In an unusually successful piece of political choreography, moments after the prime minister had finished a speech in Hull on the “flabby and unresponsive” state and dramatically declared the abolition of NHS England, his health secretary was on his feet in the Commons setting about the task.
As is his distinctly unflabby and responsive style, Wes Streeting didn’t hold anything back. He declared that thousands of individuals at NHS England would lose their jobs. The transition will take two years and yield “hundreds of millions” of pounds in savings. The opposition benches didn’t put up much resistance, and any necessary primary legislation should find an easy parliamentary passage. Change is on its way.
There’s no doubt that something has changed with Sir Keir Starmer. There appears to be a new air of authority and confidence. Perhaps he has taken the best out of what has been perceived as the worst of Donald Trump: decisiveness and decision-making. If this is the beginning of dramatic change, to get rid of waste and duplication, lethargy and lack of leadership in the most important institution in Britain, Sir Keir will have gone from being low in the polls as of a few weeks ago to the most high-achieving Labour prime minister in history.
So, in stark contrast to the countless waffly prime ministerial speeches about reducing inefficiency and reducing civil service numbers that we have heard over the decades, Starmer and colleagues have at least started on a more audacious and tangible project. With the recent departure of the NHS England chief executive Amanda Pritchard and others in the senior team, the work on winding down the biggest quango in the world is already underway.
Mr Streeting made a strong case for these reforms, based on evidence from the Darzi report and the Hewitt review. They will reverse the last “top-down” reorganisation instituted in 2012 by Andrew Lansley, the then health secretary, which was hugely disruptive and distracting for all concerned, and in the end, added complication and reduced accountability without any obvious improvement in patient outcomes during the coalition government’s “age of austerity”.
Mr Streeting will obviously need to take care to ensure that his own top-down reversal of the Lansley reforms doesn’t inflict similar chaos and uncertainty. The health secretary is convinced that the degree of duplication between the staffs of NHS England and his department is both vast and glaring. We shall soon find out if Mr Streeting’s optimism is well-founded – and he knows as well as anyone that the fortunes of the government and his own ambitions depend on clear and unequivocal success.
Such success is not preordained. There will, inevitably, be disruption, and, given the size and complexity of the health service, it’s not obvious why abolishing NHS England, rather than devolving more functions from Whitehall to the agency, was the more efficient solution. As Norman Fowler, one of the longest-serving health secretaries, remarked about his own experiences of reform in the 1980s: “If you ask me what is the best way of running an organisation as massive and complicated as the health service, I would not say that it was to have all the strands going back to the health department. It would be much better to have it run as you would run any other big organisation, but with that organisation being responsible to the minister.”
Mr Streeting should always bear in mind the parable of Chesterton's Fence: “Do not remove a fence until you know why it was put up in the first place.” Even so, as a down payment on the wider project of reforming the state, folding NHS England into the health department, with mass redundancies, could hardly be beaten for ambition. It is the kind of thing that might have been expected from the most radical of Conservative administrations but was never achieved even after it became apparent that their own previous reforms had failed.
Under previous governments of all parties for more than half a century, the trend has been for functions previously undertaken by departments to be either privatised completely or else hived off into more commercially-minded operationally independent agencies, to save public money even at some cost to democratic accountability.
Everything from the telephone system, railways and prisons to the DVLA, HM Passport Office, National Savings and Natural England, and of course the NHS, was given the treatment, with mixed results. In other words, some functions are more suitable for outsourcing than others. The danger now is that the government will, if anything, go too far in the other direction in its zeal for savings, efficiency and economic growth that may not be forthcoming.
What is more encouraging is that across a wide range of government policies, Sir Keir is following his instincts and an evolving philosophy that might be generously termed “extreme pragmatism”. In some areas, such as with Great British Railways, Great British Energy and the Office for Value for Money, the government is busily creating new quangos. In others, as with NHS England and the Payments System Regulator, bodies are being rationalised.
Perhaps it is just “horses for courses”, but it would be reassuring if there was a little more clarity and consistency around what the government is doing. In the end, though, the voters will be able to make their own minds up based on their own experiences as to whether these reorganisations and the much-vaunted application of artificial intelligence really do combine to make trains run on time, lower energy bills and see that patients are promptly attended to in A&E. If people feel that “nothing works”, as they do now, then the government that fixes that dismal situation deserves to be richly rewarded at the ballot box.
Sir Keir has shown leadership and stamina in the most difficult landscape: Ukraine, with Trump as an illogical manipulator of truth. We hope that the prime minister is turning the corner for better fortune and this perceived leadership carries on as he tackles the biggest domestic problem in the UK after growth: how to make the NHS work better.
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