This week: Sir Chris Wormald, permanent secretary at the Department of Health and Social Care
Why he matters: As well as leading the DHSC since 2016, Sir Chris is the head of the civil service policy profession, responsible for improving the way policy is developed and implemented across government.
This article is based on a speech Sir Chris made in April at the Institute of Government on ‘The future of policy making’ (follow this link to watch the lecture in full). The context was provided by a new set of rankings which placed the UK civil service as the most effective in the world, but only third on policy making (after Finland and Denmark).
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“The era of policy making where tremendously clever people went into a dark room together, had a brilliant idea and then announced it to a grateful nation [is over],” Sir Chris told the IfG audience.
However, before explaining what a new “era” would bring, Sir Chris began by attempting to define policy making.
“It is about the bringing together all of the evidence, the analysis, the subject knowledge. It is [about] the interface between democracy and policy and understanding how that interplays, and then asking yourself the question, ‘will it [the policy] actually work?’”
Policy makers should be “confident and humble”, said Sir Chris. This means they do not necessarily have to be “experts” in any one subject. They should, however, be able to “reach out to world-leading opinion”.
Effective policy makers should know: “Who are [the] experts, what do they think and how do I bring them in? [They should also know] which jurisdictions are better at whatever the subject is [being considered]. Is it Germany? Denmark? Finland?”
He explained the DHSC was “doing a big push on changes to organ donation today. Wales went first [and] we learned from them.”
This approach, said the DHSC chief, requires policy makers to “think it is their job to be up to date on latest thinking on how you make policy, in the same way that every doctor in the country thinks it is their job to be up to date with… the limits of medical practice”.
“I don’t think we’ve quite got the culture yet,” he added.
The need for and lack of evidence-based policy is a constant matter for debate within the NHS.
Sir Chris told the IfG: “In the Department of Health we do a survey of which policy submissions reach [the] evidential standards acceptable [to] our chief economist and chief scientist.”
But, he argued, there is a need to reach out further beyond experts and try to involve the wider public in policy making, and said digital technologies offer that opportunity.
“My department did a huge [digital] exercise about the actual experiences of carers – and people were contributing as they were doing it. That is so different from [just] holding a consultation meeting or asking the representative groups.”
And digital engagement is an area in which the head of the civil service’s policy profession says the UK government has the most scope for improvement. InCise – an international index for civil service – ranked the UK below average for “digital services” and a league away from leaders Estonia, Denmark, Latvia and Austria.
Great policy, just couldn’t be implemented
Drawing on a wider input, Sir Chris suggested, would help avoid “group-think in policy making”, as well as improve “diversity and inclusion” in evidence collecting.
He also suggested it would make sure policy making served “the taxpayer and the voter” as well as the users of a public service.
Sir Chris said improving the evidence base would help remedy the biggest problem with civil service advice – consistency.
“A lot of feedback from ministers is that the best civil service advice is brilliant… But it’s not all like that, and the gap between the really good and the not [good] is quite wide. I’ve had some ministers say to me ‘there is no middle ground’, that they’ve never read a moderate piece of policy advice, it’s either been ‘this is what I want’ or ‘I don’t want to read it.’”
Another challenge is policy across departmental silos. The DHSC permanent secretary said the departmental approach created focus but can fail when addressing complex issues, like climate change.
“If you look at the policy problems we have not solved, they are very frequently these big cross-cutting things where it’s not obvious whose job it is to solve them.”
The head of the civil service policy profession said it was getting better at making sure “the person who would be implementing” the policy was “in the room” – something which was especially useful when ministers were demanding things happen unrealistically fast.
But he admitted: “You still occasionally [hear] ‘it was a great policy; it just couldn’t be implemented’. Which is an extraordinary definition of what a great policy is.”
To produce deliverable policy, Sir Chris says, civil servants must advise ministers on when and how to implement policy, as well as explain the rationale for it to those affected.
