Coffee House Shots
Keir Starmer: the NHS will get 'no more money without reform'
Subscribe to the spectator in September and get three months of website and app access absolutely free. Follow the Tory leadership campaign, the Labour's inaugural budget, and the US elections with Britain's best informed journalists. And get your first three months free. Only in September. Go to www.spectator.co.uk/sale24. Hello and welcome to Coffee House Shots. I'm James Hill and I'm joined today by Kate Andrews and Isabel Harpen. Now this morning it's been a big speech by the Prime Minister on fixing the NHS. It's just finished about 10 minutes ago. Isabel, what were the top lines? Yes, so this was responding to Lord Darsey's quick fire review of the NHS in which he basically says the NHS is seriously broken but still has its vital signs so it can still survive but it needs major reform. And Darsey doesn't set out particular prescriptions for reform. He says that wasn't within his terms of reference. But what he does do is set out the areas that need reform and it does quite a clear sort of direction that he would like the government to go in. And so Kostama then gave a sort of broad brush response to what that direction would be and none of it's a massive surprise. So firstly he used the report really as the sort of NHS equivalent of the shock Tory £22 billion black hole saying things were much worse than we expected and that's something that Darsey says in the report that despite having worked in the health service for decades and being a health minister in the last Labour government, even he was shocked by what he found and how the report came together. So Starmer used that really to sort of beat the Tories over the head and say look, things were worse than we expected in the economy and in the health service. But he then went on to talking about the key areas of reform from his perspective and they were better digital services, their prevention and I think there was a really interesting line in the speech that I think was designed to get a lot of attention which was no new money without reform and trying to sort of break with the idea. Even I think under the last Labour government which was a very reformed minded government that you can just pour more money into the NHS and things will get better. But we have to fix the plumbing before turning on the taps. So hear me when I see this, no more money without reform. I'm not prepared to see even more of your money spent on agency staff who cost £5,000 a shift. And yeah, I mean it was an interesting speech. It's going to be a very difficult road to reform if he actually does pursue the detailed things that need to be done. So if you're not giving more money but you're restructuring, fine but that means you're shifting money from acute to preventative. So people are going to get very upset about hospitals. You're not saying that A&E is going to get more money. So people may, you know, the sort of shop window of the NHS for a lot of people may not manifestly improve. What are you going to do about primary care which doesn't have the same, as Darcy says, the same sort of performance targets as acute. Are you going to try to make GP's nationalised as it were because they're not at the moment. How do you get GP to a very resistant to reform? How do you solve the NHS retention crisis? You know, GPs, even when they're working well, have a huge shortage. And so that's one of the key reasons why people have to wait so long for appointments is they're just aren't enough GPs around. There's a huge row within general practice and the NHS more widely but particularly within general practice, about the use of physician associates to get people through the doors quicker. Are they appropriate staff to be working in primary care? Can they often miss key things? So all of this is going to get, what I'm basically saying is all of this is going to very quickly get mad in a lot of fights. And Starmer did nod to that. He did say that he was going to stand up to those who sort of opposed reform. And people always oppose NHS reform. And not just people generally, the BMA always opposes NHS reform. GPs are always resistant to attempts at reform with them. So it's going to be really hard. And sure, this speech sounded like it was making all the right noise is on most things. But what does the follow through look like? And Isabel there talks about how Lord Dazzi had a clear idea of the direction the NHS should go in. Okay, you've read the 160 page report this morning. What's your takeaway of what that direction should be and how likely is labor going to be to pursue proper reform, as Isabel says, given all the institutional challenges in the way? Well, what Lord Dazzi makes very clear is that if you don't redirect your focus from hospitals to communities and from acute care to preventative care, the system is not going to function in the future. And you can see this with the way that demographics are changing. We have aging demographics. You can see this in the way that there's just more and more demand on the healthcare service. I mean, there's just, there's so many damning examples in this report. It is an incredibly harsh, honest report about the state of the NHS, about how things just aren't moving along, things aren't improving. So despite the fact that it's got a record amount of funding for day to day spending, productivity is just not keeping up. The NHS workforce has risen by 17 percent since 2019 and 2023, 35 percent more nurses, but productivity has been going in the wrong directions. The wait lists are even worse than I think that headline 7.6 million figure shows for NHS England. The report says that if you arrived at a typical A&E in 2009, you had about 40 people ahead of you in 2024. It's 100. So records amount of funding, things are getting worse. But also, we've had a lot of information in the past about how the NHS compares quite badly to its counterparts for things like treating common types of cancer. But in over a decade, the NHS has simply not improved in catching cancer in stage one before it gets to stage two. These are the kinds of things that have to change. You have to have better preventative care. It just raises, as Bill says, so many questions about whether government is going to do about it. First of all, I think it's so important to say, you could have never seen a report like this commissioned under the Tories. They would have never done it. They would have been terrified to actually have to say out loud these kinds of results so much easier for politicians over successive governments just to praise it, to literally pray to it last year in Westminster Abbey than to actually have somebody independently say, "Your system is at a critical point. It's failing." So you credit to the Labour government for actually putting this stuff on paper saying it out loud because now it means they have to tackle it. Those details are the ones we still don't have, and we've never had. Labour has been very clear that they want to reform the NHS, but when you get into those details, that's when the