The Tories have surrendered power to quangocrats and vested interests

Have you heard of Amanda Pritchard? She employs more than 1.2 million people, and spends around £160 billion per year. She is more powerful than most ministers and company chief executives. The organisation she runs suffers from poor productivity and declining performance. Yet she remains remarkably unaccountable.

This is not a personal criticism of the NHS England chief executive. It’s a criticism of the way the Health Service runs. Ten years ago, Andrew Lansley, then health secretary, radically redesigned the NHS. Its independence from the Department of Health was enshrined in law. Its chief executive, not the health secretary, was put in charge. Ministers were barred from allocating NHS resources.

The reforms were meant to put clinicians in control of commissioning services. But commissioning has proved a disaster, with billions wasted in administration, clinical staff bogged down in procurement rules, and unaccountable quangos duplicating activities and unable to coordinate.

As a senior NHS leader puts it, “We have three organisations that treat and care for patients: GPs, trusts and private providers. But we have dozens of organisations from ‘clinical senates’ to ‘academic health science networks’ creating work, costing money and achieving little.”

The reforms aimed to make GPs the “gateway to choice in the NHS”, but the choice is illusive and GPs elusive. New figures show a third of us wait more than a week for an appointment, and millions are still carried out by phone, not in person. Now GPs have voted to close their doors at five o’clock.

With an ageing population and a Covid backlog, budgets are constrained. But spending is not the story. The budget for NHS England is up 12 per cent in real terms compared to two years ago, there are 13 per cent more doctors than three years ago, 10 per cent more consultants, 11 per cent more nurses, and 10 per cent more clinical staff. Yet the NHS is treating fewer patients.

Since Lansley, successive health secretaries have complained that they are powerless, and that NHS independence only means its chief executive ends up responsible for everything and therefore accountable for nothing.

All of which raises an obvious question. Since 2010, the Conservatives have reformed public services to reflect their belief that these vital institutions are better run by professionals, not politicians, and that power is best devolved away from ministers and officials in Whitehall. But is this really the right thing to do?

Health ministers past and present bemoan the lack of levers available to them, and explain that those things that worked well during the pandemic happened despite not because of NHS structures. There are similar such examples across the public sector.

The Home Office has removed itself from local policing matters, for example, but the College of Policing and National Police Chiefs Council have centralised and determined policing policies, to the frustration of ministers. To understand why officers are so keen to empathise with rather than arrest criminal protestors disrupting roads and vandalising private property, read the guidance issued by the College.

Universities are another example. During the Coalition, the Government raised the cap on tuition fees to £9,000 and cut public funding for tuition. This shifted the balance of funding from the taxpayer towards individual students – theoretically at least, since most graduates will not pay back their debts, leaving huge liabilities for the Treasury.

There were other perverse outcomes. Many universities now depend on fee income from foreign students. Despite ministers’ concerns, some have compromised on freedom of inquiry and expression on campus to maintain relations with China. Many sell not only education but long-term immigration to Britain, for foreign students and dependants. When ministers floated limiting student visas to higher-quality institutions, critics laughed that it was impossible because many universities are over-leveraged and have precarious finances.

Other examples abound. Climate change policy is directed by a supposedly independent committee. Decisions about quantitative easing are made – with remarkably little scrutiny – in the Bank of England. Research councils use public funds to commission entirely useless academic and deeply political projects.

This is not to argue that it is wrong for ministers to decentralise power and delegate decision-making. School reform, which freed schools from local authority control, remains the greatest domestic policy of the last decade. We are better off now the Home Office no longer thinks it can issue policing plans from London for areas as specific as Stapleton Road in Bristol and the Grange Estate in Stoke.

But we cannot afford to decentralise and delegate without a plan. It is unwise to transfer power to supposedly expert committees or institutions, whose advice ministers find it impossible to reject. It is not unusual for officials and ministers to share concerns about analysis and recommendations from these entities but conclude anyway that it would be too damaging to disagree.

It is sensible to decide, by decentralising to councils and mayors for example, that Conservative ministers should empower local Labour leaders. But it is counter-productive and undemocratic to transfer power to unaccountable quango bosses who pursue agendas in accordance with their own political beliefs.

And if we do decentralise and delegate, we must align real power and accountability. Important services like the NHS must be accountable at local and national levels. Where broader policy is decentralised, leaders like mayors need the powers and single budgets to take decisions and do their jobs well. But equally they must not have the space to evade their responsibilities and blame central government instead.

In a country so used to centralised power, we should settle on the right political units – ideally cities, counties and metro mayors – to run most services. And we should deliver a “big bang” of decentralisation so local leaders are genuinely empowered and the public understands where power lies. The Tory urge to give power away is not wrong – but such power must serve the public, not vested interests and minority political causes.