The vices of patronage for health services under reform

Michael Lambert | 21 July 2021

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Executive Summary

• The history of non-executive appointments in the NHS is interwoven with struggles over control and accountability between the political centre and the service periphery.
• Within NHS organisations, the role of non-executives has always been ambiguous due their reliance on medical, managerial, and monetary experts for information in decision-making.
• Before 1979, the largely voluntary basis of non-executive appointments in the NHS reinforced an elitist and traditional public service ethos which struggled to cope with resource constraints, the politics of changes, and increasingly complex services.
• Weaponising the appointment process of non-executives across NHS organisations was a crucial instrument in the transition from the ‘old’ command-and-control NHS to the ‘new’ marketised one which intensified from 1979 to 1997. This was marked by a shift towards direct party-political patronage and business interests over balancing the representation of interest groups mediated by those dabbling in public service.
• Ensuring democracy, accountability, and transparency in the NHS through non-executive scrutiny is only possible through resolving larger political tensions across the service and organisation. Technocratic adjustment or a return to the past is insufficient.

Introduction

Lay oversight of health services has been a staple of its provision for centuries. It has been a historic source of tension between clinicians and managers, which has determined the organisation and delivery of modern medical care in Britain. At the heart of the struggle is a conflict between clinical autonomy in the best interests of patients and available resources. Non-executives who oversee such struggles have been crucial umpires. Since the creation of the National Health Service (NHS) in 1948 – which brought these services under centralised national control – there has been a further tension between the desires of the political centre and the interests of the service periphery. This tension hinges on the extent of resourcing and successive government reforms since 1948 have brought these tensions to the surface.

The latest NHS reform is no exception. The Government’s 2021 White Paper Integration and Innovation proposes to end decades of marketisation and competition with a move towards place-based organisation which emphasises partnership with local authorities, communities, and third sector agencies. The 42 Integrated Care Systems (ICSs) covering England which provide the organisational blueprint to realise the reforms have been established in shadow form on the expectation that they will be operational by April 2022. Once again, as part of these reforms, the issue of non-executive appointments to local NHS organisations, and the nature of their role, have been brought to the surface.

Crucially, the White Paper also proposes sweeping powers for the Health Secretary. These include making non-executive appointments to NHS bodies, including ICSs, removing that function from NHS England, which was established in 2012 to remove political interference from everyday activities. This opens the door to patronage. Speaking to the Guardian, Shadow Health Secretary Jon Ashworth suggested that the reforms would ‘institutionalise cronyism’, citing the example of local Virgin Care director Julia Clarke obtaining a non-executive role on the ICS for Bath, North East Somerset, Swindon and Wiltshire. Patronage can be political as well as commercial. In the wake of Health Secretary Matt Hancock being dismissed for appointing his lover to a role as a non-executive director (NED) in the Department of Health and Social Care (DHSC), the Institute for Government found that more than one in five of such appointments in Whitehall had close links with the ruling Conservative Party. As Mark Knights wrote recently for History & Policy, it seems ‘New Corruption’ constitutes a system rather than individual transgressions.

The rise of something akin to the ‘Old Corruption’ in the appointment of NHS NEDs during the Conservative Governments of 1979 to 1997, and its fall with the establishment of the NHS Appointments Commission in 2001 under New Labour, provide an instructive lesson – and warning – from history. Indeed, concerns about patronage and undue political interference in NHS appointments constituted the single largest source of complaints to the Nolan Committee on Standards in Public Life. The subsequent first Nolan Report in 1995 outlined seven principles of public life – selflessness, integrity, objectivity, accountability, openness, honesty, and leadership – to restore confidence in the oversight of services.

Integration and Innovation is the latest in a round of reforms which have brought the place of NEDs in health services to political attention. Whilst, historically, non-executives have mediated medical independence and managerial control through competition for scarce resources, this has been entangled with central-local tensions in the NHS since 1948. To whom are NEDs ultimately accountable: government or their local population? The nature and process of the appointment is critical to validate either form of accountability. The lesson from history is stark: politicisation and patronage of NEDs undermine the role of lay administration and public accountability in the NHS.

