In response to Keir Starmer





By Jim Gralton

On January 15th 2023 the Labour Leader, Keir Starmer, published an article in the Sunday Telegraph about NHS reform and later had an interview with the BBC Political Editor Laura Kneunssberg which dealt with some of the same matters.

Below is a commentary on Keir Starmer’s article and his BBC interview.

When it comes to the health service, hard truths are currently in short supply. Well-meaning reverence for the ideals it represents and the care it can deliver has supplanted reality. And that reality is simple: if we don’t get real about reform, the NHS will die.

After a decade of poor planning and platitudes from Tory governments, the situation for patients is intolerable and dangerous. Ambulances queue outside A&E with stroke victims left in the back; cancer patients wait to see specialists; people are stuck on hold at 8am every morning, desperate for a doctor’s appointment. The idea that the service is still “the envy of the world” is plainly wrong.

There is no question that at the end of a dozen years of Austerity and Tory ideological changes that the NHS and social care are on their knees.


There has to be change. Any strategy that results in a continuing Tory government is condemning the NHS and social care to terminal decline.


Tacking issues of access to the services – at primary care, unscheduled care and hospital waiting lists – has to be addressed.

I am not prepared to accept the Government’s excuses that this is yet another thing out of their control. Covid made things worse, but the NHS waiting list had almost doubled in the nine years between the time Labour left office and the first lockdown. The report on the Prime Minister’s desk into the waiting-list crisis, commissioned by the Department for Health, says: “We have essentially had 10 years of managed decline. This is not a Covid problem.” We owe it to the country to face the facts as they are, not as we’d like them to be. The problems that face the NHS and social care predate Covid. Covid has made things worse and thrown the inequalities of people’s experiences into much sharper relief.

As health and social care struggle only those with sufficient resources can expect to get timely and quality care.

We have to move from managed decline to managed rehabilitation and recovery.

We can favourably compare NHS performance under the last Labour government and the 12 years of Tory mismanagement. And it was towards the end of 2000s that the levels of public satisfaction with the NHS were at their highest levels.

Nor am I prepared to accept the idea that the NHS should somehow be off-limits, treated as a shrine rather than a service. It is incumbent on those who want to fix it to be frank about what has gone wrong and how only a proper programme of reform and renewal will get us out of crisis.


We do need to be radical in our thinking.

Many of the left  (e.g. Doctors in Unite 2021 ) have come up with a wide range of radical proposals to improve public health, to make primary care more attractive and to introduce an occupational health service.

The Labour Party Annual Conference (2022) unanimously voted for  the establishment of a National Care Service.

There are forces of caution and  conservatism that will oppose a number of these changes. Some of them will be within health care professions and indeed within our own political ranks.

There is no solution that doesn’t involve expanding the workforce. That’s why I have committed to doubling the number of graduating doctors and district nurses and providing thousands more training placements for nurses, midwives and health visitors.

It’s also why the Prime Minister’s idle threats to sack nurses who go on strike will only make matters worse – not a serious response but pure political grandstanding.

This is a fundamental priority which deserves unconditional support.

Health and social care requires more people to meet need and to provide a higher quality service.

But we need to point out that recruitment is but one side of the equation. Retention must go hand and hand with recruitment.

The present round of industrial action has to seen and supported in this context

But reform doesn’t mean rearranging chairs with top-down impositions from Whitehall. And investment alone won’t be enough. Instead, we need a ruthless focus on ensuring patients are treated better and sooner.

When I was Director of Public Prosecutions, I saw how public services focus far too much on treatment rather than prevention. Every serious case review that came across my desk, was the same story: lives that could have gone differently, let down by a lack of early intervention. The similarities with healthcare are clear. The opportunities to turn this around are huge.

Again this must be highlighted at a key outcome “ensuring that patients are treated better and sooner”.

In the first instance this requires more staff as has already been acknowledged.

But we also need to use this additional staff  to work in improved ways – reflecting growing health inequalities, the levels of multi-morbidity resulting from an ageing society and mental health problems.

This will involve recruiting more  GPs  who will be part of multi-disciplinary teams, making greater use of IT and working more closely with social care, housing and public health. 

GP services are the front door of the NHS and the key to that early intervention. But the demand for their care outstrips supply. They now carry huge patient lists. We’ve lost more than 4,000 GPs and many practices have closed over the past decade. This is an acknowledgement of the problems created by the failure to retain staff.

 In recent years GP numbers have declined rather than increased as promised. This means longer delays at GP surgeries and less time with patients which will in turn result in more people choosing to use A & E  departments. Managing long term illness and providing more preventive care in a community setting becomes more difficult.

