How radical will Wes Streeting’s NHS reforms be?

Wes Streeting has spent years talking about NHS reform – but he’s always had a red line on ‘free at the point of use’. At the start of the year the Health Secretary suggested he’d rather ‘die in a ditch’ before giving up on this principle. But is something about to give?

Asked today at the Tony Blair Institute’s conference if the UK needed to keep ‘free at the point of use throughout the NHS’ – or if some kind of top-up system could be considered for those who can afford it – Streeting did not give his usual, straightforward answer. Instead, he seemed to create a new definition for the concept.

‘Free at the point of use is about fairness and equity,’ he said. ‘And defending a system that means when you fall ill, you do not need to worry about the bill. And I think that’s an equitable principle that’s worth fighting for.’ 

The Health Secretary then went on to reiterate his case for more private sector involvement in NHS care. ‘People are already making the choice. And what we’re seeing is the opening up of a two-tier system,’ he noted. ‘‘Why should those without means wait longer while those who have means are seen faster. That’s an affront to my left wing principles.’

This comes after Streeting’s comment over the weekend that the new policy of the health department ‘is that the NHS is broken’. So what can we make of his description of ‘free at the point of use’ – and his refusal to rule out changes to that principle?

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What’s interesting about Streeting’s comments is the reframing of ‘free at the point of use’ as a matter of affordability. Not paying anything upfront for treatment has long been the UK’s way of making sure no one is landed with a bill they can’t afford due to sickness. But rather than ruling out charges completely, Streeting leaves open the idea that perhaps some people would be able to afford a small bill – or something like a copayment – in a way that would not be seen as unfair. 

If Streeting is as serious about reform as his comments often indicate, it’s wise not to rule out the possibility of co-pays or top-up charges, like those used in social health insurance systems throughout Europe (which still guarantee universal access to care). 

It is also very hard to imagine a system in the UK that has anyone being asked for credit card details when they arrive at a hospital. But having spent time in Australia and Singapore late last year, Streeting is well aware that there are plenty of ways to structure a health service – and if he’s given the opportunity to seriously reform the NHS, he can come up with a bespoke model that fits within the fundamental principles he wants to protect, including access to healthcare regardless of one’s income or wealth. 

Streeting seems acutely aware of his limited time frame to make such changes – not just on system reform, but on tackling the NHS waitlist as well. Streeting heads from the TBI conference into his first conversations with the junior doctors this afternoon, who are preparing a new ballot for August if an agreement cannot be reached.

Streeting said again this morning that while pay discussions remain on the table, a pay rise of 35 per cent is not going to be possible. He has also said that he is ‘genuinely angry about’ the way junior doctors are treated by the NHS. 

This will be a telling moment, not just for the government’s negotiation tactics, but for the BMA’s ultimate goal. While the 11 junior doctor’s strikes over the past 20 months certainly had political elements to them, their main goal was to increase pay. That goal has, presumably, not changed just because the government has changed.

Streeting only has a matter of weeks, then, to avoid another strike. The most recent walkout, just ahead of election day, is estimated to have led to over 60,000 cancelled appointments. If the strikes continue, it’s going to take much longer for the NHS waitlist to fall. And fighting constantly with the doctor’s union is going to take up much of the time the Health Secretary is going to need to reform the NHS.

Update: Since publishing, the Health Secretary’s team has been in touch to confirm that Streeting categorically rules out NHS charges, clarifying that when Streeting said, ‘I think that is an equitable principle that is worth fighting for’, that was to mean that there would be no changes.