Lay Administration before the NHS

In 1948 the NHS effectively nationalised an existing tripartite division of lay oversight in health services between primary, secondary and community care. Primary, which was largely general practice, was overseen by local Insurance Committees. These were created in 1911 to widen access to a limited range of services for insured working men, not their wives and children. Nationally they were run by the National Health Insurance Commission which was chaired by senior civil servants as part of a board which comprised representatives from employers, unions, and the medical profession. This system was mirrored at the local level with a territorial footprint mirroring that of the local authority, and it continued unreformed after 1948.

Community services were directed by the powerful Medical Officer of Health (MOH) – an omnicompetent servant of Victorian public health – and overseen by local authority health committees. These grew in strength, status, and size from their mandated creation for both urban and rural local authorities in 1875 to their zenith in 1929 through the municipalisation of Poor Law hospitals. Health committee membership was drawn from elected local councillors, although as the scope of MOH responsibilities expanded, different functions were overseen by a proliferating number of subcommittees. Such subcommittees typically co-opted senior figures from local voluntary and charitable organisations given the moving frontier in the mixed economy of health services at the time. Community services remained subject to such oversight after 1948, given that large portions remained funded by local ratepayers rather than central government.

Before 1948, secondary hospital services were divided in two between municipal public hospitals managed by local authorities and private voluntary ones overseen by their philanthropic benefactors. Here, lay administration related directly to allocating resources and mediating tensions with the medical profession over autonomy. In public hospitals, there were typically smaller house committees accountable to the local authority health committee which were dominated by the leading clinician: the Medical Superintendent. Parallel lay and medical hierarchies were clear: doctors working in hospitals reported to the Superintendent who, in turn, was accountable to the MOH. Mental hospitals maintained by local authorities often existed in splendid isolation from their lay committees and their visiting delegations. Ultimately, local authority health committees controlled resources and served local ratepayers rather than dictating policy.

However, public hospitals were nationalised in 1948 and removed from the control of local authorities. They were nationalised alongside private philanthropic (so-called ‘voluntary’) hospitals: voluntary because they were individual, independent, and based on the principle of voluntary rather than state action. They were typically overseen by a lay committee of affluent donors, or their representatives, who were responsible for admitting both needy and medically interesting cases to the hospital for treatment by the elite of the medical profession. Doctors were appointed on an unpaid and honorary basis. Their income came from private practice earned through attending to more affluent patients. This changed during the interwar period when a funding crisis in the voluntary sector was only overcome by workingmen’s associations and unions establishing hospital contributory schemes. Such schemes permitted access to local hospitals and services in return for a regular subscription. Accordingly, the schemes demanded representation in management.

Lay administration by hospital and health committee members – NEDs in modern parlance – before the creation of the NHS, reflected the origins of each of the tripartite branch of the health system, and their sources of funding. Appointments were on an interest and representation basis: from workers’ and employers’ organisations for primary; from elected representatives and co-opted stakeholders for community; and from the benefactors who funded private hospitals for secondary, coupled with local authority oversight of public hospitals. Before 1948, these competing systems and competing interests produced ‘discord and fragmentation’ as I have argued in another History & Policy paper. Reform brought these tensions to the surface.

Nationalising the Health Services

Although the NHS nationalised each of the branches of the tripartite system and its concomitant administration, it created a new hierarchy of bureaucracy to connect the centre of government with the service periphery. Insurance Committees paying General Practitioners (GPs) for services continued unreformed as Executive Councils, answerable to the Ministry of Health. Local authority health committees also remained but Medical Officers of Health were left responsible for a residualised rump of community and other services with the nationalisation of their biggest asset: hospitals. Secondary hospital services were bifurcated between teaching centres of excellence run by Boards of Governors (BoGs) which were accountable only to the Minister. The remainder – and overwhelming majority – of hospitals were put under the jurisdiction of Hospital Management Committees (HMCs) which brought together voluntary and municipal hospitals in localities. These, in turn, reported to Regional Hospital Boards (RHBs) which were overseen by the Ministry of Health.