It also recognises the importance of manageable list sizes to deliver sooner and better care. In their policy statement on primary care Doctors in Unite call for a target of list sizes of about 1,200 patients per GP with priority being given to areas with the most illness and highest list sizes.

When people can’t walk through that front door they inevitably end up going through another, more expensive one – the hospital. Quality care in the community provided by GPs is the difference between a diabetes patient living a happy, fulfilled life versus needing an emergency amputation. It is that stark. This is a recognition of the importance of preventive care and the management of chronic disease being provided within a primary care framework.

It is the better option and can be the least expensive as well, in the long run.

But our primary care model isn’t working. Not enough young doctors want to take on its burdens and liabilities when older partners retire. It’s time for us to think about a new, sustainable system, one that allows GPs to focus on caring for patients rather than the admin that comes with effectively running a small business.

This would be a big change and it won’t happen overnight. But I am a pragmatist, focused on what works for patients. As GPs retire and those contracts are handed back, I want to phase in a new system that sees GPs fairly rewarded within the NHS, working much more closely with other parts of the system. Not everyone will want to hear this – but it is the direction we need to go in.

The  NHS  must provide a salaried GP service where doctors can focus on clinical care and not on the bureaucracy of running a business. They must also have an alternative to working for the corporate bodies that seek to benefit from the privatisation of primary care.


This will be done on a pragmatic basis and will not be introduced on a “big bang” nationalisation of general practice.


There is also an awareness that the forces of caution and conservatism ( small “c”) within the profession may not welcome this.

We also need to be ruthless with the bureaucratic nonsense you encounter every day in the health service. Why can’t people with persistent back problems self-refer to physio? Why if you notice bleeding do you have to get a GP appointment, simply to get the tests that you then do yourself at home?

Every patient will have their own experience of these mundane inconveniences and inefficiencies. Across the system and across the country each one adds up, resulting in a mind-boggling waste of time, energy and money, all of which could be better spent.

As was highlighted in the Scottish Health and Sport Committee Report (2021) co-production of health care must involve enabling patients and service users to self-negotiate through the health and care system.

GPs should no longer be seen as a gatekeeper to be overcome to obtain specialist care but rather a gateway that directs patients and users to the most appropriate level of service.

At the moment there are  health services which patients can access directly ( sexual health, drugs service, family planning, mental health, child health) – either for an initial service or, more often, re-activation of a care pathway that they are already on. There is scope to expand this but it must be done in a carefully planned and evidence based way. 

 Simply allowing open access to all specialist care will not provide any extra doctors. It can only lead to the inappropriate used of already over-pressurised services.

In virtually all instances patients will recognise that they need GPs’ professional knowledge to ensure they get the correct service and they should be facilitated to get this timely access.

And in this instance the capacity to directly book GP appointments and obtain primary care advice must be greatly expanded.

Sadly the examples that both Wes Streeting ( the lump on his head) and Keir Starmer ( internal bleeding) used to illustrate their case were particularly bad and inappropriate.

 A major element of needless bureaucracy, competition, duplication and waste in health and social care is the continuing operation of a commercial and/or internal market. If efficiencies are being sought and our workforce to be valued it is time to recognise that the “commercialistation” of key public services, begun by Mrs Thatcher over 30 years ago,  has been a costly failure.

Some people recoil when I talk about change in the NHS. They think Labour’s job is to merely defend public services. I have never believed that. Labour’s job is to drive up standards, so that services don’t need defending. It is precisely because my mum and my wife worked in the NHS, because my parents were cared for by the NHS and because my children were born in the NHS that I want to make it work again.

What we are setting out now is just the start. I want to be utterly clear-eyed about it. That’s why I am hungry for new ways of working, for tackling ingrained thinking, for reform and modernisation. The Prime Minister says he wants to be judged simply on whether waiting lists come down a bit.

That is the same old path of least resistance: the stale route to further decline. By contrast, I am prepared to do the hard yards and tell the hard truths to give patients back the services they need.

The SHA can share much of the same agenda that Keir Starmer is attempting to set out.

In his BBC interview he said that was not advocating the private sector that as the key to unlock or drive reform but rather that he was looking for a preventative model. This is something that  the SHA could wholeheartedly endorse.

In this context the main role he envisaged for the private sector was to clear the backlogs in care. This is not unreasonable. It was done before under the last Labour government and it could be done again.

For over a century there has been a steady increase in life expectancy. Since 2010 these increases have stalled and have even reversed for the most disadvantaged sections of our society. This is not just due to under-investment in health it is also due to the wider effects on Austerity on the major non-medical determinants of good health.