“The vast majority of policies are implemented by consent, both of the people doing them and the people who are benefiting,” he said. In my world it is simply impossible to implement a policy that contravenes medical ethics, and so no one tries.
“The Department of Health is, today, launching our campaign on changes to organ donation from an opt out system to an opt in system. When we were developing the policy [there was] obviously a technical bit: is it the right thing to do? Can we actually do it etc? But there’s [also] a huge public opinion piece [too]. Public opinion changes and policy cannot work unless it is in line with public opinion.
“[Organ donation] is an extremely interesting debate – not really party political, but deeply moral and ethical. There were very different opinions amongst the public about kidney and heart transplants, [as opposed to those on] hand and face transplants. And [so] we don’t have the same policy [for all transplants]. You have to be where public opinion is.
“Understanding the dynamics of the public debate is intrinsic to whether you can create a deliverable policy or not.”
Getting things right also means being “much more iterative” in policy making.
“The traditional way of doing policy, [which is] we’re going to publish a white paper, consult on it, and [then implement it]… implies the government always has the answer. [Digital technology allows] a much more iterative way of doing policy, where you try things out, you get responses, you amend 5 per cent of it, and [you recognise] it’s never [finished]. You don’t say, ’here’s the finished policy’.
“Social care is a great [example], [the answer] is going to change as demographics and technology changes. There’s never going to be a [final] answer, and therefore what you want is a much more iterative type of policy making that is a conversation with the country.”
Sir Chris stressed there was a time when a solution was best sought through a “civil society debate” rather than government action.
There were many good examples in the health sector, he added, highlighting end of life care which, he said, “is debated in the health service and by individuals and by the voluntary sector without government participation”.
The NHS is different
At HSJ’s request, Sir Chris then turned to how NHS policy is made.
He declined HSJ’s invitation to say specifically whether the 2012 Health and Social Care Act would have been improved by the new approach, but added that the method “where you decide on a model, legislate for it, then deliver and discover that it doesn’t quite work how you wanted it to, but you now can’t change because it’s set in legislation is not a great way to make policy”.
He continued: “There is a dilemma here and the NHS is a perfect example of it. It is right that government can only act in accordance with the legislation it has passed…but you also need to be flexible enough to allow yourself to try some things out so that you know that what you’re doing is working, and squaring that circle in how you make policy is always a challenge.”
In an attempt to do that the DHSC has taken a back seat on much healthcare policy and allowed NHS England and others take the lead.
“What we’re doing in health is actually a different way of making policy whereby the NHS itself is proposing things and testing them and then coming to government and saying, ‘If you want us to do x, this is the type of legislation or kind of policy framework we would need.’”
This means, said Sir Chris, that you can then “legislate for a model that you’ve tested somewhere and now know works – having learned some things along the way”.
“So, when you go to Parliament and say ‘I want powers’, you’re actually getting the model that you want.
“You’ve got a sector of 1.4 million people, [so] of course a few civil servants or ministers are not taking every policy decision and you wouldn’t want them to. You want the person who understands the local area to take the decision and the person who’s the specialist in the area, the person who’s got the medical expertise. But then of course you [also] want overall ministerial responsibility and for the voter and the public to know what they’re getting and be able to hold us to account.”
[Editor’s note: Those interested in how this “different” way of making policy is playing out in practice should have a look at the transcript or video of the 24 April Commons public accounts committee hearing with Sir Chris and senior NHS leaders. If you do, be sure to witness the fabulously catty exchange between Simon Stevens and retiring National Audit Office chief executive Sir Amyas Morse at the very end.]
Coming up: Ryoji Noritake, chief executive of the Tokyo-based Health and Global Policy Institute and expert on the ’super-aged’, Harvard professor of public health David Williams, NHS VAT campaigner Karin Smyth MP, and health secretary (and would be PM) Matt Hancock on the NHS in 2050.
If there is any political or influential figure you would like me to interview, please email alastair.mclellan@wilmingtonhealthcare.com or if you are reading this on the website leave them in the comments box.
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