Nationalisation brought centralisation, and the Minister had the ultimate authority to approve the appointment of members to each of the organisational identities of the unified NHS. However, this was tempered with a clear legacy of representation inherited from predecessor bodies. Ministers rubber stamped the continuation of previous practice. Local employers and unions retained a stranglehold over Executive Council membership, combined with some local authority representation. Equally, local authorities continued to operate as they had before 1948. The two hospital systems had a different system of representation. BoGs ensured that teaching interests, especially universities, were prominent. RHBs were to reflect local authorities, voluntary societies, and other community interests. However, the right of medical representation on all governing bodies in the NHS was absolute. Indeed, conceding medical representation on all NHS organisational bodies alongside their own professional clinical bodies was pivotal in getting the NHS off the ground.

Despite possessing the power to approve or reject appointments, Ministers were largely content to allow each of the organisational entities at a local level to continue existing appointment processes. Tenures were often long and Vice Chairs routinely inherited from Chairs. The only exception were the newly formed BoGs and RHBs. Whilst appointments came from within the areas overseen by the bodies, they were used by both the Conservative and Labour Parties to recognise respected establishment figures. For instance, the Chair of East Anglian RHB from 1959-74 - Sir E. Stephen Lycett Green - was a prominent local and national solicitor. Sir W. John English was appointed as Chair of South Western RHB from 1966-73, coming from a background in union politics. Edward Hyde Macintosh held the Chair for Northern RHB (Scotland) from 1948-65, securing the post on standing down as the Governor of Khartoum after the Second World War.

Such establishment figures in senior NHS roles did not inspire much confidence when it came to providing accountability. Secretary of State Richard Crossman wrote in his diaries whilst in office that the RHB Chairs – which met monthly with the Minister in Whitehall – were ‘fairly feeble creatures trying to do a bit of public service but really dominated by their officials’. In a later lecture reflecting on his tenure, Crossman described them as ‘self-perpetuating oligarchies’ whose relation to him were like those of ‘a Persian satrap to a weak Persian Emperor. If the Emperor tried to enforce his authority too far or at least he lost his resources or something broke down’. This was especially the case for more muscular Chairs. Indeed, for Manchester both the RHB and BoG were held in tandem and maintained by a dynasty under Sir John Stopford – the Vice Chancellor of the University of Manchester – from 1947-53 and succeeded by Sir Norris Agnew from 1953-67.

In short, NHS nationalisation of health services and their oversight bodies carried forward the same individuals, cultures and patterns of appointment which had preceded them. Local health systems perpetuated themselves in their own image, leaving much of the influence in the hands of officials who ran them. The creation of new organisational entities did, to an extent, provide a new form of patronage for Ministers; but this was used to appoint establishment rather than partisan candidates. Although idealised as a ‘golden age’ by many, the ‘classic’ welfare state of 1948 to 1974 had very limited non-executive scrutiny, accountability, and transparency.

Weaponsing Appointments for Reform

Non-executive appointments remained a largely apolitical and non-partisan issue before 1979 because there had been no significant challenge to its oversight role. This began to change during the 1970s, catalysing what was to come under the Conservatives during the 1980s. Where resources had steadily increased from the 1960s through the Hospital Plan and growing numbers of appointments, the 1970s brought economic crisis, industrial disputes and a government imposing cash limits to maintain control. Such crises brought the reality of maintaining local services into conflict with the economies of the centre, putting local medical services and clinical autonomy in jeopardy. Furthermore, investment in modern capital also meant closures for ageing Victorian hospitals as part of efforts towards rationalisation and concentration of acute services. Local hospital closures produced fierce opposition across the country. Non-executive relationships in local systems remained cosy because they remained largely untested until the 1970s. Such a crisis combined with a government ideologically committed to reducing the welfare state created a perfect storm.

