What are the ‘unthinkable’ reforms Labour could bring to the NHS?

Much has been made of Keir Starmer’s “reform or die” speech on the NHS. At times challenging in tone, the prime minister made it clear that there cannot be extra money without radical changes.

He wants mass digitisation, new scanners, new hospitals, improved mental health and maternity care, and a new emphasis on prevention and public health. So what are the kinds of “unthinkable” reforms that Starmer and his combative health secretary, Wes Streeting, might have to consider to achieve their objectives?

This is certain to become an issue. Streeting has placed reform of GP services firmly on the table, stating his ambition to move from the present model of private, self-employed partnerships on contracts towards salaried GPs working in community-based health centres, complete with upgraded diagnostic kits (and GPs are already on a work-to-rule, some limiting appointments to 25 per day).

A further controversial reform would be to permit patients to “self-refer” to a consultant, taking away the GP’s traditional role as gatekeeper. Similarly, pharmacies are being asked to do more at a time when their own costs are rising. So tough negotiations there, too.

Similar changes could be implemented across the NHS, potentially reducing staff numbers in some areas. The upshot will most likely be strikes. The recent pay rise for junior doctors helped calm tempers but they remain dedicated to regaining the real value of their wages after years of below-inflation increases. Labour may come to regret its decision to repeal the “minimum service obligation” imposed on NHS strikers under recent Tory legislation.

Even now, it is not quite true that the NHS is “free at the point of use”, and in fact prescriptions haven’t been free for most since 1968. The present charge of £9.90 could be raised significantly to pay for NHS investment, and exemption for the over-60s could be pared back, perhaps raised to the state pension age or means-tested (analogous to the arguments over the winter fuel payment and bus passes). But it would look like a war on pensioners, and thus be electorally hazardous.

This remains an option (it is not ruled out in the Labour manifesto, for example). The benefit would be to reduce the waste and disruption caused by patients not turning up to see their GP. But while a cash fee deters wasted resources, it cuts against the idea of improving preventative medicine. It could be means-tested but would still mean poorer patients would be adversely affected.

The most spectacular example of this is the virtual disappearance of free adult dental care. A more recent example would be treatment for blocked ears; it was a routine procedure, usually carried out by the practice nurse in GP surgeries but in 2020 junior minister Edward Agar announced: “The provision of ear syringing is an example of an enhanced service. If a local clinical commissioning group has decided not to commission an enhanced service, this may relate to population needs and value for money.” So now, unless your hearing is in danger, you’ll have to go private and pay about £60 to £80. It is a small act of privatisation enacted without much debate or protest. There may be more of this incremental erosion of NHS treatment to come.

This has been used in the past as a way to clear waiting lists, especially for less complex procedures. It can be effective, and Streeting is cheerfully committed to the option, as long as it improves health outcomes, because it doesn’t violate the principle of “free at the point of use”. The main issue is lack of capacity; private hospitals just don’t have the resources to take on much more NHS work.

This would be radical, and selling off these assets would raise huge amounts of money. Trusts would make contracts with the NHS to provide certain levels of care, in return for payments – a kind of franchise model. It assumes the profit motive would make them more efficient, create more competition and reduce costs, and all still be free at the point of use. However, it would also break the manifesto commitment that “with Labour the NHS will always be publicly owned and publicly funded”. Experience with other public services also suggests privatisation of this kind only works if the state is prepared to let a company – in this case a hospital – go bust after owners have piled on debt and extracted generous dividends; like rail services and water suppliers, they would then have to be rescued at enormous cost by the taxpayer.

A common model used in Europe, and often advocated by the radical right. It would be the end of the social insurance system and begs some uncomfortable questions about the fate of those unable or unwilling to get private insurance policies, including (as in the US) those with pre-existing conditions.

It would be a two-tier system at best, and what’s left of the NHS would be a very poor substitute, with little popular political support to keep it in good shape. Quite the opposite, in fact, if a majority are resentfully paying tax to care for others; it would no longer be “our NHS”. Overall, an insurance system might not save much money, and might even cost more overall, albeit with more choice from those in the system.

Conservatives can make huge political capital out of opposing any and all of these reforms (as with the winter fuel payment), but their problem is committing to find the money to reverse them were they to be elected. Reform UK is better placed because it could claim that tax rebates and private insurance will solve everything (just like Brexit did).