It’s an old cliché that politics is the art of the possible (in fact, Bismarck said something much more interesting, namely that “politics is the art of the possible, the attainable – the art of the next best”). But in the case of the NHS, the Overton window of what is possible for a Labour government with a large majority is much larger than it has been for any Conservative government. After all, it was Labour’s Alan Milburn who brought in private providers to successfully bring down waiting lists. It would have been condemned as an egregious example of NHS privatisation if it had been done by a Conservative government. But will the Health Secretary, Wes Streeting, use the opportunity he now has?
After the pandemic, the issue is not money. The UK spends less than France and Germany on health, it’s true. But at 10.9 per cent of GDP it is well above the OECD average of 9.1 per cent. The question instead is why its outcomes are so much worse even than countries like Denmark and Australia, which spend less.
As the longest-serving health secretary in UK history and author of a book on the NHS called Zero, I have thought about this a lot. My conclusion is that the NHS, as the world’s largest healthcare system, has become just too big and bureaucratic. Managers are weighed down by hundreds of operational targets in a way that would be inconceivable in other countries. Even GPs have nearly 80 “quality and outcome” targets. It is the most centralised healthcare system in the world. Faced with job-threatening operational targets that have to be delivered within weeks, how can a hospital chief executive possibly implement long-term strategic change such as a new IT system, improvements in patient safety (say, maternity units) or AI-enabled note-taking for nurses?
When Streeting announced the abolition of NHS England I said it would work if it led to fewer targets, but fail if it just switched to micromanagement from the Department of Health and Social Care instead. Since then, former health secretary Patricia Hewitt has sounded the alarm. She runs Norfolk and Waveney Integrated Care Board and told the Health Service Journal that exactly what I feared is now happening: “The real problem is combining the abolition of NHS England with hugely increased micromanagement from the centre,” she said. “If [Streeting] was proposing to combine abolition with decentralisation… then I’d be all for it. But as it stands, it’s one more tightening of the screw, I fear.”
As a prospective parliamentary candidate I actually slept out overnight in Parliament Square as a protest against a local reconfiguration. Patricia Hewitt was trying to push through in my patch. But I came to have high regard for her, even asking her when I was chancellor to do a report on how to decentralise the NHS. She did, and we implemented her recommendations. NHS England targets in the planning guidance were massively reduced.
Now is the moment to go further and scrap national targets altogether. When Home Office targets were scrapped in 2010, police forces were freed up to allocate resources in the smartest way. Crime (at least non-computer crime, which was all that was measured then) fell dramatically. The story was the same with school standards, which have soared since we freed up heads (something Labour is foolishly trying to reverse for academies). If we want to transform the NHS we should empower integrated care boards (ICBs) and hospital senior leadership teams in exactly the same way: full accountability for standards of patient care, including safety, quality and waiting times through transparency – but total freedom as to how to get there.
Indeed, why not go the whole way and make ICBs report to local mayors rather than the Health Secretary, as happens in Scandinavia? It would stop the NHS being turned into a political football at elections. It would unleash local innovation and transformation on a scale and at a pace quite impossible under the dead hand of Whitehall bureaucracy. It would be bold – but the NHS will not be fixed by timidity.
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