The first warnings of the coming storm came in August 1979, just months after the Conservatives won a slender majority in the May election. Secretary of State Patrick Jenkin called in the commissioners to Lambeth, Southwark and Lewisham Area Health Authority (Teaching) (AHA(T)) after they set a budget which would breach the cash limit imposed on them. The AHA(T) was the product of the NHS reforms in 1974 which unified regional BoG and RHB administration into one: Regional Health Authorities (RHAs). Beneath RHAs, a new tier was created – AHAs – which were responsible for overseeing the work of local District Management Teams (DMTs). Crucially, RHAs and AHAs retained a board and Chair, whilst DMTs were a purely executive instrument. The Chair of Lambeth, Southwark and Lewisham AHA(T) was a Liberal Councillor, Stan Hardy, in an overwhelmingly Labour area, and he was adamant that funding cuts would not mean a loss of service. The AHA(T) fought back, taking the matter to the High Court. The Government lost. The imposition of commissioners was deemed a breach of Ministerial authority and, following a gentleman’s agreement not to exceed cash limits in future, the Chair and AHA(T) members were returned to their role.

The Conservatives had their first chance to appoint NEDs in 1982 as part of their policy to abolish the AHA tier and turn DMTs into District Health Authorities (DHAs), each with their own Chair and board. Much like trickle-down theory, however, they started at the top from RHAs. RHA Chairs who were vocal critics of the government’s handling of the pay dispute were ousted, with two of the six being replaced by Conservative Party members: Jim Ackers for the West Midlands and Donald Wilson for Mersey. The others were in keeping with appointing recognised elites with a background as Chairs in major NHS organisations at the local level: Dr Bryan Thwaites arrived at Wessex having been Chair of Brent and Harrow AHA whilst J. Michael Carlisle became Trent RHA Chair from Sheffield AHA.

Increasingly politicised, a sense of how these appointments were made and weaponised can be seen in correspondence from the time between Health Ministers and the Conservative MP for Brighton Pavilion, Julian Amery. On 30 July 1981, Gerard Vaughan wrote a letter marked ‘personal and confidential’ to Amery explaining that ‘The appointments of the chairmen of the new health authorities will clearly be extremely important for carrying out our health policies in many parts of the country’. Vaughan also noted that ‘Colleagues in the House have been immensely useful over recommending people for these appointments’. However, the political nature of the request meant that Vaughan asked Amery to ‘treat this as totally confidential at this stage since names have not yet been confirmed’. Amery had earlier suggested Dr Anthony Trafford – later Baron Trafford of Falmer – a former Conservative MP for The Wrekin from 1970-74 in a letter of 19 February to Tony Newton. However, in his reply to Vaughan of 26 August, Amery instead backed Julia Cumberlege. She served as Chair of Brighton DHA until 1988, becoming Chair of South West Thames RHA and later Health Minister herself in 1992, becoming Baroness Cumberlege of Newick in 1990. She has undertaken several high-profile health policy reviews for both New Labour and the Conservatives in the decades since. [Churchill Archives Cambridge, Julian Amery Papers, AMEJ/2/1/105 for Newton and AMEJ/2/1/108 for Vaughan]

The weaponisation of appointments intensified throughout the 1980s in order to secure politically amenable NEDs who would, unlike Lambeth, Southwark and Lewisham AHA, back controversial government reform policies. However, the constitutional composition of bodies – maintaining a delicate balance between the medical profession, local authorities and other interests – provided a clear limit to such an approach. Even the introduction of general management following the 1983 Griffiths Report, which led to a further round of politicised appointments, could not prevent vocal opponents from obtaining a voice as NHS NEDs. Further weaponisation required an overhaul of NHS organisational hierarchies.

