all standard operating procedure.

The definition of the word or concept of “national” was mentioned. These are not just a matter of a political assertion but are connected to identity and belonging. A regulatory regime is often thought to be important, but in the situation of localised applications, regulation may not be measuring the same things in a way which makes comparisons useful or meaningful.