Labour’s NHS plans – 2 views


Labour’s NHS mission plan: a great edifice of reforms that lacks a foundation  –  Alex Scott-Samuel

Labour’s recent weekend policy summit was designed to lay the foundations for the general election manifesto. In addition to discussing proposed amendments to the draft National Policy Forum report published earlier this year, the meeting also received Labour’s 5 Missions for a Better Britain – the third of these being to Build an NHS Fit for the Future.

The National Executive Committee meeting which followed the summit agreed to support the 5 Missions. It did not however discuss the detailed policy briefings which accompanied the missions. The NHS briefing (Ref 1) includes 20 pages of analysis and policy commitments showing how a Labour Government will put the mission into practice.

The briefing commits Labour to making great improvements in the public health as well as in the NHS and social care. For example, it points out that a girl born today in Winchester will live for 12 more years of disability–free life than will a girl born in Blackpool. It commits Labour to remedy this by creating a fairer Britain where everyone lives well for longer. This will be achieved by tackling the structural inequalities that contribute to poor health for disadvantaged groups. The plan acknowledges the need for ‘health in all policies’  which will be achieved by establishing a Mission Delivery Board at the heart of government, which will bring together all government departments whose policies affect the social determinants of health.

Those who understand the causation of health and other inequalities will recognise that these proposals commit Labour to root and branch reform on a grand scale. Relative inequalities in healthy life expectancy between rich and poor (as opposed to absolute differences in the impact of individual diseases) can only be reduced by tackling their fundamental causes – such as inequalities in personal power, influence and ‘beneficial social connections’ between the more and less privileged in our society; inequalities in income and wealth; and in knowledge and education.

These fundamental causes are an inherent, essential element of neoliberal capitalism. So it’s useful to consider what happened the last time a UK government attempted to address these issues. It was no mistake that the Treasury’s 2002 Cross Cutting Spending Review of Health Inequalities, aimed at reducing the contribution of all government departments to the causation of health inequalities, omitted to examine the Treasury’s own contribution – through the well established inequitable impacts of its market based macroeconomic growth policies. When I quizzed the senior civil servant responsible for this omission at a professional meeting in 2003 about this failure by the Treasury, his response was ‘I couldn’t possibly comment’.

It’s evident that none of the above can be achieved without establishing a national health promotion agency – this is notably absent from the briefing. The last Labour Government first changed the name of the national health promotion body (from the Health Education Authority to the Health Development Agency) in 2000 and then abolished the HDA in 2005. It’s quite clear that Labour’s ambitious improvements to the public health won’t be achieved without quasi autonomous coordination by a properly constituted health promotion agency.

Similar principles apply when we consider Labour’s commitments in the mission briefing to reviving our national health service. Several references are made to the important principle of a universal service for all people. But no reference is made to eliminating the discriminatory treatment of migrants and of minority ethnic groups.

Most worryingly, there are several references to the Integrated Care Systems introduced by NHS England and entrenched in law by the Health and Care Act 2022. The Act replaced England’s national health service with 42 legally autonomous Integrated Care Boards, each with the freedoms to  choose which services to provide (and to deny), to set its own pay, terms and conditions, to deskill and to deregulate all health professions. The wording of the 350 page Health and Care Act deliberately created an Americanised system that undermines NHS institutions and invites commissioning and delivery of services by private corporations on a massive scale. It even includes new contract forms which reward providers who cut costs by denying care to patients (‘risk-reward contracts’). But the mission plan refers to a national NHS risk pool, while apparently accepting the fragmented, local, insurance-friendly risk pools created by the Health and Care Act.

The briefing strongly emphasises community based as opposed to hospital care. While it’s correct to say that many people are comfortable with the concept of care closer to home, the briefing carries a strong implication that, just as in the current Americanised NHS, people will increasingly be treated in community hubs staffed by new (and of course cheaper), less skilled staff like physician associates and apprentices. We have already begun to learn that an understaffed NHS gives these kind of aides unrealistic responsibilities and inadequate supervision. This has already led to avoidable deaths. Labour must not introduce this approach unless the apprentices have carefully restricted responsibilities and strong professional supervision. That is only possible following a massive prior expansion in the medical and nursing workforce.

The briefing refers to a national social care service based on high national standards, with fair pay for staff. This would of course be very welcome and should be a high priority in the early days of a Labour Government.

The emphasis on a new era in public health, with a focus on both primary prevention (taking action to stop the development of ill health) and secondary prevention (early detection and treatment) is long overdue and very welcome. Examples given of the new public health approach include a new, legally binding decent homes standard; a Clean Air Act; action to guarantee clean water; and a ban on zero hour contracts.