Reforming Appointments and Patronage

The introduction of the split between purchasers (health authorities) and providers (independent self-governing NHS trusts) facilitated an opportunity to take the politicisation of NED appointments to its logical conclusion. Alongside a completely new set of appointments the new boards of both DHAs and NHS trusts would be smaller, comprising 5 NEDs, 5 executive directors and a Chair. This would also be replicated in RHAs, the zenith of NHS hierarchy, which were retained owing to their political utility. Former Permanent Secretary in the Department of Health Sir Chris France here noted that ‘The [RHAs] survived. I think this was largely a political decision. They were stuffed to the gunwales with Tories and we know they were influential locally’. He cited Don Wilson, Mersey RHA Chair as ‘the quintessential example of this’, able to act as ‘a great fixer’ on behalf of the government and a necessary instrument for ensuring such controversial reforms succeeded.

As the reforms were implemented in waves, the number of new appointments proliferated. Ministers used their continued power of appointment to install those politically amenable or sympathetic to the reforms. Suggested candidates, as with Cumberlege in 1981, came from within local or regional networks and were submitted for approval. Subject to loyalty to the reforms. Indeed, a 1993 press release by the Shadow Secretary David Blunkett commented that ‘we have seen the creation of a one-party state as friends of the Tory Party, ex-Ministers, failed candidates and MPs’ relatives have been packed onto health authorities and Trust boards of management’.

This was not, however, a case of individuals using the appointments to advance their own private or commercial interests. Many of those appointed through patronage maintained a public service ethos and sought to defend their local communities from swingeing cuts. In 1992 Sir Nicholas Winterton, the Conservative MP for Macclesfield and former Health Select Committee Chair, used Parliamentary privilege to decry the ‘Machiavellian developments’ of Mersey RHA Chair Sir Donald Wilson in prioritising careerism over the health needs of the population. The local DHA and NHS trust Chairs were equally emphatic despite their party membership. Despite the extent of patronage and public outcry, divisions within the Conservative Party – which intensified with the departure of Margaret Thatcher as Prime Minister in 1990 and the slim majority provided by the 1992 election – served to limit the basis of the one party state alluded to by Blunkett.

This should not be overstated. A 1995 report by the Institute for Public Policy Research concluded that ‘There is evidence that a large proportion of NEDs have Conservative Party affiliations and that NEDs are more likely than executive directors to sympathise with Tory values. They are unlikely to mount any serious challenge to the views of the “chair/chief executive duopoly”’. Mark Exworthy and Ray Robinson in their study of the chair/chief executive duopoly similarly found that by the end of the 1990s ‘party politics and patronage’ remained a significant consideration in relation to senior appointments.

It is therefore unsurprising that in a context of sleaze which led to the creation of the Nolan Committee on Standards in Public Life that NHS appointments were the largest source of grievances. The first report, published in 1995, noted that:

We heard suggestions from many of our witnesses and correspondents that a disproportionate number of posts are given to Conservative party activists, ex-candidates or those who have donated money to the party, both as a reward for loyalty and as a way of ensuring boards who will be supportive of Government policies and uncritical of Ministerial decisions.

Whilst the report averred from correlating appointments with membership – pointing to the more complex dynamic between the commercial and private world, support for Conservatism and the nature of marketisation in the reforms – it was an inescapable conclusion that patronage had been a crucial instrument in creating the internal market. Whilst identifying and appointing candidates for Ministerial approval continued to emanate from localities and within the service as they had done previously, NEDs under the Conservatives were weaponised to serve the centre rather than the locality. As the authority of the centre intensified despite claims of decentralisation, accountability was increasingly framed in political terms to government rather than to local people.

Weaponisation of NHS NEDs was challenged following the creation of NHS Appointments Commission in 2001 by New Labour. This removed Ministerial authority for appointments and introduced a more robust system of selection and evaluation. The Commission was subsequently abolished in 2012 as part of the package of Lansley reforms. However, some independence was maintained through the responsibility for appointments being managed by NHS England. Whilst many appointments came from within the health policy and NHS community rather than representing the views of the local population – particularly given the mounting complexity of services and the primacy of financial knowledge – it provided a clear counterweight to the centre. The return to centralised Ministerial direction in a context of major reform points to the very real threat of political weaponisation.

