What does a radically different state look like for a Labour Government?

Could a model of change be emerging as Government plans for state and public service reform emerge? A recent speech by the Health Secretary suggests so. But there are pitfalls.

The UK state is subject to relentless critique given wider social and economic pressures: stagnation, stressed public services, and deep-seated regional inequalities. The emerging picture of Government reform is less one of missions and more one of departments grappling with reform in different ways as an analysis by Ed Dorrell identifies. The most intriguing story of reform, and given the importance of the care economy as it has whole economy resonance as previously outlined, is emerging from the Department of Health and Social Care.      

Before we explore an intriguing speech from the Secretary of State for Health and Social Care, Wes Streeting, it’s worth a brief glance at the other side of the discussion, the new Leader of the Opposition, Kemi Badenoch. Continuing the themes of her Leadership campaign, in a Sunday Times oped she dug into bureaucracy, legalism and managerialism as the blockers of change. 

I suspect that there is a potentially energetic conservative opportunity here - the small citizen against the bureaucratic state. That opportunity doesn’t reside in the relationship between Ministers, officials and the law with more power at the political centre as the solution. In fact, in the wake of Covid “VIP lanes” and Grenfell there will be a lot of nervousness at the thought of Ministers bypassing processes and good governance. Until we have omniscient political leaders, unlikely to be any time soon, having some institutional checks and balances is no bad thing. Don’t believe me? Just keep watching the US under Trump Mark II. So the Conservatives are in a bit of a blind alley at the moment it would seem.

Streeting’s analysis of the pathways of change is rather different. In fact, upskilling managers in a new college of executive and clinical leadership will be a key part of reform: improving rather than alienating. All the headlines around his speech at NHS Providers conference, nonetheless, emphasised a top-down measure of hospital league tables. And yet, the reform package is far more sophisticated than that and more interesting, and possibly revealing, as a result. Though he didn’t put it in these terms, the reforms would appear to combine top-down direction, local collaborative leadership, and individual professional and patient agency in a potentially innovative way. Will it work? There’s a big danger that I’ll come back to: authority undermining the rest of the system.

The fundamental affliction faced by the NHS is how to balance treatment and wider health when the former is immediate and urgent and the latter unfolds its impacts on our physical and mental well-being over time. The wider social determinants of health are of course crucial but the health system, that goes way beyond the NHS, into the food system, communities, and into our own bounded rationality, struggles to both upstream healthier lives and treat the volume of ill-health that is prevalent as a consequence. But you have to start somewhere and, in seeking to balance Herbert Morrison (local innovation) and Nye Bevan (equality) with a dash of individual patient rights, last week’s speech was an attempt to lay out the ground.

I’ll cover each main element of what he outlined in turn. Firstly, acute care will be overseen by NHS England - this means hospitals in effect. There had previously been some confusion where authority for overseeing the system lay- NHS England or localised Integrated Care Boards. An increase of almost 13% in capital expenditure was announced in the Budget to support better hospital outcomes. It should be noted the Darzi Review reported a £37billion investment shortfall since 2010 so there is still considerable ground to make up. Hospitals will be subject to significant centrally driven pressures to improve alongside increased investment. 

Integrated Care Boards will meanwhile have oversight of local and community services with a wider health perspective at play. Chris Ham recently explored local system leadership in the North East and Yorkshire spotting the emergence of strong collaborative system leadership across the region, a culture of engagement with staff and communities and system-wide learning, and notable improvements. He recounts practice that is neither bottom-up nor top-down but a “constellation” of collective leadership and learning. 

For this element of the Streeting approach, such systematic leadership will have to be replicated across the whole service and beyond, if treatment is not to continue to overwhelm the health elements of the system. In a fringe event at the Labour party conference I heard two Labour MPs with a background in the NHS, Paulette Hamilton and Peter Prinsley, both locate the challenge of better health more in the space of workplace culture through better teamwork and more humane forms of management. This will not be unlocked through top-down structures. 

The third element, and the one that ignites the greatest passion in the Health Secretary, is the patients’ rights element. It hardly warrants repetition that patient experience of engaging with the service can be extremely dispiriting and frustrating. Yes, waiting lists are important (and they drive a lot of negative experience) but so is just feeling like you are a human being and you have some sort of agency and voice when you need care. Unlocking this is big and will require enormous shifts in culture, management, technology and capacity but this third element of reform has to remain in sight.

So there is an identifiable triple logic of reform in Streeting’s emerging plans: authority, local collaboration and individual agency. It bears some relationship to the successful improvement of London schools in the 2000s in the way it combines different animating logics of change.   

And I said there is a huge potential pitfall and here it comes. The big risk is that the different cultures of change will be unbalanced and the default system logic of top-down, authority-driven change will predominate and the treatment system will overwhelm the health system. That would be a pity but it is the number one risk and would mean that we are locked into a service in a pattern of unsustainable reactivity. 

If we are to have a functioning care economy, these reforms matter, and so, we have to hope, that all involved realise the potential tensions and are thinking through how as the galleon banks in the storm as it will, it won’t only be the rope of top-down authority and deliverism that they will grab in desperation. In case of emergency, hold your nerve.