Why Wes Streeting is set for war with the health service

Wes Streeting, the new Health Secretary (right), has described the NHS as 'broken'
Wes Streeting, the new Health Secretary (right), has described the NHS as 'broken'

The history of the NHS is littered with attempts by ministers to reform the institution for the benefit of patients.

When Wes Streeting, the new Health Secretary, described the NHS as “broken”, and said it was now the policy of the Department of Health to treat it as such, he was laying down a marker for the scale of the challenge ahead of him. But he may have inadvertently set himself up for the mother of all battles with health service bureaucrats and unions.

Jeremy Hunt, former chancellor and health secretary, suggested in his acceptance speech on Friday that Labour’s majority may leave it better placed to “make much needed reforms to the NHS in a way that seems difficult for Conservative governments to do”. But Stephen Dorrell, who had his share of battling the NHS “blob” when he served as Conservative health secretary under John Major, said Mr Streeting had to be careful not to squander the good will he will enjoy as a new minister with a strong mandate.

“As a new minister you have got a stock of political capital which you have to use, but you’ve got to use it intelligently and selectively,” he told The Telegraph. “You can’t win all the battles at once and you can’t deliver health care without the staff being willing to give you a chance – that’s the first battle to be won.”

Mr Dorrell added: “It’s always been the case that Labour has permission to do more with the NHS than a Tory health secretary does and Labour has more freedom of manoeuvre, but the problems of the NHS don’t end with a change of government.

“All the issues of small ‘c’ conservatism that Tony Blair spoke about remain within the health service. I certainly wish Wes Streeting all the luck in the world. He’s going to need it.”

From its inception, the NHS has resisted change, with its founder Nye Bevan forced to threaten, cajole and do deals with private consultants to get them to come on board a system based on free healthcare at the point of demand.

Throughout its 75-year history, ministers have repeatedly warned that reform was vital if the health service was to survive. As a way of tackling patient waiting lists and introducing efficiencies into the system New Labour established an internal market in the NHS. But critics said this pitted one hospital against another, with services left to compete for scarce resources.

The failure of reform has been a constant theme over the past decades, with the last Tory administration seemingly unable to make progress on its stated aim of reducing waiting lists and offering patients greater choice of out-of-hospital care in order to reduce the burden on inpatient services.

Only last year, a report by the Commons’ Public Accounts Committee (PAC) said any reforms would founder if the major systemic problems in the NHS were not addressed by the government at a national level. Dame Meg Hillier MP, the then chair of the PAC, said: “Far from improving the health of the nation, staff shortages and the dire condition of the NHS estate pose a constant risk to patient safety.

“But government seems paralysed, repeatedly rethinking and delaying crucial interventions and instead coming up with plans that do nothing to address the fundamental problems of funding and accountability.”

Anne Marie Morris MP, the PAC’s lead member, said at the time: “Everything changes yet nothing changes. While the ambition is right, the tool kit simply isn’t there to deliver on it. As one of the biggest spending departments funded by taxpayers, more transparency is needed to show what, how and by when the taxpayer will see not just an improvement but a health and care system that works and is truly there when it’s needed.”

These are the questions that the Treasury also asks every time there is a demand for more money. However, since 2013, the Department of Health has not, in fact, been responsible for the day-to-day running of the NHS in England. This has been the job of NHS England, a non-statutory body set up to improve accountability of the health service. And so governments have faced continual lobbying for extra funds from a body that always seems to have a reason to ask for more money.

Between 2014 and 2021, the chief executive of NHS England was Simon Stevens, now Baron Stevens of Birmingham, a man feted by successive prime ministers but one whose political nous and media profile made him a de facto minister in his own right. A year before the announcement of the Health and Social Care Levy in 2021, an increase in National Insurance to provide extra funding for the NHS and social care, Stevens used his clout as a respected public servant to leverage his agenda through the media, making the relationship between the two sides more complicated.

Baron Stevens was a powerful figurehead for the NHS and was able to lobby successfully by using public opinion to press his point. In July 2020, he went on the BBC’s Andrew Marr show to call for urgent action to improve social care.

Unfortunately for the then government, senior Conservatives were appalled to learn it had failed to secure commitments from NHS England to increase the availability of face-to-face GP appointments as part of the settlement, with sources reporting the Treasury had requested such assurances but could not enforce them.