Conclusion

There are no unambiguous lessons from history in relation to lay administration of health services. Appointments have always been open to patronage throughout the history of the NHS and there has never been a ‘golden age’ of clear representation and accountability. NEDs have largely been drawn from the elite, dabbling in public service, or appointed in recognition for a record of social contribution.

Despite this, the actions of the Conservatives provided a break with the past. Their intentions to remove the voice of the locality, the medical profession and critical voices in everyday NHS affairs combined with an ideological commitment to private sector efficiency and commercial knowledge from 1979 to 1997 served to weaponise NED appointments. Nowhere is the impact of this more visible than in the Nolan Report. Given the crisis in public service confidence which preceded its publication, mainly around government sleaze, moral hypocrisy and cash for questions in the Houses of Parliament, the very fact that NHS appointments provided the main source of grievance points to its significance. Centralising and politicising NEDs fundamentally undermined trust in the NHS by those who worked in and used its services.

It would be wrong, however, to view all NED appointments under the Conservative Government as working against the true interests of the NHS, or as instruments of privatisation. Whilst many were parachuted into solidly Labour areas to quell opposition and smooth the implementation of marketising reforms, others remained in the traditional public service mould. Although many were ruthlessly purged by New Labour from 1998 to 2002, others went on to make major contributions in local, regional and national affairs. Patronage was in evidence at a systemic level, but its legacy is far more equivocal at an individual level.

There remains a fundamental tension in NHS organisation which is reinvented through NED appointments and reforms: to whom are NHS bodies – be it Executive Councils, District Health Authorities or NHS Trusts – accountable? Given that their main role is to act as intermediaries in the tension between clinical practice and managerial intentions determined by the availability of resources, whose voice should they be amplifying? Political appointments under the Conservatives during the 1980s and 1990s served to shift accountability to government ministers and party masters. The prospect of commercial appointments to Integrated Care Systems (ICSs) as part of the latest round of government reforms has the potential to distort this accountability even further.

Simply returning to the past or technocratic tinkering with appointments is insufficient to answer these questions. Ensuring democracy, accountability, and transparency in the NHS through non-executive scrutiny is only possible through resolving larger political tensions across the service and organisation. These ultimately relate to questions of authority between the political centre and service periphery, and the distribution of scarce resources.

Here, the virtues of decentralisation can counter the vices of patronage. Local government, community stakeholder, workforce, and – above all – patient representation should be developed not decried. They can offer meaningful scrutiny on organisational actions and address government shortcomings on touted cooperation between health and social care in the ICS blueprint, something that remains largely aspirational rather than a reality. Moreover, a robust regional tier has the potential to provide enough power to challenge the centre whilst overcoming local service rivalries. This can, in turn, empower local officials charged with organising and managing health services, building relationships and nurturing them over time rather than leaving them vulnerable to the latest dictates of the centre. Resources are fundamental. To prevent non-executive representation becoming a choice between the Devil and the Deep Blue Sea – of cutting services and limiting treatment to meet government austerity – services need to be funded on an equitable footing rather than on the basis of centrally-imposed and adjudicated goals and metrics.

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About the author

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Dr Michael Lambert is a Postdoctoral Fellow in Social Inequalities and works for the Centre for Alternatives to Social and Economic Inequalities based in the Department of Sociology at Lancaster University. The paper reflects research undertaken whilst he was a Research Associate in the Department of Public Health, Policy and Systems at the University of Liverpool working on the ‘Governance of health: medical, economic and managerial expertise in Britain since 1948’ project funded by the Wellcome Trust and directed by Professor Sally Sheard. He is on Twitter at @GrandCamouflage.

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