When Victoria Atkins was appointed as the new Health and Social Care Secretary this week, two things were instantly apparent.
First, the top job had gone to someone with a total lack of experience in health policy. Second, the NHS in England was getting its fifth secretary of state in just five years.
As the health service faces yet another winter crisis, there may be a new face in the department but many of the system’s deep-seated problems remain unresolved.
Jeremy Hunt is under pressure to use next week’s Autumn Statement to deliver a £1bn cash bailout to cover the cost of this year’s strikes.
Yet doctors are still in dispute with the Government, with more industrial action not ruled out. For good measure, a damning new report found that Boris Johnson’s 40 “new” hospitals are either too small, imaginary, or late.
All this as waiting lists have soared to a record 7.6 million, many struggle with the “8am rush” to book a GP appointment, most maternity units are deemed unsafe and social care limps on.
But while Labour’s Wes Streeting has been witheringly critical about the litany of woes afflicting the NHS, his own plans – and in some cases, the lack of them – are coming under increasing scrutiny.
In the latest episode of our i podcast, Labour’s Plan for Power, we explored just how Streeting plans to balance the urgent need for investment with his longer-term vision for reform.
As an unashamed “moderniser”, he is clearly tempted to borrow from some of the Tony Blair playbook, but with the NHS facing much greater pressures and the economy in worse shape than the 90s, his room for maneouvre is limited.
Critics say that it’s hard to see how Streeting can square the circle without tax rises, but he told i: “We can’t just reach for the solutions of the last Labour government and say, ‘oh, we’re just going to chuck up national insurance to fund the NHS’ – because people can’t afford it.”
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Streeting stressed that his current plans to spend £1.1bn on extra overtime for staff to clear the waiting list backlog, on more scanners and more dental appointments, were just “first steps”.
Yet he was also unabashed about the way the spending taps won’t come on quickly. “Even if Rachel Reeves had a complete personality transplant and suddenly became this big spending Chancellor, the money simply isn’t there,” he said.
Crucially, Labour insiders quietly signal that while the extra health cash already announced will be fleshed out in the manifesto, there really won’t be any new major spending announcements on health or social care policy before the election.
So, the real battle for the future of the NHS is likely to take place behind closed doors, in Rachel Reeves’s first Treasury spending review – with a new, three-year, cross-Government plan either in late 2024 or early 2025.
That’s when we may discover exactly how much Labour will change the Tories’ current trajectory of yet more squeezed capital funding on things like diagnostics and IT.
Whenever the party gets round to specifics, the key request of many I talked to was for certainty. Anita Charlesworth of the Health Foundation points out the contrast between the enduring nature of the NHS (in its 75th year) and the stop-go funding it has suffered for decades.
“If you look at the funding over that history… It’s boom and bust. We run it on an hour-by-hour, almost week-by-week model,” she said. “And that volatility makes it really hard to plan services, it makes it really hard to run care efficiently. If we were able to provide more stability of funding, we would find, actually, that we didn’t need quite as much funding.”
Former Health Secretary Alan Milburn, who is as keen as anyone on reform, says that a strong signal of money coming down the road is also essential.
“The really critical thing that people forget about our time in office, is that it wasn’t just the scale of the resourcing, it was the visibility of resourcing over a period of time. The critical thing I found when I was doing the job is what people really needed was line of sight, they needed visibility, so that they could plan for change over a period of years.
“So one of the things I think a new government should think about… [is] where it can be very clear with local healthcare systems that ‘this is the amount of money that you’re going to have’, not just for one year, but over two, three or four years, so then they can plan for the changes that lie ahead.”
Trade unions in the NHS would welcome some stability of funding, but Labour’s current reluctance to say anything specific about public sector pay will certainly be tested in office too – as the Royal College of Nursing made clear to us, it was ready to keep striking to get its way.
Andy Burnham, himself a former health secretary who ditched some of the private sector’s role in the NHS, is another reminder that Starmer will face opposition within his party if he pushes that issue again.
Some in the NHS also worry that Labour are making a mistake in reaching for the same levers – including top-down targets – that Blair tried to pull a generation ago. Starmer has announced he would reinstate New Labour targets for ambulance response times to cardiac arrests (within seven minutes) and return to the target of 95 per cent of all A&E patients being seen (within four hours).