It is however absolutely clear that Labour’s important and progressive NHS and public health goals will not be achieved without an explicit commitment to early legislation in the first session of Parliament to reinstate a 21st century national health service in England, to repeal the 2022 Health and Care Act and to eliminate Integrated Care Systems, together with all other structures and functions introduced by the Health and Care Act. This year’s party conference must take the bull by the horns and commit itself to a reinstated National Health Service in England as if all people mattered – a universal, comprehensive (including dentistry!), fully publicly provided NHS for us all.



“Reform, reform, reform” seems to be the main currency of the Labour front bench plans for the NHS and social care in the event of winning the next UK general election.  But what does “reform” mean?

At the recent National Policy Forum, which dealt with health matters, members were presented with a 20 page briefing to help shape one of  Keir Starmer’s  “5 Missions for a Better Britain”  Build an NHS Fit for the Future. The document is intended to be a  staging post towards the development of Labour’s  election manifesto.

The briefing’s central theses are that the NHS is seriously broken. To deal with this we need to change a “ ..NHS (which) is still designed for the world of 1948”. While it debatable how far  the latter point is true , there is no doubt that major change is needed. That is hardly a matter of debate. The question is – what change do we need?

The briefing does set out a picture of what it sees as being the future. It will be an NHS and a National Care Service with many more, better trained and better paid staff. The services will be more accessible and responsive to the needs of patients and carers.  Care will be delivered by a more  multi-disciplinary team which can be accessed in a more timely and diverse way making full use of  modern information technology.

Continuity and personalisation will be central, reflecting the changing demography and disease patterns in the population. There seems to have been a welcome retreat from self-referral to scarce, expensive specialist but NICE will be asked to explore how patients may be able to access a range of services than are currently only possible via a primary care clinician referral.  This is much more sensible as it will provide an evidence base to enable patients negotiate their health care pathways.

There will be a new emphasis on a  “prevention revolution” and early intervention with mental health and suicide risk being identified as priorities. Groundbreaking technology will be used to identify those at risk and provide more effective treatments within the context of a universal service with pooled risk sharing.

And to ensure early benefit from the most modern of  advances health care research needs a new priority. It will be encouraged with an added drive to increase public access to  and participation in clinical trails. But while the potential and commercial benefit of this are highlighted the risks of over-medicalisation,   the medicalisation of social problems or data security scarcely feature.

This vision will be overwhelmingly delivered in primary  and community care settings with the NHS becoming as much  “a Neighbourhood Health Service”  —- “healthcare on your doorstep, there for you when you need it.” This approach complements  the need for “(c)ross-departmental working ( which) is vital to improving the wider determinants of health – the social, economic, and environmental factors that affect people’s ability to lead healthy lifestyles.” The continuing problems of tobacco consumption is acknowledged but alcohol and substance abuse scarcely merit a mention. England will become a “Marmot Country” with cleaner air, healthier workplaces, decent housing and a  better start to life for our children which will tackle health inequalities at source.

Equally social care have a greater preventive focus which a much greater emphasis on “home first” provision. There will be consistent national standards for eligibility,  care and terms of employment. The vital role of paid and unpaid carers needs to recognised with  a multi-agency duty to ensure that none fall between the cracks.

There however is no reference to social care charging regimes in either community or residential / nursing settings even though this remains a central issue for all service users except for those who are on the lowest incomes and the fewest assets.

While there is much to commend in this vision but the omissions and anomalies do not sit easily together.  The document provides a continuing list of challenging hospital and ambulance performance targets. These are about the only reference to the hospital sector in the whole document even though it consumes about 80% of NHS resources – and even then there is no reference to performance targets for cardiac and stroke emergencies. It is not clear how the NHS is to be rebalanced to achieve these important targets while at the same time delivering a community based, preventive service.

Most of  these plans will improve health and well-being but they will not be cost neutral, much less save money.  This is a programme which will require substantial public investment to even return  to the levels of performance that the last Labour government achieved. And as a consequence much of what is good in these proposals is written on a very big unsigned cheque.

And in venerating before the shrine of “reform” it is more than surprising that the elephant of the  continuing  commercialisation of the NHS is over-looked.

Integrated Care Systems, the internal market in health and social care as well out-sourcing and private provision will all remain. This means that the corporate, for profit sector will continue to become more involved in service delivery. But where has this experiment with the market  delivered significant innovation, better care or improved efficiency since it was introduced by Mrs Thatcher over forty years ago?  If there evidence was there one would have thought it would have become abundantly clear by now.

It is recognised that the Tory ideological ineptitude is leading to an NHS  “ …becoming a two-tier system with creaking NHS care for those who can’t afford to pay, and timely care only for those with the money to go private present growth in the need to use private health care.”  But, paradoxically, the corrosive erosion of public sector provision will be allowed to continue. And if it persists it will drain the essence from a public service NHS and social care.