What does Wes Streeting mean when he describes the NHS as broken?

In his first statement after being appointed to Keir Starmer’s cabinet, the new Secretary of State for Health and Social Care Wes Streeting made the bold claim that the policy of the Department of Health and Social Care “is that the NHS is broken.” The accelerating decline of the NHS since 2010 offers plenty of evidence to support this statement: long waiting lists and waiting times in many areas of care, avoidable deaths in overcrowded hospital emergency departments, public satisfaction at a record low, and concerns about the health and wellbeing of staff resulting from work pressures are among a long list of challenges for the new government.1

Streeting has used his time as shadow health and social care secretary to develop plans for tackling these challenges. They include ambitious aims to return to treat 92 per cent of patients on waiting lists within 18 weeks, a target not achieved since 2016, and to treat most patients attending emergency departments within four hours in the government’s first term. Cutting waiting lists will involve paying for NHS patients to be treated by private providers and adopting high intensity surgical practices of the kind used in Guy’s and St Thomas’s NHS Foundation Trust to treat more patients.2

Hitting the four hour target in emergency departments will require action across health and social care to support people at home and expedite discharge from hospital. Integrated intermediate care services in several parts of England are showing what can be achieved. These services illustrate that fixing the broken NHS must involve other partners in local government, and the voluntary and community sectors, if the underlying causes of current pressures are to be tackled and not just the symptoms. This includes ensuring that these partners have sufficient funding to play their part and the role of informal carers is recognised and valued.

In seeking to deliver results quickly, it is essential that the government puts in place a long term strategy for renewal and reform. Key elements include preventing illness and tackling inequalities in health outcomes; supporting people to live independently in their own homes; strengthening primary care and community services to enable more care to be provided closer to home; using hospitals only for those people who cannot be treated and cared for more appropriately in other settings; and drawing on the power of people and communities alongside the resources of the public sector.3

These and other changes are needed in response to the changing burden of disease and new risk factors in the population as well as the immediate pressures facing the NHS. Peer support for people with chronic health conditions is one way of promoting shared responsibility for health and care and reducing overreliance on hard pressed professionals. It also recognises the positive role of each person in keeping healthy and using services wisely.45

A start has been made in developing a long term strategy in the new government’s stated mission to improve healthy life expectancy for all and halve the gap in healthy life expectancy between different regions of England. There are lessons in how to deliver this mission from the experience of the strategy developed by the last Labour Government, which involved 82 commitments. Evaluations show that inequalities in health outcomes narrowed because of the strategy, although it took time for this to happen. Increased social investment in the most deprived areas was particularly important alongside high level commitment across government backed up by national targets.6

These changes were facilitated by increases in public spending in many services and were halted by the period of austerity that followed the 2010 general election. The context today is quite different from that facing the last Labour Government with the scope for investing more in public services limited and difficult choices to be made about which services should take priority. If the new government is serious about improving healthy life expectancy this may mean prioritising other public services over the NHS, at least until the public finances improve, recognising that this may delay much needed improvements in NHS care.

By referring to the NHS as broken, it is important to be clear that the delivery of care needs fixing to avoid misunderstanding. There is no evidence that adopting a social insurance system of the kind found in parts of Europe would offer advantages over general taxation, nor that new or increased patient charges would bring benefits. Both would entail major changes and their introduction would consume disproportionate amounts of time and political capital. Far better to focus on the broken delivery system and keep the current funding model.

Streeting should also be explicit about the need to fix social care as well as the NHS. Spending cuts have reduced publicly funded social care to a threadbare safety net while impacting on the ability of the NHS to deliver its objectives. Policies to compensate for these cuts by using some NHS funds to support social care have also been found wanting. Simon Stevens, former NHS chief executive, argued that you do not create a watertight solution by combining two leaky buckets, and this remains the case. Bringing forward plans for a properly funded National Care Service must be the way forward.