There’s a concern that such Blair era targets are outdated, would need much more funding than currently offered and would waste money better spent elsewhere. The hope is that he will somehow finesse them in office, following expert advice.
Streeting has shown a willingness to change tack, not least from what looked like an original plan to “tear up” the GPs’ contract and practice model. In our podcast he was notably warmer to GPs’ main concerns about cutting red tape and allowing “face-to-face” consultations for those that need them, rather than the Government’s straitjacket of a two-week target to see a GP.
On social care too, some are prepared to cut Labour some slack on their lack of a public, detailed plan for funding reform – itself almost inevitable given the “death tax” and “dementia tax” weaponisation of the issue in recent elections. Its immediate focus instead will be on improving pay and training, which in turn can help tackle the sector’s huge staff shortages.
But that patience relies on the party working up a programme in private that it could start consultation on pretty soon. The King’s Fund’s Sally Warren said she was relaxed “as long as there’s some pace” on developing a 10-year plan and “that we’re not still debating it in five years”.
Streeting sounds open to working with the Conservatives if needed. “I really hope that we can build the kind of national consensus around social care that we’ve had for most of the last 75 years on the NHS. So we can’t keep on allowing bad politics to hold back social care.”
Yet some experts privately believe the key is for the party’s manifesto to at least set out a vision for social care – skillfully worded and sufficiently flexible so that Starmer can then claim he has a mandate for change if he hits political opposition that has derailed so many previous attempts at reform.
Milburn is certain of the need to have plans ready to go. When I asked him the one piece of advice he’d give Streeting, he replied: “Go further, go faster. Change, as a rule, in my experience, always takes twice as long as you think. And particularly when you’re trying to turn around what is an enormous supertanker of a care system, health and social care, you’re having to influence one and a half million people’s behaviour. And that’s hard. And it just takes time.”
And this is one place where he admits New Labour failed – by not having a plan early. “My biggest regret in a sense is that that is what we didn’t do. When Tony Blair rang me to ask me to become the Minister of State, number two to Frank Dobson [Blair’s first Health Secretary] in ‘97.
“I asked him on the phone, what is it that you want me to do? And his reply, which is seared in my memory, was ‘we need a health policy, Alan’. For six months, we worked on ‘what was the health policy?’ The truth is that should have happened in the previous six months or the previous 12 months or previous 18 months.”
Another figure from that time, Blair’s former No 10 policy chief Matthew Taylor (now at the strictly non-political NHS Confederation), had another mea culpa – that the party didn’t devolve enough power to local NHS trusts or health authorities.
“I think in ‘96 we were arguably a bit more kind of polished, maybe a bit more charismatic, a bit more, kind of exciting than the current Labour opposition might be. But I think if I look back to that time, there was also a certain arrogance about us.
“There was a kind of view which was that the only real problem with the country was the wrong people were running it and once the right people were running it, things would be okay.
“I sense in the current Opposition, a pretty deep understanding of how great the problems of this country are.”
But among all the most acute shortages in the NHS and social care at the moment, perhaps the most telling is a shortage of hope.
Time and again in interviews for the latest podcast, the need for hope was the most common theme – with clear staging posts to show progress in the first term of a new Government, and worked-up plans ready to go from day one.
The BMA’s Katie Bramall-Stainer says staff deserve to know sooner rather than later what Labour’s detailed plans are – in order to implement them smoothly and quickly if need be.
“Certainly the workforce needs hope, and it needs a light at the end of the tunnel… that light at the end of the tunnel is fragile and it can be blown out. And the egg timer is running out. So we don’t have a lot of time.
“We know that manifestos will come out next summer, but that’s probably too long. We need something sooner. We need a little bit more, need to flesh out this plan so we can start engaging with it.”
Charlesworth agrees. “You need to provide and hope for the public and patients, and hope for staff, but realistic hope. The public and staff are not stupid, you know, they do understand that to get enough staff to get the sort of facilities that we need, the capacity we need, you can’t suddenly turn that tap on, it will take time.”
Starmer, Streeting and Reeves clearly hope they can buy time for themselves by appealing to the goodwill and patience of NHS staff and the public. But both goodwill and patience may run out very quickly unless Labour has the plans and the cash to show some early signs that change is on its way.