“Stevens pretty much got everything he wanted,” said a former Whitehall adviser. “Which minister wants to say no to the NHS? What the public wants is for politicians to get out of the way. We want doctors and nurses and experts running the NHS. The problem is when politicians do that, the public still blame them regardless. Wes Streeting is going to have the exact same problem.

“There was some mistrust with Simon Stevens, because of who he was and how he operated. He was effectively a politician. The NHS would actively brief against the government in newspapers and it became like another government department with an unruly secretary of state. He personally created a lot of problems for the government.

“To some extent the lobbying worked. Once you give in to it, it’s going to keep happening.”

The belief inside government at the time was that the line of questioning Baron Stevens was subjected to as chief executive on programmes such as the Andrew Marr show was less aggressive than that faced by ministers, even though he was the one ultimately responsible for running the service.

Amanda Pritchard, who took over as chief executive in 2021, is generally considered less political and more focused on the job at hand.

But the challenge faced in the last couple of years of the Conservative government, and awaiting the new Labour ministry, is that any plans for reform must take place amid huge backlogs, in part a legacy of Covid. The Treasury is an institution that prefers not to think beyond five years, but the exception is the Long Term Workforce Plan, which requires a spending commitment covering a 15-year period starting from 2021-22 and costing the equivalent of £50 billion.

“The NHS is always looking to stick within budget, but the incentive to do so doesn’t exist because they know fundamentally that ministers will bail them out and give them more money,” added the adviser. “There are always conditions attached, but, when push comes to shove, if they need more money they need more money.”

The strength of the bargaining position of the NHS is, in effect, seasonal, and increases as winter approaches, with ministers keen to downplay the public concern of a “winter crisis” even though these always exist in varying degrees of seriousness every year. There is always the possibility that they will have to answer to doctors and claims by NHS England that they need more money to cope with the effects of the cold weather.

“Requests for funds will go to the Department of Health first or, if it’s new money, to the Treasury,” said the adviser. “Discussions over the budgets are open as all sides can see them, and, eventually, a compromise is reached. This happens on a weekly, if not daily, basis. When there is an urgent, acute issue to respond to, it does require new money, especially in winter.”

A new government with a clear mandate provides a brief window to address the chronic short-termism of the NHS. “If Labour is going to do something, it has got to do it now,” said the adviser. “It’s very painful, you burn through a lot of capital and the results are quick. Labour can get away with a lot more than a Conservative government can, including private providers. If the Tories try to do it people cry ‘evil baby killers’.”

Possible resistance remains

The response of NHS unions and professional bodies to Mr Streeting’s description of the health service as “broken” suggests the possibility of resistance remains to any proposed changes to the way it is run.

They warned that while they welcome Mr Streeting’s sober assessment of the problem he will need to negotiate with them rather than impose reforms from above.

Prof Philip Banfield, BMA chair of council, whose junior doctor members have been engaged in a protracted pay dispute with the previous Tory government said he had written to Mr Streeting offering to “work together to get the NHS back on its feet”, with the aim of “resolving disputes, bringing waiting lists down and delivering an improved health service for staff and patients”.

He added: “With the right leadership and the right investment in staff, our NHS can recover.”

The Royal College of Nursing (RCN) said the difficult issue of pay had to be resolved if services were to be improved.

A spokesman for the RCN said: “NHS staff haven’t given up, but they are exhausted and need the secretary of state to help.

“A fair pay settlement for all is the first step into rescuing health and care services, along with proper investment to boost recruitment and retention. We can’t keep asking the same dedicated health workers to do more with less.”

‘Get down to work’

Sir Julian Hartley, chief executive, NHS Providers, the membership organisation for NHS hospital, mental health, community and ambulance services, said: “Trust leaders welcome Wes Streeting to the job and are ready to get down to work with him.

“It’s vital that the Government works with trust leaders to get to grips with the challenges facing the NHS, as well as the opportunity to make the NHS better for patients and staff.”

Sir Julian said NHS Providers welcomed Labour’s recognition that more and capital investment was needed for essential repairs to crumbling NHS buildings, equipment and facilities and for social care services.

Christina McAnea, Unison general secretary, said Mr Streeting was right to paint a picture of the NHS in desperate need of urgent repair.

“The NHS is indeed in dire straits. Years of under-investment have left services with too few staff to meet the growing demands being made. Change is essential if delays, waits and the backlog are to be consigned to history,” she added.

“That means upping resource levels, tackling the staffing crisis and fixing pay across the NHS, something the previous government failed to do.”