The thinking behind Rachel Reeves’s spending plans for the next three years was revealed in her statement on Wednesday. It is crude and probably correct. Of the government’s three priorities, there is only one that ministers can control, so she will throw money at that one.
The voters care about the cost of living, immigration and the NHS. There is not much the government can do about the first. It has to talk about growth and hope for the best. We are at the mercy of Donald Trump, various wars and the bond markets.
Nor do ministers think, in their heart of hearts, that there is much they can do about the Channel crossings. They have to talk about falling legal immigration, a trend they inherited from the Conservatives, while getting cross with the French for not doing enough to stop the small boats – but not so cross that the gendarmes shrug and fold their arms.
That leaves the NHS. The chancellor has put all her chips on the blue and white oblong on the casino table. The health service received the most generous settlement on Wednesday, planned to grow by 3 per cent more than inflation over this parliament.
There are those – and Nigel Farage is one of them – who will mutter “bottomless pit” and “good money after bad”. Those of us who are a bit more sophisticated will mention the NHS productivity crisis. Before the spending review, for example, I pointed to figures from the Institute for Fiscal Studies showing huge increases in the numbers of doctors and nurses in the NHS over the past five years, and small increases in the number of patients seen.
But I also cited evidence that NHS productivity was improving after the one-off shock of the pandemic, and now there is more hopeful news to share. Reports are beginning to emerge about what is in the 10-year plan for the NHS, to be published by Wes Streeting, the health secretary, next month. It sounds like a good and ambitious plan to shift incentives so that patients are kept out of hospitals and needless in-person appointments are abolished.
Speaking to The Times, Streeting said: “Much of what’s done in a hospital today will be done on the high street, over the phone, or through the app in a decade’s time.”
It might seem a bit slow. He has been in government for nearly a year and is only now coming up with a plan?
Government is slow – Keir Starmer has taken to asking repeatedly, “Why not today?” – but it is important to get big changes right, and Streeting has thrown himself at a lot of the less visible work in his first 11 months, including abolishing the NHS England bureaucracy and taking the NHS back under the direct control of his department.
He has learned the lessons from the last time Labour saved the NHS under Tony Blair, including bringing back some of the key people who did it: Alan Milburn, Blair’s health secretary, and Michael Barber, the head of his delivery unit.
The blueprint is all there in a new book, The Art of Delivery by Michelle Clement, my colleague at King’s College London. It is based on Barber’s diaries and is the fullest account of how the public services were turned around in Blair’s second term as prime minister.
The book makes clear what ought to be obvious, which is that it takes time for the combination of more money and reform to start to change measurable outputs, and even longer before the general public notices an improvement. Nor is improvement a steady upward gradient, because there are policy mistakes and personality clashes along the way.
One of Barber’s greatest strengths was his ability to manage relationships put under strain by politicians’ impatience for delivery. When one permanent secretary ranted at him for giving his department a traffic-light rating in a note to Blair without consulting him, Barber said: “This has always happened. I’m just telling you.”
Now it is happening again. The good civil servants and NHS managers will realise that it helps them to have objective performance indicators and stretching targets if the whole service is starting to move in the right direction.
Barber had to persevere for two years before the indicators started to shift, but in the NHS, the momentum of change gathered pace thereafter. By 2004, Barber told the cabinet that an episode of EastEnders showed Ian Beale complaining that “people spend at least five hours in A&E”, to which Jane, his wife, responded, “It’s a lot better nowadays.”
Barber began to talk confidently about how the changes in just three years were becoming “irreversible” – a claim that was mocked by the parsimony and incompetence of the Tory years, which managed to reverse the Labour gains eventually.
The point is that the NHS can be changed in a single parliament. The challenges are different now, and so are the technologies. But the principles are the same: more money accompanied by devolution of power to successful managers and aligning staff incentives with the interests of patients.
Time is already running out for this government, and the stakes are high. Most cabinet ministers understand that. One of them was quoted anonymously by The Times today. If it wasn’t Streeting himself, it was someone who thinks just like him: “The truth is there are a lot of people whose lives have been shit for a long time. They rolled the dice with Brexit, they rolled the dice with Boris and then they rolled the dice again with us. They need to see results otherwise they will roll the dice again with Reform.”
Time is running out, but Streeting is one of the few cabinet ministers to have made good use of it so far.
