A landslide: where now for health?

It’s the morning after, as of writing. While many fellow Britons will be in a sleep-deprived, caffeine-fuelled fug, new PM Keir Starmer has his sleeves rolled up and is already at work inside Downing Street. 

As we all know, a super-majority does not reduce the massive challenges ahead, many of which felled the last government. And many of them in our backyard – health. So what next?

Short-term moves may be more tricky than the medium term 

While the public will surely have patience for a few months, they will want action and some quick results. 

Clearly settling the junior doctors' strike will be a top priority. But remember that for at least a decade, public sector workers’ wages have stalled and many will be demanding more. With the total public sector wage bill at circa £200bn, even small increases agreed for one group will send a loud signal to others and potentially tot up to a lot. So whatever is agreed on pay for junior doctors (as well as what might be extracted from them in return), could blow a big hole in any extra investment extracted from the Treasury this year.

And on that, the new government has to decide quickly if it wants to have a short-term budget this autumn covering the next 18 months, and a bigger spending review (covering the following 3 years) next autumn. Or go more quickly and have a full 3-year spending review this year completed by December. If money is so tight and there is only one fiscal moment to get serious investment for health and care, then surely it would make sense to have a proper go at it next year? This year’s budget could cover some of the short-term must dos to build credibility for a bigger ask next year, underpinned with the thought and analysis it needs.

On the short-term must dos, apart from junior doctors’ pay, the immediate concern ahead is winter. Given the risks are always uncertain, the real questions include how much investment would be needed, and spent on what and when, to mitigate the risks of a crisis. Surely the focus will be on social care (including to speed up discharge from hospital), but there will need to be a clear plan on how any extra funds would be distributed most effectively. Any extra money should be spent on areas with latent capacity. There isn’t much time to prepare for this and the investment ask needs to be immediate. 

Set against this is how much risk the new government will be prepared to tolerate. A reforming government wanting to be tough on the NHS might consider winter a shroud-waving exercise for more investment that can be ignored, not least with such a large majority, and blame any crisis on the previous government’s legacy. This is possible, but not a good look and runs against the spirit of Starmer’s entry speech to Number 10 – public service and country first, party and politics second.

Boosting access to primary care is the other obvious short-term priority, given public concern. While aggregate figures on numbers and speed of appointments do look encouraging (see our GP dashboard), clearly people in some parts of the country are being failed. Anyone listening to the Today programme a few weeks ago will have heard a shocking feature on Telford, with patients unable to be seen at all or hanging on a phone – ‘You are number 47 in the queue.’ Targeting practical remedies on areas of the country that have effectively become GP ‘deserts’ must be the first step.

Getting these first moves right will be essential, as will making progress on a small number of things the public care about. This may come through a mixture of some targeted funds but also, I suspect, some initial frank and dirigiste interventions from government.

While this is happening work should begin on a refreshed NHS Long Term Plan, linked to a bigger investment ask (focused more on capital and prevention) and a thoughtful approach to delivering change that commands more widespread support. Without recourse to massive investment, the main latent asset is clearly the motivation and talent of staff. And on the direction of the new long term plan, there is much consensus (including antibodies to structural reform), not least as the old one is still largely fit for purpose. However, bigger features in the mark two version should be technological change (including skilling up staff and patients to exploit the benefits) and attention to the financial flows and incentives within the NHS. Thinking on both is surprisingly underdeveloped.