As Steve Barclay – the newly reappointed Health Secretary – sits down at the cabinet table with Jeremy Hunt – the relatively newly appointed Chancellor – there will be some interesting dynamics at play. Barclay had a brief stint in the role over the summer, but when Liz Truss took over at No 10, she installed her close ally Thérèse Coffey in his stead. Two months as secretary of state would have been barely enough time for Barclay to even begin to get to grips with the issues.
He will now find himself working alongside a chancellor who knows more about health and social care than virtually anyone in parliament. Hunt remains the longest-serving health secretary having held the post for six years under David Cameron then Theresa May. And for the past two years he has been a passionate chair of the House of Commons Health and Social Care Select Committee, overseeing several substantial inquiries during which – freed from the constraints of ministerial collective responsibility – he proved willing to put his own government’s record on the spot, a record he has expressed some regrets at having being a part of.
Barclay retakes the reins at a time of unprecedented crisis in both the NHS and social care. From his few pronouncements over the summer, he understands workforce vacancies to be a pivotal issue, though his solution – greater recruitment from developing countries – is ethically dubious and may meet stiff resistance from the anti-immigration Home Secretary, Suella Braverman (assuming she remains in post). Barclay also identified top-down targets and centralised control as problematic, and was minded to liberate local leaders to develop their own solutions to the challenges faced by their services.
Hunt will be sympathetic on both these issues, but he will also recognise them as sticking plasters rather than the strategic rebalancing the entire system requires. It is now widely accepted that without radical steps to transform social care into a decently remunerated and attractive career, the crisis in our hospitals will never be solved.
Alongside this, Hunt’s select committee’s report into the future of general practice – which was published just days after he moved to the Treasury – has shed stark light on the concomitant crisis in NHS primary care. The committee reiterates the need to expand doctor numbers in order to restore adequate capacity in general practice – something Hunt promised to do in 2015 but failed to deliver on. Just as importantly, over the course of its year-long inquiry, Hunt’s committee became intimately acquainted with the overwhelming evidence of the vital importance of continuity of care.
This is where doctors and patients build relationships and interpersonal knowledge over time: the notion of the “family doctor” is shorthand for this. Continuity has been gradually declining since New Labour introduced its disastrous 2004 GP contract and has gone into free fall since 2010, accelerated by the impact of Conservative austerity together with the policy to push GP surgeries to operate at ever-increasing scale. The select committee report details how continuity not only results in far better patient experience and healthcare, it also substantially reduces activity in hospital and emergency services. Its restoration is the second key strategic shift required, something Hunt’s committee has at last put firmly at the centre of the policy stage (even the Telegraph, which along with the Daily Mail has been waging a campaign of denigration against general practice since 2021, has now joined calls for the return of the “family doctor”).
Transformation of social care and the re-establishment of proper general practice will both take considerable investment, which they will repay in the medium to long term by reduced activity in the resource-intensive hospital and emergency service sectors. They represent a classic instance of “invest to save” (which will also greatly improve quality and patient experience). But even though Hunt will understand this keenly – and would naturally be sympathetic to policies Barclay may propose to address the challenges – his role as Chancellor puts him in an unenviable quandary.
Charged with rescuing the Conservatives from the market mayhem provoked by the Truss/Kwarteng mini-Budget, Hunt is having to contemplate public spending cuts – a rerun of the Cameron/Osborne austerity that helped create the current health and social care crisis. And the positive impacts from those major rebalances in the health and social care system will take considerable time to come to fruition. Short-term sticking plasters rather than long-term healing must be tremendously tempting to an unpopular government facing electoral retribution in less than two years’ time.
Waiting in the wings is the shadow health secretary, Wes Streeting. Barely a year in post, he is developing a promising strategic vision – one that strongly suggests close attention to the inquiries conducted by Hunt’s select committee. Labour’s response to the NHS workforce crisis would be to dramatically expand UK medical, nursing and midwifery training places. Judging from his recent essay in the New Statesman’s policy supplement Spotlight, Streeting has also grasped the imperative to restore continuity of care in general practice – although he remains paradoxically enthusiastic about direct access to specialist services that would be injurious to both patients and the NHS.
Could MPs from both major parties with a passion for health and social care – who evidently share much common ground – come together to create a long-term plan that supersedes political machinations and the electoral cycle? The answer should be yes but will inevitably be no. Another indictment of a governmental system that kicks vital public services about like the proverbial political football.
This article was originally published on 4 November. It has been republished in light of the news that the Royal College of Nursing has announced the first national strike in its history.