Since Labour won power last July, Keir Starmer has repeatedly affirmed his deep affection for the NHS, close family ties to it, intention to “fix” it – and also his determination to change it.
In a speech last September, he said the health service in England is in such dire straits that “it’s reform or die” and his government’s plans to overhaul how it works “could amount to the biggest reimagining of our NHS since its birth” in 1948.
Wes Streeting, his high-profile health secretary, echoed that same cold-eyed message in his address to Labour’s party conference two weeks later. The choice facing the country’s most vital service was “reform or die – we choose reform”, he said.
Beyond that bold rhetoric, however, Starmer and Streeting have – until now – given little in the way of concrete detail about exactly what that plan for reform will entail. The detail will be set out in a 10-year health plan, due in late May, which is being drawn up by Streeting and a coterie of advisers. It will put flesh on the bones of the “three big shifts” in how healthcare is provided that both have promised: from an analogue to a digital service, from care in hospital to community-based care and from treating people’s illness to preventing them from getting sick in the first place.
But the biggest, most radical element of the plan is now in the public domain: the abolition of NHS England, which the prime minister announced in a speech on Thursday about re-engineering the state. The executive body has run the health service in England since its creation in 2012, when it was handed independence from ministerial control and given responsibility for the operation of its 220 trusts, delivering treatment waiting times and making its ever-larger budget fit.
Streeting is merging NHS England with his own Department of Health and Social Care (DHSC) and axing half of its 15,000 staff. The unexpected move amounts to a dramatic and brutal grabbing back of power that every health secretary since Andrew Lansley – whose controversial Health and Social Care Act 2012 spawned the now-doomed organisation – has wanted to do but never attempted, as Streeting pointedly reminded MPs in his Commons statement on Thursday.
By deciding to abolish NHS England outright, rather than clip its wings, Streeting has marked himself out as the most radical health secretary since Lansley. Siva Anandaciva, the head of policy at the King’s Fund health thinktank, says the move is “a sudden and dramatic revolution in how the NHS is directed and managed. A radical reshaping of how the health service is led will [mean] a seismic shift in power back towards ministers and government departments, who will have more control and direction over how the NHS operates.”
The potential advantages to ministers should be less duplication between NHS England and the DHSC, quicker decision-making and more ministerial oversight of how the NHS operates, he adds.
Richard Sloggett, a DHSC special adviser under Matt Hancock, said: “Like many other secretaries of state who have come before him in the post-Lansley era, Streeting has concluded he needs more power to deliver change in the NHS. But unlike those Conservatives who were reluctant to grab too much power, fearing the political fallout, Streeting has concluded that a takeover of NHS England is possible and indeed necessary under a Labour government.”
He sees the impending departures of most of NHS England’s senior leaders such as its chief executive, Amanda Pritchard, its medical director, Prof Sir Stephen Powis, and the finance chief, Julian Kelly, as proof of “Streeting’s ‘night of the long knives’”. Given the huge number of dedicated, knowledgable NHS staff who will lose their jobs, it is unsurprising that others have likened the casualty count to blood-letting more reminiscent of ancient Rome or an episode of Game of Thrones.
The abolition is also a mystery as well as a surprise. Streeting had previously, explicitly ruled out a reorganisation of the NHS. His planned reform would not need one, he insisted. Indeed, as recently as 30 January he ruled out reorganisation as a costly, complicated and politically challenging waste in an interview with the Health Service Journal (HSJ). “My conclusion at this stage is that I could spend a hell of a lot of time in parliament and a hell of a lot of taxpayers’ money changing some job titles, Tupe-ing over staff and changing some email addresses and not make a single difference to the patient interest.”
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He assured the HSJ that he would not get into legal scraps. He would simply do more to “eliminate waste and duplication” across the two bodies. Yet he has now embarked on an undeniably massive reorganisation and one which he acknowledged will require legislation. The history of NHS-related legislation does not inspire confidence that the ensuing bill will proceed smoothly.
There are other risks too: that the restructuring will prove a distraction, consume valuable energy and worsen morale among NHS staff among whom discontent is already widespread.
So why take such a gamble? Those privy to his thinking say that, behind his respect for the NHS itself and those who have led it in recent years, including Pritchard, he has become convinced that putting ministers back in charge – going back to the pre-2012 model – is the best way to ensure that Labour’s ambitious plans, to “fix” the service the most rely on most, can succeed. He has reached that conclusion after developing “massive frustration” with what he sees as an apparent inability by NHS England’s leadership to make meaningful progress in tackling persistent problems such as taking the pressure off hospitals and GPs by keeping more patients from needing emergency healthcare in the first place by looking after them better at home.
Streeting, a driven, impatient character, has been left in “shock” by what he has perceived to be a can’t-do mentality among senior people who, when asked what their plans are to address key challenges, respond by stressing how difficult they are to fix.
Starmer has pledged to get treatment waiting times back to where they were under the last Labour government and make the NHS work better in ways that patients notice. Both have to happen by the next general election in 2029, and both are huge tasks. Opinion polls show that nothing matters more to voters than the NHS. That absolute imperative seems to have persuaded Streeting, who needs to visibly turn the NHS’s performance around, to act so decisively, despite the cost and peril involved.
