Nigel Crisp, permanent secretary at the Department of Health, has started, without fanfare, on a corporate merger that will change the face of the NHS.
It abandons the idea, hatched by the Thatcher government, that the health service should be run at arm's length from ministers by an executive board taking responsibility for all operational matters. That led, in 1991, to the creation of a separate management structure, based in Leeds and known since 1994 as the NHS executive.
After taking over three months ago, in a new job amalgamating NHS chief executive and health department permanent secretary, Crisp began to dismantle this never entirely convincing arrangement. "I am managing a merger," he says. "It's a merger of all the elements of the department. We have to carry out the same functions, but in a different way."
On his first day in office, he spent almost £500,000 reorganising the department's social care regions to make them correspond with the eight NHS regions. A single senior management board, including health and social services chiefs, has replaced the NHS executive board and parallel departmental bodies. Crisp emails a standard monthly newsletter to chief executives in the NHS and local government and they communicate on a common, private website.
This amalgamation at the top mirrors the plan for much closer integration of health and social services at grassroots level. As the permanent secretary puts it: "We can't operate centrally in silos and expect them to work in a fused way locally."
The health service still carries the NHS executive logo, but that organisation "has to some extent disappeared", Crisp says. It is too soon to say whether the reform will be taken to its logical conclusion. "You are asking a question we are about to address . . . We will be looking, over the next two months, at how well the department is organised to deliver the NHS plan and the changes in social care. At that point we may end up making further organisational changes."
Does this mean the health service has been centralised, with operational power reverting to ministers and their senior officials? And how does this square with the frequent protestation of Alan Milburn, health secretary, that the NHS cannot be run as a monolithic nationalised industry?
Crisp insists the NHS was never a single entity. While it is commonly described as the biggest employer in Europe, it is really a group of linked employers, including 400 trusts, 100 health authorities and thousands of self-employed GPs.
"We should ask what it would be like if we behaved as if we were one organisation. What would be the advantages if we were one NHS?
"Some of the ingredients are already in place. The NHS plan provided a corporate vision and there are now national standards for cancer and other key areas of clinical care."
The "one NHS" management strategy would ask what other important decisions should be taken nationally and then devolve everything else. "We are talking about local creativity within national standards," Crisp says, citing the promised "earned autonomy" for greater investment to meet local priorities.
This promise of devolution may still ring hollow to NHS managers at trust level, who complain of a constant flow of edicts from national and regional controllers. But Crisp says they will soon come to appreciate the extra autonomy being offered.
That does not mean there will be no more cracking of the whip when things go wrong. Last month, the chief executive of the Bedford hospitals trust resigned within hours of Crisp ordering an inquiry into newspaper pictures of bodies stored in an inappropriate overflow mortuary. He says he would not hesitate to intervene on a matter of public concern, even if no rules had been broken.
There will always be a tension between national standards and local flexibility, Crisp acknowledges. But he says: "If we were having this conversation in a year's time, people would be saying they have more discretion and I would be saying national standards are better established and we are more prepared to let go."