huge fights begin and you're going to have to start burning your political capital to get through them. I mean, the outstanding question for me is that Labour still completely refuses to address the fundamental structure of the NHS. It is going to, they say, continue to be a single-payer system, which is funded by taxpayer money. Now, potentially, you could still be looking at something like a health care savings account with taxpayer money. At the moment, though, this is funded through day-to-day spending, yearly taxation receipts, this is not sustainable if you want to tackle waiting less than you want to improve preventative care, right? Because if you have that kind of system, every health care system in the world, rations health care, everyone does. But if you have a single-payer tax-funded system, you're going to ration with wait times. You're going to ration with wait lists. You're going to make it harder to access treatment. It's going to be more limited. If you're not willing to tackle that structure, then you're never really going to be able to lean into preventative care. I think the way that the UK might like to do, because that's not going to be the most urgent thing. And you're still going to be struggling with wait times. I mean, I think one of the things that COVID and these crazy wait lists have brought up was, was it ever acceptable to have people waiting 14, 16, 18 weeks in pain for serious operations? Is that actually the gold standard or does the UK want to do even better? The report gives labor a little bit of cover, at least for a while, to actually think through some of these plans, because it's saying this is a 10-year project. What's not said is probably in five-year sum of the next election. Not only will the NHS still be in critical condition, it might be even messier if it's mid-reform. So I think that that 10-year timeline is a benefit to be set out loud for the labor government. But truly, I'm so impressed that they want to say this stuff out loud, that they want to tackle it. We really don't have those details yet, and I think that's what everybody is waiting for. The report, Lord Darcy, talks about how it has the reform, the plan has to be built by NHS staff and patients. Well, those are just two stakeholders in the NHS. We can immediately think of quite a few ways in which their interests might differ. We have GPs doing collective action and talking about capping the number of patients they see every day, whereas patients need to see GPs in the evenings and on weekends in order to get the care that they need. These groups are not always going to have the same interests. That's what happens when you try to reform the biggest institution in the UK, one of the biggest institutions in the world. It is about you literally wrote the book on forming the NHS and its challenges and changes and how different ministers have fared with that over its history. What advice would you give and take away as you've learned from your book on how best to reform the NHS, given the many institutional challenges and opposition it's going to face. As Kate says, the time is going to evolve to it because it could be a 10-year project, and of course, they will have to go to the polls by 2029. I think what's interesting is how much they've replicated from the Blair government around 2001, 2002, when they were doing their NHS plan back then, when the NHS had its last big existential crisis, nothing on the scale of this one, it has to be said, but there's a lot of phrases in the report that feel very familiar, particularly about A&E and public faith in the health service. Back then, when they did produce that NHS plan, one of the things they did that Darcy has done again this time and I suspect we will see as the government starts to set out its detailed plans, its white papers on reform, and so on, is getting institutional and organisational buy-in. The NHS plan was signed, highly unusually at the time, by organisations across the health world. It was the more colleges, it was cancer charities, and so on. The purpose of this, instead of having this very worthy ministerial forward that no one reads, having this list of people signed up to it, was basically saying, look, you're bought into this and you're backing this and you have to be part of this, and some are fascinated by that idea of partnership and bringing people on board. If you talk to anyone who was doing all of that stuff back in 2001, 2002, the other side of it was, well, look, you can't criticise us now because you signed up to this. We're giving you what you've asked for in terms of money, which they did do at the time, but also you're going to have to get with the reform programme and some of that reform was very challenging in terms of targets and then later on in terms of structures. I think in terms of the lessons from how reforms tend to pan out, we've already talked about the trade union and institutional resistance. I think we're also probably going to see quite a shake up in terms of the management of NHS England. I'm not saying this because I've been briefed it or anything like that. It's just a suspicion that's widely held in the health world that the NHS management at the moment may not remain in place within the next few years. It may well be that Amanda Pritchard isn't chief executive of the NHS as this reform programme continues. She's been very anxious to show that she's totally on board with all of these changes in terms of prevention and so on. She gave a speech just before the election day, the NHS stands ready, but I think there is a sense that there might need to be a change in personnel there as well. I think the other thing that I would say that I'm still quite disappointed in from Starmer's speech and from his general agenda is that they're not cracking on with social care reform. I feel like I say this in every podcast and we'll be saying it from my still badly funded care home when I'm in my 80s, but you can't say yes, we acknowledged that the NHS needs social care reform, which Starmer did today, and then not get on with it. You can't leave it to later on in your term in my view because it is one of the hardest things to do, and there's a reason that governments haven't succeeded in doing it, and a reason why governments have that have legislated on this, have then ended up delaying caps and saying, oh, you know, local authorities aren't ready, or, oh gosh, people across with us, so we're going to U-turn on this, and you burn through political capital doing this. You need to be at the point where you have the most political capital, which, you know, despite the opinion polls, is now, as opposed to in five years' time, to just get on and do it and accept that people aren't going to thank you initially, but the NHS needs that social care reform to be able to function is not the only problem that the NHS has, but it is a significant driver of waste and inefficiency in wider healthcare world. Lessons for Word Street in there. Thank you, Isabelle, thank you, Kate, and thank you for listening to Coffee Our Shots. [MUSIC PLAYING]