Where did the levy money go? That really is a question for the ages – and the recent NHS management review doesn't make it less so. The management review appeared to swerve fundamental issues of NHS reform and made proposals more in line with the status quo than proposals to bring efficiency and discipline to the health service.
This has prompted the interesting question of the NHS' place as the nation's sacred cow – what exactly defines it, and what can be done to improve it? Is an attempt to bring in private sector-style efficiencies an encroachment too close to privatisation for comfort – or is it keeping this public service up to date? How much of taxpayers' money has gone to aiding the improvement in waiting times or patient services – and if so, is that where the government's priorities lie, or do managers know the answer?
For the last 12 years of Conservative government, NHS reform has been a tricky tightrope to walk. Labour is keener than most - as the party that 'founded' the NHS - to defend its place in the nation from the encroachment of privatisation. Sir Keir Starmer, as recently as February, wrote that he regarded both NATO and the NHS - founded during the Attlee government - as "legacies of that transformational Labour government that we need to be proud of and to protect".
Looking back at the NHS' origins are no doubt a means of seeing how far the NHS has come and how it has grown, but the various pitfalls and resistance Tory Health Secretaries in recent years have faced brings up an interesting question of what exactly 'our NHS' is. If the Tories are being framed by the left as on the march to dismantle the NHS by bringing in the odd reform or attracting foreign investment, what NHS are they seeking to hark back to?
There is no doubt the National Health Service needs updating and it needs reform. The Health Secretary recently commented, in Cabinet, that the NHS was a 'Blockbuster health system in age of Netflix' - that NHS technology was decades behind. This is a concern that creates clear inefficiencies for patients, suppliers, and the nation as a whole, and has focused the question on to how to deliver better, patient-centred services. The Health Secretary's comments have prompted criticism from the Shadow Health Secretary, Wes Streeting, who said that "We have a government that is not governing and doesn't have answers. It just has generalities". Labour's plan hasn't provided much in the way of how efficiencies will be made, the recent management review hasn't gone further. Moreover, it appears that the review failed to propose alternative governance structures or wide-ranging reforms to the health service.
However, the Health Secretary needs to do more than tinker or excoriate disparities – he needs to radically reshape the health service. It needs to be one that upholds the original core Beveridge Principles upon which the NHS was founded, and one that can adapt to the modern world – including embracing aspects of market competition from using economies of scale to lower costs to improved open tender systems – as well as embracing modern technology to bring data and information to patients as efficiently as possible: all of which has been done in other countries' public health systems.
Let us note firstly that the NHS, through the National Health Service Act 1946, is a result of the Beveridge Report proposals, which the Attlee government adopted. While there remains active debate over the Beveridge Report – be in no doubt that Lord Beveridge's proposals sit at the bedrock of the national health service as we see it.
Many of those vehemently opposed to interactions with the private sector and Conservative policies will be the first to come to the defence of Beveridge's three principles. After years of debate on left over whether we have 24 hours, one month, or even a year to save the NHS, we must go back to basic and interrogate what people would be trying to save.
So, that brings us to the question: how does today's NHS size up to Beveridge's Three Guiding Principles?
Beveridge's Report, officially Social Insurance and Allied Services was a government report influential in the founding of the welfare state, and prompted numerous other pieces of legislation when its proposals were adopted by the Labour government, from the Family Allowances Act to the National Insurance Acts.
The report offered three guiding principles:
1. Proposals for the future should not be limited by "sectional interests". A "revolutionary moment in the world's history is a time for revolutions, not for patching".
So – the National Health Service couldn't be one specifically designed for any specific group: not doctors, not administrators, and certainly not to any political entity or ministry – but to the wider public of patients. The NHS should be based around patients and at the time, it needed to offer a wholesale revolutionary alternative. Has the modern NHS lived up to that?
The recent NHS management review found poor behaviour and attitudes such as "such as discrimination, bullying and blame cultures in certain parts of the health and social care system" - with the government pledging the "the biggest shake-up in health and social care leadership in a generation".
How that will come about remains to be seen. So, one might ask, does this live up to the first principle? Instead of focusing on issues with the NHS' system of separate trusts affecting management styles or the specific background of NHS management, they focused on the existing managers. You might wonder, say, the ratio of leadership with backgrounds in medicine and without backgrounds in medicine might be of interest. Perhaps the report could have focus on the ratio of specialists to GPs and proposals on how managers could improve that. Overall, while we recognise the need for any organisation to have a strong level of staff cohesion and unity in the ranks – the emphasis on management of the NHS over delivering medical services for patients shows the focus needs to be shifted from managing the NHS to providing a better product - I.e., medical services.
New proposals, from mid-career programmes for managers to "stronger action on equality and diversity to ensure inclusive leadership" focus on the internal issues of leadership and appear closer to human resources concerns than to a report working to create a patient-centred NHS.
2. Social insurance is only one part of a "comprehensive policy of social progress". The five giants on the road to reconstruction were Want, Disease, Ignorance, Squalor and Idleness.
In this instant, the health service is meant to solve the issue of Squalor, one part of this pursuit of social progress. No doubt the idea of universal healthcare can very often bring about social progress – in theory. Whether the NHS management today has done a good job at effecting it is a different question.
Doctors and nurses have certainly helped chart the way forward in bringing about this progress, even in recent times. The government's press release credited hardworking staff with cutting waiting times, saying "the number of people on the longest waits has halved in the past 4 months". This is to be applauded.
But, in terms of the management review and what it recommends within management: how does this bring about any broader social progress? Yes, proposals such as an improved system of appraisal and a career management function will help keep the base of manpower for administrators strong – and it can be effective in keeping people within the NHS. But, can we say these tweaks to how administrators' careers are managed contributes to the effecting or fulfilling of this principle?
Therein lies the question. Recommendations such as an NHS integrated between trusts, or bringing down the walls between the neighbouring trusts of health and care entirely would be what brings about management efficiencies and cuts overhead costs. These are the internal reforms that can help bring social progress its effecting. To the Health Secretary's credit – some of this was noted in his address, but not as emphasised in the review.
3. Policies of social security "must be achieved by co-operation between the State and the individual", with the state securing the service and contributions.
This directly related to the controversial Health and Social Care Levy – or the NI rise, from back in September 2021, and the management review was a direct result of that. This, for one, is certainly true, and is the principle that has remained consistent throughout.
Overall, it is a very interesting picture when taking a look at the state of the NHS today. It's a much larger organisation than when it was first founded and has gone through 4 Acts (NHS Acts 1946, 1977, & 2006, and the Health and Social Care Act 2012). Yet, NHS reform remains a contentious topic. For many on the left, the threat of privatisation is the Tory-imposed Sword of Damocles that hangs about the NHS and any hint of reform or changes that ruffles some feathers is seen as an encroachment too far.
In following that logic and looking back to what 'our NHS' stands for, and in looking at the original guiding principles, the proposals of which were accepted by Labour back in the postwar government and celebrated now, we see how the NHS' recent management review has deviated from those principles. We see how delivery for patients is far from the centre of these debates, how bureaucracy means internal strife is on mind more than efficiency or expertise, and how the dream of a universal and comprehensive NHS isn't being worked towards.
With proposals of using technology to create a more efficient system and the need to harness new technology noted by the Health Secretary himself, it will be more important than ever to show how reforms ought to be brought about, and how it should be more patient-centred.
