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Nick White is a practising Consultant Surgeon who has worked as a Medical Director in both the NHS and the Independent Sector
It is easy to say the NHS needs reform as a sound bite to gather votes but a very different proposition to say what policies should be introduced to change it. Until last week the Labour government had only got as far acknowledging it is broken and describing 3 shifts to change it (from analogue to digital, from hospital to community and from sickness to prevention).
These approaches have been muted in one form or another by successive governments of all political persuasions over the last 30 years. The shifts were underpinned in the autumn statement by a funding increase of £22 billion by the end of the 25/26 financial year.
The elective reform plan has now been launched and is described as a whole system approach to reducing waiting lists, by the end of this Parliament, with a range of measures and targets. Wes Streeting has explicitly stated that his number one priority for the NHS is to cut waiting times, particularly aiming to decrease waiting times from 18 months to 18 weeks.
This is not unreasonable based on the deleterious effect long waits have on the rest of the NHS. However, many of the initiatives in the reform plan are not new but are extensions of existing programmes.
There is nothing wrong with expanding what has been shown to have helped but wrapping it up as reform is misleading. It is plausible that these were in the NHS England pipeline anyway, and would have been introduced if there was still a Conservative government. None of this has been linked to any genuine attempt at reform despite manifesto commitments to no new money without reform.
There are two main goals to the governments approach: reducing costs and increasing performance through choice. The cost of treating people in the community is less than in hospital settings and the UK delivers proportionally more of its care in hospitals, so a shift in where the care is delivered may reduce costs. Hence the expansion of schemes like Advice and Guidance.
However, moving activity from one part of a system to another is small steps rather than major change.
Choice is being used as a driver for improvement. This would work well if the current NHS was responsive to change. Maybe being offered a choice of five different providers on the NHS App is an illusion of choice, akin to being allowed to go to only one restaurant and there being five identical dishes on the menu.
There are no incentives in place to reward organisations doing more work or consequences for those doing less work; in fact, counter-incentives exist around not having big waiting lists and not attracting in work. There are descriptions in the plan on how money flows and income streams might change but they lack detail other than by offers of rewarding success.
Nothing is said, meanwhile, about what will happen to less successful organisations, their leadership… or their accrued deficits.
Neil O’Brien has described two types of NHS reform which he calls type 1 (managing what we have better) and type 2 (changing what we have). I prefer the terms internal and external, which mean much the same.
Labour’s NHS approach is very much an internal type 1 “doing what we currently do but doing it better”; which is underpinned by the belief seen throughout this government that the country was in a mess largely because the Conservatives were in power; now they had been replaced by Labour, things would automatically start to improve.
None of what we have seen from the current government is the introduction of external change. This is why we currently have an opportunity to describe what the introduction of genuine choice may look like, and how it could be delivered through a road map to a more mixed model of healthcare provision. To provide the necessary capacity to enable choice and improvement can we reform healthcare rather than just reform the NHS?
An alternative vision could be developed in opposition over the course of the next four years with three guiding principles: absolute commitment to universal coverage free at the point of need, genuine choice as the means to improve, and a road map to a more mixed model of healthcare provision.
Discussions around the NHS at general elections revolve around two extremes: commitments to ever increasing amounts of taxpayer’s money going into the NHS or allegations of wanting to change to an American style healthcare provision with the suggestion of privatisation.
An alternative vision could be developed, one designed to deliver financial sustainability and improve outcomes whilst maintaining an absolute commitment to universal coverage free at the point of need (which is the case in the vast majority of healthcare systems across the developed world).
The current time in opposition presents an opportunity to have a challenging discussion for a number of reasons. One is the fragmentation of the two party system may lead to the possibility of a majority government with only 35 per cent of the vote, which makes easier debate of difficult issues such as healthcare reform. It will be made easier still if this Labour Government does not make demonstratable improvements, particularly in the waiting list reduction goal it has set itself.
A much-used example of successful system reform were the education reforms in the 2000s and 2010s. There was a genuine drive for increased choice and local autonomy with accountability for budgets.
Much of this was driven through the New Schools Network, bringing together stakeholders with a common set of goals, acting as both a think tank and advisory body; sharing best practices and policy recommendations. Would a New Healthcare Network, drawing on a group of stakeholders, be able to develop credible plans for a road map to a more mixed model of healthcare provision? A role could be developed as a supporter and advocate for innovative approaches around policy, funding mechanisms and the place of third sector and independent sector organisations.
There is not a need to put in the next election manifesto an obligation to adopt a particular approach; but there should be a commitment to review best practice from different health care systems around the world and introduce them step by step in a pragmatic fashion to widen choice.
Finally who would this approach be attractive to as a coalition of voters is assembled for the next election? Yes, voters lost to Reform who touched on some of these issues in their manifesto, as well as 2019 Conservative voters who did not vote for in 2024, perhaps due to a lack of trust in conservative plans and an ability to deliver them.
But most importantly this is an opportunity to re-engage with younger voters. Polling shows younger generations are open minded about other types of health care provision and are active using commercial apps and private healthcare. Is an honest conversation about healthcare reform one of the ways to attract them back as younger voters are used to choice and expect it.
This is ultimately about how we preserve and maintain financially sustainable universal coverage free at the point of need by having an honest conversation about wider healthcare reform rather than just NHS reform.
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