31 October 2022

Delivering continuity and unity. Easy as ABCD?

Rishi Sunak faces several crises, health and social included

We now have our third Prime Minister in seven weeks. Understandably, Rishi Sunak’s primary focus, at least initially, is to restore market confidence and economic stability, while holding together the warring factions of the Conservative party. His administration’s first announcements have made clear that returning to the election winning 2019 manifesto will form a core plank of these efforts; fracking will be un-unbanned, levelling up is back in vogue, and the promise of “a stronger NHS” is here to stay.

To do so, Sunak has appointed Steve Barclay as Secretary of State for Health and Social Care to deliver “unity, continuity and experience.”

Barclay has considerable ministerial experience, including, perhaps crucially, Chief Secretary to the Treasury during Rishi Sunak’s time as Chancellor.

Likewise, he ticks the ‘continuity’ box having served as a Minister for Health in 2018 and having had a short summer stint as Secretary of State in Boris Johnson’s final cabinet. His time in the Department saw steps taken to help the NHS prepare for a challenging winter period, blighted by flu, COVID-19 and the cost-of-living crisis.

However, given the fractured political environment, delivering the unity needed to tackle the many seemingly insurmountable challenges facing the NHS – either within Cabinet or the NHS – is surely his greatest challenge.

A united cabinet? 
When it comes to the NHS and social care, the cabinet is divided along two main lines: funding, and immigration.

On his appointment earlier this summer, Barclay was reported to have previously viewed the NHS as a ‘bottomless pit, resistant to change and unaccountable’ – but heading into a potentially challenging winter, the NHS will be looking to the Secretary of State to try to wring something extra from the Treasury to alleviate the challenging financial situation that has turned the air blue in Skipton House.

As Chair of the Health and Social Care Select Committee, Jeremy Hunt spent his time calling for greater funding for the NHS and action to address the workforce crisis. Much has been made in health policy circles of whether any of these beliefs will survive their exposure to Treasury orthodoxy. With “decisions of eye-watering difficulty” on public spending imminent, it seems unlikely that Hunt will be turning the spending taps back on for the NHS.

With allies for greater NHS spending surely short around the cabinet table, Barclay may instead focus on building support for other measures to manage the pressures on services. In the summer, he publicly stated his support for recruiting social care staff from overseas, in part to help unlock the challenges in delayed discharges from hospital – one of his last acts was to establish an international recruitment taskforce to enable care providers to recruit internationally. Generating support from cabinet colleagues may not be straightforward - immigration is likely to be a contested topic around the Cabinet table, with the re-appointment of Suella Braverman indicating that a quiet retreat from the 2019 Manifesto commitment to reduce overall numbers is unlikely.

However, with care workers already on the shortage occupation list and recruitment costs not impacting on public spending in the same way as NHS staff, there may be an opportunity for progress - perhaps the care workforce crisis will become the litmus test that proves whether Cabinet unity can be achieved.

A Unified NHS?
It’s no secret that Steve Barclay’s appointment was not entirely well received by health service leaders upon his appointment as Health Secretary in early July. However, this was hardly bucking a trend of close collaboration and partnership - even before Barclay’s summer appointment, relationships between NHS England and DHSC had broken down.

The gap between the two organisations stems from the creation of NHS England as a separate entity in 2012, but it was widened by the assertive approach that Simon Stevens took to promoting its independence during his time as CEO. While Amanda Pritchard has forged a different path since her appointment, levels of trust remain low on both sides.

In his second stint at the job, Barclay will need to repair these relations – cultivating an improved mutual understanding and respect between DHSC and NHS England, if he is going to deliver the improvements and unity the service needs.

Why unity matters
The scale of the challenge facing Barclay cannot be overstated.

Therese Coffey’s A, B, C, Ds will still be close to the top of the in-tray – but so too are a range of other issues that that Coffey’s Our plan for patients did not address:

  • Wider health and care workforce: Recruitment and retention challenges are particularly acute in nursing, especially in emergency and mental health care where vacancies are highest

  • Infrastructure: There is an urgent need for investment in capital – existing commitments on hospital building and expanding diagnostic capacity seem to have stalled and could be put at risk if the capital budget is raided again to manage rising cost pressures

  • Prevention: One of Coffey’s four ‘Ps’ was prevention, but the Truss administration’s determination to roll back state interventionism led to conversations around scrapping the sugar tax, tobacco control plans and the health disparities White Paper – setting a clear direction on prevention and establishing priorities for the system should be an early priority for the new administration 

Barclay is facing an uphill battle. But if he can get both cabinet colleagues and the NHS on side – there is a chance he could relieve pressure on both the NHS and government in the months to come.

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