The British people want their NHS to be fixed – not replaced

Reform or die.” Even by his own recent gloomy standards, Sir Keir Starmer’s stark warning to the NHS is a dramatic, headline-grabbing one.

To be fair to the prime minister, his words, though dramatic, are not out of line with what he and his now health secretary, Wes Streeting, have been saying for some years, while in opposition.

Mr Streeting in particular, an able if sometimes abrasive figure, has been telling it like it is to anyone who will listen, refusing to rule out radical changes to the way the NHS operates, and constantly “making no apology”, to quote a favourite phrase, about involving the private sector in the cause of patient care.

The government’s logic is clear, and amply borne out in the investigation into the NHS conducted by Ara Darzi. Fourteen years of misguided reorganisation, austerity, misallocation of limited public funds, and outdated technology and procedures have left the NHS “broken” – but, as Sir Keir adds, not “beaten”.

The system established in 1948 is a sound one and, at its best, as it was not so very long ago, ranks with the finest in the world. It is capable, even now, of delivering world-class, pioneering treatments, and satisfaction levels, while disappointing, are not disastrously low.

Sir Keir implied all of that in his keynote speech at the King’s Fund, but he might have done well to have emphasised the positive side of these proposed reforms, as well as the dangers of inertia.

Things are certainly not where they should be, and that is why the NHS was such a high-profile concern for the voters at the general election, and, in large part, why the Conservatives were so badly punished, and why Sir Keir finds himself in No 10. The British people have not given up on their NHS and want it fixed – not replaced.

Sir Keir understands this, and knows what is wrong; to take one example, in Accident and Emergency departments, more than 100,000 infants are waiting for six hours or more, and about a tenth of all patients are waiting for 12 hours or more, often in pain. It is worsening health outcomes, and it is intolerable.

Similar failures at GP surgeries, in midwifery, mental health care, the ambulance service and, of course, in social care add to this miserable picture, and tend to leave hospitals taking on the unfulfilled needs.

It may not be entirely fair to blame the coalition and Conservative governments since 2010 for everything that has gone badly; the Covid pandemic was always going to overwhelm the system, even with the best official response. But successive ministers have to take their share of the responsibility.

Lord Darzi calls the now almost forgotten NHS reforms of 2012 a “calamity without international precedent”. There were many other mistakes by ministers, including over Covid. Mr Streeting, mercilessly, tells Victoria Atkins, now the shadow health secretary, that she was “the worst of the lot”. That is debatable, but the Darzi report is certainly an indictment of the Conservative record.

So now the age of reform begins. But there will be no substantial extra funding without change – “we have to fix the plumbing before turning on the taps,” says Sir Keir.

So what will change look like for the NHS? It will be pervasive, at least according to Sir Keir. A new NHS app, for example, will transform the way patients interact with the service. Records, he says, “must be digitised”. The fact that a prime minister feels the need, in 2024, to make these now commonplace assumptions about how we live our lives into some sort of futuristic vision says all too much about how the NHS has been left behind by technology, as well as how disastrous have been previous attempts to shift the service to digital from analogue.

There will be a new emphasis on moving certain procedures out of the big hospitals and into community-based clinics – a “neighbourhood health service” that can undertake more tests and scans, with improved GP access. Prevention and public health, especially vaccination, will be emphasised.

Also promised, once again, is the integration of health and social care. Such changes should mean that a more efficient and responsive NHS spends its funds more productively.

Mr Streeting also places some hope in the ability of artificial intelligence to help raise productivity, as it is already doing in diagnostics. Some tentative moves in this direction were underway under the Sunak administration, but the pace is now to be much accelerated.

Ideally, the government will find health professionals, the trade unions and trust managers willing partners in what is envisaged to be a decade of change. The prize is an NHS that will be serviceable for the next 75 years of its existence, saving lives and relieving pain and hardship, irrespective of ability to pay.

It will be a place where its staff can fulfil their vocation in the true spirit of the NHS, and where the new technologies and working practices can make their working lives easier. Advances in medicine, clinical techniques and technology can help lift the workload.

There are risks and challenges in all of this. As noted, the NHS has an appalling record on IT – one reason why staff and patients are so attached to paper systems. There remain severe staff shortages and a political reluctance to confront the fact that the NHS and the social care sector need immigration at all levels of skill to function, reformed or not.

Brexit has exacerbated the staff shortages, and they have strengthened the bargaining power of NHS workers. The unions and the British Medical Association are still dissatisfied with levels of pay and staff retention, even after recent settlements. Thus, the threat of industrial action has not much dissipated simply because Labour is now in control. There will be strikes.

Yet all that, for now, is to be too gloomy. Recent weeks have actually been tremendously encouraging for the NHS. It now has fresh leadership from the political party that founded it, believes in it, and, as such, is the only one that can be trusted to radically reform it – on the “Nixon goes to China” principle. And it has the Darzi report offering up the truth about the current position – sometimes shocking, but often full of confidence about the fundamentals.

There is a long-term plan and, in Sir Keir Rachel Reeves and Wes Streeting, the sort of determined ministers to persevere as they make the necessary reforms, even without as much money around as when Labour last had the job of putting the NHS back on its feet.

Success is no less than a matter of life and death for this cherished institution, and, as it happens, for this government winning a second term. There is no time to waste.