When Andrew Lansley proudly published Liberating the NHS on 9 July 2010, he had many reasons to be cheerful. It was sunny. The NHS plans he’d long talked about were moving towards reality. Being in a coalition government hadn’t derailed his strategy too much. He had also set a new record: taking a mere 62 days since the election to publish a health white paper.
With Jeremy Hunt now back at the Department of Health, let’s look at what will be happening behind the scenes to turn post-election ideas into government policy…
In putting together a white paper, where does a Secretary of State start? They will have many ideas in their heads, no shortage of others offering their own suggestions and, post-election, a myriad of manifesto commitments to fulfil. The real question is one of priority. For Lansley, the NHS came first (July 2010), then public health (November 2010), and finally social care (July 2012). Jeremy Hunt has already said his 'biggest priority now is to transform care outside hospitals' so that’s a pretty hefty clue as to his intentions (let’s leave for a future blog that this is what Patricia Hewitt’s 2006 Our Health, Our Care, Our Say white paper was supposed to do).
Great, so they have an idea. Next comes a merry go-round of civil servants, the Secretary of State, special advisors, junior ministers (when the Secretary of State wants them) and others, turning loose ideas into workable policy. This stage is now a more complicated process given the dispersal of power across the national NHS bodies. It’s no longer possible for the Department of Health to work out NHS policy on its own when the power to implement them sits in NHS England, Monitor and elsewhere. This was shown through Jeremy Hunt’s two major NHS documents of the previous parliament (Hard Truths and Transforming Primary Care) and implies that the 2012 Act means any future NHS white papers will have a plethora of logos on the front cover – and some tricky conversations behind the scenes to broker agreement.
At this point ministers need to decide how widely they want to go outside the national policymaking bubble. There’s a broad spectrum: Patricia Hewitt’s white paper was the result of an extensive public engagement exercise, and the preface of Alan Milburn’s NHS Plan (2000) was signed by 25 professional leaders endorsing the government’s strategy. In contrast, Liberating the NHS expressly was not a consultation on its main tenets (although it did ask for views on details) – a decision which contributed to the infamous ‘pause’ the following spring.
Right, so you’re now able to publish something for consultation. Time for cross-government clearance: every document containing major new health policy needs to be signed off by the Home Affairs Cabinet Committee. This is the point where the Secretary of State for Health is vulnerable to his Cabinet colleagues. If Treasury aren’t happy about the cost of the policy, they’ll say so. If Communities and Local Government think there’s an additional burden on local government, they’ll say so.
As a policymaker, cross-government clearance is a genuinely nervy part of the process. There will have been many meetings before this, but you can never be quite sure what you’ll get back – and whether that will then knock your publication timing off course or, even worse, whether you have to go back to the policy drawing board. If you’re ever reading a government document and come across a mention of a policy which seems wholly superfluous and irrelevant, chances are it’s there as a condition of cross-government clearance.
If you have consulted, all of the responses need to be gone through, the policy amended and finalised, and any additional clearances received. The happiest people in the department will be those given the task of putting together the impact assessment – (laudably) aimed to be the purely factual assessment of a policy’s costs and benefits. However, impact assessments can fall prey to evidence following policy rather than the other way round (they are government documents seeking to justify government policy, after all).
When all this is done and a title combining superlatives and sentiment picked, you get to publish. Cue a media launch, breakfast news clips of the Secretary of State walking down hospital corridors, delivering a speech surrounded by nurses, and a sound bite from a health think tank or two.
Likelihood of a Jeremy Hunt white paper within 62 days? Almost non-existent. Rather, 6-8 months is the average time to emerge through this process: six months for Lansley on public health and Frank Dobson’s 1997 The new NHS; eight months for Patricia Hewitt, and the same for Alan Milburn’s 2001 NHS Plan.
So a major government white paper, most likely on out-of-hospital care – I’d bet on it arriving just in time for Christmas.