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Stuart Carroll: How David Cameron should go about reforming the NHS quangos

Stuart_carroll Stuart Carroll is a senior health economist and Policy Analyst who chairs the Bow Group's Health Policy Committee. Here he summarises the new research paper he has co-authored for the Bow Group, "People Power: Reforming QUANGOs – Is this Applicable to Health Agencies?", which is published today and can be downloaded here.

In July 2009 in a speech to Reform, David Cameron made the unequivocal statement that “we do need to reduce the number of QUANGOs in this country” to increase public accountability and save taxpayers’ money.  Although the Conservative Party leader made it clear that it would be far too “simplistic” to propose a “bonfire of the QUANGOs”, he emphasised his strong appetite for significant reform of these organisations and a general rolling back of unelected governmental bodies.  Indeed, on the back of this speech Mr. Cameron asked his Shadow Cabinet to review every QUANGO within their respective policy briefs in a process continuing “up to and beyond the general election”.  

Given that the Conservative Party has pledged to ring-fence the NHS budget and is committed to real terms spending increases as way of number one policy priority, it is an important question to ponder as to which health QUANGOs could and should be scrapped; reduced in scope and size; reformed and renewed; or merged.  This is not least the case given the continual push for better healthcare service deliverability and efficiency; the parlous state of the public finances and associated recessionary pressures on NHS spending; and the wide-ranging number of health agencies that currently exist.   

In the same Reform speech, David Cameron set out the following questions that his Shadow Cabinet will have to ask when undertaking their QUANGO review:  

  • Does this organisation need to exist?
  • If its functions are necessary, which of them should be carried out in a directly accountable way within the department? 
  • And which, if any, should be carried out independently, at arm’s length from political influence? 
  • If there really is a need for an independent QUANGO, how can we make sure it is as small as possible, operating with maximum efficiency, frugality and respect for taxpayers’ money?

In our research published today, we apply Mr. Cameron’s criteria to each of the key health agencies and bodies in the UK to better understand which health QUANGOs (defined as agencies, committees, advisory boards and other organisations) should be scrapped, reformed or merged.

In particular, we focus on The National Institute for Health and Clinical Excellence (NICE); The Medicines and Healthcare products Regulatory Agency (MHRA); The Care and Quality Commission (CQC); The Health Protection Agency (HPA); The Joint Committee for Vaccination and Immunisation (JCVI); The Council for Healthcare Regulatory Excellence (CHRE); Monitor; and Regional Development Agencies (RDAs).  

Using expert interviews with many of the Chairs and Chief Executives of these agencies, our key findings include: 

  • Retain NICE, but ensure appraisal process is modified to account for wider evaluation and not simply economic evaluation.  Subsume the National Screening Programme into NICE.   
  • Further entrench the MHRA and build on its reputation as a global leader in the world of drug licensing and safety assessment
  • Ensure the CQC does not simply focus on badness, but also the promotion of goodness.  This is fundamental to fostering improved NHS efficiency and productivity.
  • Integrate the JCVI into NICE as a separate vaccines committee, but with important qualifications.  
  • Promote greater cross-collaboration between the HPA and other agencies.   
  • Consolidate the independence of Monitor.  
  • Conduct a comprehensive independent review of RDAs in terms of their impact on the healthcare sector should be performed.  
  • Abolish the Appointments Commission allowing its functions to be subjected to competitive tendering.

A key consideration for policymakers is the relative, and often marginal, trade-off between scrapping QUANGOs – and therefore usually having to significantly reconfigure parts of the NHS with associated cost and disruption – versus a more pragmatic approach of targeted reform and mergers.  Under the current Labour government, the NHS has been subjected to enough reconfigurations and reorganisations – most of which have been vacuous, gimmicky and fruitless – to last it a lifetime and certainly a couple of parliamentary terms.   

Although QUANGOs offering no or limited value should be abolished, the reality is often more complex.  In the new “age of austerity”, David Cameron is absolutely right to demand the comprehensive review of all QUANGOs, but ensuring his own criteria is applied with appropriate context and meaning is all-important.  This is important when assessing the relative merits of totally scrapping existing agencies.  In many cases, returning responsibilities to the DH would be disastrous and outright unworkable. 

There is little scope for the outright abolition of any of the major agencies such as NICE, the CQC, MHRA and HPA.  However, there is considerable scope for:

  1. Targeted reform to enhance operational efficiency and better foster opportunities for value added and value for money;
  2. Greater cross-collaboration and synergistic working across health agencies; and
  3. The integration and merging of smaller agencies – particularly advisory committees and bodies – into major health agencies of relevance. 

It is in accordance with this 3-point plan where a future Conservative government should channel its efforts and endeavours, and where the current Shadow Health Team should focus its attention.  This is the best way to bring about “people power” and to ensure that any reform of QUANGOs is made applicable to the needs of patients and the NHS.


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