Keir Starmer’s shake-up of NHS England is a brave move

Good morning. Keir Starmer has announced that Labour will not just trim down but abolish NHS England, the body created in 2012 to run the NHS in England. Although the 2012 reforms have few fans, unpicking it is a big gamble for Labour. Some more thoughts on that below.

Shaken not stirred

The problem facing every health secretary since Andrew Lansley introduced his ill-fated reforms to the NHS has been that the structures he created are not particularly effective and create confusion in both Whitehall (who speaks for the NHS, the secretary of state or the head of NHS England?) and on the NHS frontline (who are we actually working for, the head of NHS England or the secretary of state for health?)

None of the problems Lansley claimed his reforms would fix (lack of competition and choice, weak commissioning within the NHS, excessive micromanagement from the centre) have improved since the Act came into law.

But to reform the Act has always meant sacrificing time that the government of the day hoped to devote to improving healthcare outcomes instead of fixing the underlying structures.

Jeremy Hunt, having been moved into the role of health secretary in the autumn of 2012, essentially with a brief of “whatever you do, don’t plunge the government into controversy like your predecessor Andrew Lansley did”, found smart ways to work around it. Matt Hancock and Sajid Javid, his successors, ended up deciding they wanted to repeal large parts of it. The “operational independence” of the NHS in England was effectively ended in 2022 as a result.

When Wes Streeting became health secretary his first move was to commission a review by Ara Darzi into the NHS’s performance, which essentially concluded that the 2012 Act was a disaster. To the surprise of many in NHS England, he did not use that review as an excuse to dismantle NHS England and instead many in that body were reassured by stories about the warm relationship between Streeting and NHS England’s chief, Amanda Pritchard.

Fast forward to last month and Streeting had essentially forced Pritchard’s exit, appointed a new “transition CEO” to remodel the body and cut half of its staff. Now it is not half, but all of NHS England that is to be scrapped. Speaking to staff at the organisation, they are all in varying levels of shock.

The trade-off, always, has been whether it is worth riding out the disruption and deterioration in the NHS’s performance you would have to go through while properly unpicking Lansley’s reforms, or if you were better off just grinning and bearing it, trying to make the organisation work and getting on with it.

As a spirit-sapping realist, I preferred the idea of finding a way to reform it from within. The problem with any “big bang” change is that when you announce it, some of your most talented staff will worry about their futures and leave while others will feel undervalued and work against you. In general, it creates difficulties. But the flipside of that is if the structure can’t be saved, you are throwing good money after bad.

What Labour is doing is genuinely courageous, both in the “Yes, Minister” sense that it means sacrificing NHS performance in the here-and-now, where it might have helped them get re-elected, for the promise of a better system later down the line, and also in the sense that some government at some point was always going to have to take it on the chin to unpick the problems of the 2012 Act.

As Laura Hughes and Sarah Neville set out in their piece on what next for the NHS, what Starmer and Streeting are sacrificing is at least a year in which the NHS focuses on patients and outcomes in the hope that having a better structure will, in the long term, improve its performance.

This approach fits well with Starmer’s sense of himself: he dislikes it when ministers bring problems and intra-departmental disputes to him, which was never going to warm him to NHS England. Streeting now has a team of advisers around him who know the NHS well and who, for one reason or another, have little time for the 2012 Act.

Whether it works for Labour’s narrow self-interest or not, we should at least be grateful that at the end of their time in office a system that has never worked for either the government or people on the NHS frontline has been done away with.

Now try this

I’m off to have dinner at one of my favourite restaurants with one of my favourite people. I am in an odd limbo period of both mourning where I live and also believing that both my flat sale and my flat purchase will collapse at the last. One restaurant I feel particularly sad about no longer being in walking distance is the excellent Jolene. Give it a go if you’re ever in this part of the world.

However you spend it, have a wonderful weekend.

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