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30 January 2023

Just repeating “Reform!” won’t magically fix the broken NHS

The reforms a system like the health service needs most can’t happen without actually spending more money.

By Jonn Elledge

Nothing can ever be guaranteed in life, except death, taxes and Boris Johnson briefing friendly journalists that he’s thinking of staging a comeback. But four months after Labour opened up a 20 point lead in the polls, it feels increasingly likely that this government is now in its terminal phase. We may have to wait another two years, but by early 2025 Keir Starmer is odds on to be prime minister.

What he actually wants to do with this job is proving surprisingly hard to pin down (and let’s be honest, you wouldn’t believe him if he told you). One thing that clearly is on the agenda, however, is another bout of everyone’s favourite game of public sector musical chairs: NHS reform. Earlier this month Wes Streeting, the shadow health secretary, proposed the most radical shake-up of primary care in generations, with GPs, currently independent contractors, potentially becoming NHS staff. New routes for patients to refer themselves to specialists are on the table, too. Backing the plan in the Telegraph, Starmer wrote: “If we don’t get real about reform, the NHS will die.” Interesting choice of moment to give NHS staff another thing to freak out about, guys.

All of this has happened before; all of this will happen again. In the run up to Britain’s last change of government the Tories unveiled plans for radical reforms to the NHS, schools and higher education, all at the same time. By contrast, last week, the shadow education secretary Bridget Phillipson told a conference that “I’m not interested in wholesale structural reform”, so while we’ll need to see exactly what that means (“I do want to smooth over the differences,” the quote in Schools Week continues), perhaps the rest of the public sector should think itself lucky.

“Reform” is one of those political buzzwords that can sometimes inspire a response out of all proportion to its actual content. To centrist or right-leaning commentators, it has positive connotations, suggesting serious politicians with serious plans, willing to do what is necessary to give vested interests a bit of a shake. The left, by contrast, is suspicious of it for essentially the same reason, hearing it as a euphemism for doing away with pesky things like the public service ethos.

This is not entirely irrational: past rounds of reform have introduced either private payments (dentistry; tuition fees) or providers (the Blair government’s waiting-list clearing Independent Sector Treatment Centres). But none of that seems to apply here – removing GPs’ independent status would be, ironically, much closer to nationalisation – and another problem with that word is that assuming it disguises a secret evil plan is sometimes to give too much credit. At times, in fact, it seems to come without any policy content at all, as a hand-wave to mean simply “things will be better”. How do we make the health service more responsive to patient needs? Reform. How do we do more for less? Reform. Say that enough times, and tedious questions like what it is we should actually do can be left to one side.

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For all this we can probably blame the Blair years, surely the golden age of moving bits of public services around to show how serious and grown-up you were. Some of the reforms of that era, like the aforementioned ISTCs, were about adding capacity; some were intended to improve standards, by subjecting public services to something approximating competitive pressure. Sometimes they worked, sometimes they didn’t, and often it was difficult to know which was which because before anything could bed in there’d be another rearrangement at cabinet level and in would come another minister determined to leave their own mark.

All of which meant that, even if the individual reforms were positive, it became hard to feel confident the constant change was anything other than a drain on goodwill. It didn’t help that most reforms seemed to be there partly to communicate Blair’s core message that, despite leading the Labour Party, he was on the side of consumers, not public sector staff.

That is surely a factor in what’s happening now: the urge to talk about reform is an attempt to genuflect to the sort of commentators who still think the Labour Party should be willing to tell workers things they don’t want to hear. But given that morale is already on the floor at the moment, one has to ask whether this is really the clever, grown-up thing to do at all. You’d have to be certifiably insane to look at the NHS as it is right now, with its recruitment crisis and its growing dependence on expensive agency workers, and conclude that the problem is that it’s being run in the interests of its staff.

There’s one other reason to be wary of the R-word: it’s sometimes pitched as an alternative to simply spending more money, and in the Blair years, “accepting reform” was often presented as the price of funding increases. But sometimes the reforms a system like the health service most needs (more stable staffing; a better social care system, so that relatively healthy elderly patients can be discharged) can’t happen at all without upfront investment. Talk of reform may be a barrier to understanding that, sometimes, the solution really is just to spend more.

So perhaps for Starmer’s Labour Party the promise of reform plays another role altogether. Perhaps it’s simply a way of finding something positive to say. “If we spend a lot of money and get everything right, it’ll be no worse than it was 13 years ago” may be closer to the truth. But really, who’d feel excited to vote for that?

[See also: Keir Starmer interview: “Am I aiming to be just a one-term prime minister? No, of course not”]

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