The continuing row about health spending (Intervention by health chief meant NHS got less, 25 November) reflects the current structure of NHS governance, which is not fit for purpose. In the old days the relevant cabinet minister was unambiguously responsible for ensuring that the NHS had sufficient funding to provide an adequate health service. But, in accordance with recent fashion, NHS England was hived off as a kind of executive agency, with its chief executive undertaking a form of contract under which he was responsible for providing an adequate service. He could make representations to the Department of Health on the minimum necessary funding, but the minister would then negotiate with the Treasury and have the final say in the settlement.
If the amount on offer was inadequate in his view, then given his formal role Simon Stevens could not continue in office without making clear in public that it would not be enough to maintain an adequate service. This structure, which is now widespread in the public sector, is convenient for ministers who want to avoid responsibility for day-to-day operations in public services. But the divided responsibility promotes “small government” dogma and unaccountable power.
Alan Bailey
(Second permanent secretary HM Treasury 1982-85), London
• The government is so weak that rather than give the NHS the money it needs to function properly it cuts it back due to the intervention of the head of NHS England. Conversely of course this could be an attempt to blame Simon Stevens for the fact that the budget didn’t award the NHS anything near what it requires. Either incompetent or cynical or both. This about sums up this government’s approach. It is so busy covering its own back that the needs of its suffering citizens are ignored.
Jennifer Budden
Plymouth
• So the chancellor has condemned patients to more delay, inconvenience and possible harm because he was having a hissy fit about Simon Stevens?
Pam Lunn
Kenilworth, Warwickshire
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