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Words of Advice to the New Secretary of State for Health

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TO: Secretary of State for Health
FROM: Permanent Secretary
SUBJECT: Your appointment

Dear Secretary of State,

Congratulations on your appointment. Although some may see it as a case of out of the frying pan and into the fire, there's an important job to do and Rupert has assured me that there are no plans for News Corp to enter the healthcare market.

The country spends over £100bn on health or about 8% of GDP. It's one of the biggest spending departments and we did well in the recent spending review thanks to your government's pledge to maintain health spending. But there's no doubt the NHS is in crisis. The country is ageing fast. Non-communicable diseases like diabetes, heart disease and cancer have reached pandemic proportions. Yet healthcare costs keep rising and, to recall one imprudent member of the former government, "I'm afraid there's no money left."

So as you reflect on your first full week on the job, here are a few words of advice. Bear these in mind and you have every chance of a successful tenure.

1. There is no option but to reform the NHS.

The life-threatening pressures on the NHS make fundamental change both necessary and inevitable. Aspects of Mr Lansley's plan were laudable including greater local autonomy, greater competition where it will drive quality and more leadership from doctors. These should be retained, whilst its well-publicised weaknesses can be binned. But don't be lured into a go-slow approach. The NHS is sick and it needs radical treatment. A system built around hospitals full of expensive doctors was fine when treating sickness was the goal. Now the NHS needs to focus on keeping people healthy, addressing the behaviours that cause modern diseases like poor diet and exercise, as a keen runner like you must appreciate. To do so it will need to operate in very different ways, employing very different skills. Downing Street may want you to keep a cork on controversy. But nothing is more risky than presiding over an increasingly obsolete NHS, no longer capable of providing services that the middle classes think worth paying for.

2. Get a plan for failing hospitals.

Remember Mid-Staffordshire? Scheduled to report later this year, the Inquiry's report is bound to make for uncomfortable reading. Even if this doesn't reignite public anger, there's always the risk of another failure on your watch--and blame will be focused on us, no matter how much we talk about local autonomy. Besides, it's an open secret that about twenty hospitals are basically broke. Currently our policy is to merge these insolvent hospitals with other, usually also insolvent, hospitals in the charming hope that bigger will be better. As a man well-versed in the risks of takeovers I'm sure you will agree this is not a much of a plan. We need to get serious about standards quick and make sense out of an insolvency regime which is at best unformed and at worst politically bonkers.

3. Fight the battle on social care.

Your predecessor was forced to kick the issue of social care funding beyond the long grass and into the wilderness, despite the sensible work of Andrew Dilnot. Our hospitals cannot go on acting as residential homes; nor is this good for patients. This may be a fight you can win. Not only is the Chancellor weaker than he once was, courting the grey vote is a political open-goal: they are a large and growing group and they can be relied on at the ballot-box come election time. Labour has been inexplicably slow to realise this so the opportunity is there for you to steal another important garment from their already denuded wardrobe.

4. Do the politics.

I need hardly tell you that a clear narrative is crucial. Mr Lansley had too many stories and so none at all. Get yourself a good pair of Special Advisors and work up a message about leading the NHS into the next stage of its evolution, focused on keeping Britons healthy, reconfigured to meet the challenge of non-communicable diseases and affordable in the long term. You'll also need to engage with the many interests groups that surround the NHS without making them feel like silly children, as your predecessor was wont to do. Some are implacably opposed to anything we do (e.g. the BMA), but others are saner and understand the need for change. Finally, be sure to court the NHS itself (beginning with David Nicholson--fall out with him at your peril!): morale is subterranean and you can't accomplish anything without convincing enough of them.

I look forward to working with you over the coming months and--if all goes well--years. You may understandably feel daunted by the challenges ahead. But at least you haven't been tasked with rescuing the economy.

Sincerely yours,

Permanent Secretary