- David Oliver, consultant in geriatrics and acute general medicine
- davidoliver372{at}googlemail.com
Follow David on X/Twitter @mancunianmedic
From 1997 to 2010 the Blair/Brown Labour government saw sustained improvements in the NHS. By the time they left office its performance had improved dramatically on a whole range of indicators, after major investment and improvement drives.1
The performance of acute, elective, and primary care has fallen drastically since then, along with staff and patient satisfaction.2 Social care funding and provision have been cut, as have grants to local public health teams, and funding solutions have been serially ducked or delayed. Health inequalities and healthy life expectancy have worsened.34 We now face a serious crisis in workforce recruitment, retention, and morale.56 And this year’s seen several industrial disputes between health workers and the government.7
None of this is inevitable, as the last Labour government’s record shows and both the King’s Fund and the Institute for Government have made clear.12 We could choose to improve things again. The Blair/Brown government inherited a strong economy and put the highest sustained real terms funding uplift into the NHS in its history, followed by the lowest and flattest period of uplifts after Labour had left office.18
The economy is no longer that strong. Labour is understandably wary of making uncosted or unaffordable pledges or any detailed spending commitments when trying to be seen as a sensible, serious potential government. Indeed, Wes Streeting, shadow health and social care secretary, told us at this week’s Labour Party conference, “Reform is even more important than investment. Because pouring ever increasing amounts of money into a system that isn’t working is wasteful in every sense. A waste of money we don’t have.”9
With Labour around 20 points ahead in opinion polls,1011 I looked with interest at Streeting’s speech for some substance beyond high level ambitions and rhetoric. He made a concrete pledge to end “non-domiciled” tax status and to use £1.1bn of the £2bn raised by this to tackle NHS elective waiting lists, by paying for extra clinical sessions to create an extra two million appointments a year. He also pledged to increase the availability of NHS dentistry with an extra 700 000 appointments a year, although without saying how or from what funding stream.
Policy scripture
Total spending on staff for NHS secondary and tertiary care is over £70bn12—which puts Streeting’s pledge in context. The current government has already promised an extra £5.9bn13 to reduce waiting lists that now stand at a record 7.7 million people,14 without making much of a dent. And there are no plans to increase the workforce in secondary care specialties that are already struggling with staffing gaps and exhaustion, or to create meaningful space for any extra work—for instance, in theatres or outpatients—although Streeting did pledge to “double the number of scanners,” without saying anything else about capital expenditure or indeed radiology staff to carry out the scans and report them.
He made the usual noises that politicians have made for decades about the need to shift towards prevention; to create a wellness service, not a sickness service; to move more activity out of hospitals and into primary and community care; and to use and modernise digital approaches, focus on early intervention and faster diagnosis, and make better use of genomics and artificial intelligence. This is by now just orthodox policy scripture: anyone can say it, and everyone does, but doing it requires meaningful plans, resources, and implementation. (Imagine anyone promising the opposite, and you can tell how platitudinous the headline commitments sound.)
Tackling these things and reducing inequalities also requires solutions well beyond what health and care professionals do, in terms of the wider determinants of health and socioeconomic policy.15 Streeting’s speech barely referenced this, beyond action on smoking. He didn’t mention restoring funding to local public health teams. Yes, he promised to “bring back the family doctor” by training an extra 4000 GPs. But the NHS England workforce plan already contains targets to increase GP training numbers and expand the primary care workforce.16 This can’t work without also focusing on retaining them.
Yet Streeting himself has at times used combative language towards GPs and has publicly doubted the viability of the partnership model.1718 And his tub-thumping use of the word “reform” is straight out of the Tory playbook, even though respected health policy commentators from the Nuffield Trust and the Health Foundation have argued that we need less “reform,” less “disruptive innovation,” and better investment in existing models.1920 This isn’t likely to win friends or raise morale. And the “family doctor” fantasy of a continuous relationship with one familiar, named GP is hard to deliver in most places given the current constraints and competing pressures—not least that of pushing more rapid access to appointments, which patients repeatedly say that they value.2122
Lack of detail
Streeting promised mental health hubs for children in every school, to be funded by ending charitable status for private schools, although we’d need to see the hard financial numbers and costings. There was nothing of note on adult mental health. Turning to social care, he pledged a “national care service”—which plenty of people in the local government and social care sector don’t want—and “national standards” for care, which are already set out clearly in the well regarded Care Act 201423 but never got the funding or political support to make them a reality.
There was welcome talk of a new deal for care workers to improve their terms and conditions, personal development, and retention. But with no detail on funding solutions for social care, nor on restoring local government funding so that care agencies can be paid a better rate by councils, nor on relaxing immigration rules to allow more overseas workers, it remains just that—welcome talk.
I have more confidence in Labour’s stewardship of the NHS, which it initially created, than I do in the Conservatives’, given the parties’ respective track records and ideological dispositions. But I saw nothing in Streeting’s speech to suggest a coherent, joined-up plan so much as a few eyecatching individual initiatives. There was little on the funding and workforce increases we need.
Otto von Bismarck described politics as “the art of the possible.”24 But if this is all that’s possible, especially when compared with the bold and concerted approach of the last Labour government, I don’t hold out much hope.
