In the abstract, almost everyone would agree with the idea that it is important to be exposed to a range of opinions, rather than retreat into an echo chamber where everyone agrees with us. It’s just that, if you spend any time on social media, you will know that most people do not actually behave like that.
In the abstract, almost everyone would agree that we need to build more houses in Britain. It’s just that, whenever a politician tries to actually do something which could make that happen, the Nimby lobby will come down on them like a ton of bricks, and their ‘allies’ will abandon them.
In the abstract, everyone except fans of Modern Monetary Theory would agree that the state cannot permanently spend more than it raises in revenue. It’s just that specific spending cuts are almost always unpopular, and specific spending increases are almost always popular.
In difficult policy discussions, an acceptance of uncomfortable truths is not worth very much if it only happens in the abstract. If it’s not followed by specifics, it’s just the political equivalent of the New Year’s Resolution to quit smoking, go to the gym, and learn French.
Speaking of acceptance of uncomfortable truths in the abstract:
Ever since it became clear that he was going to be the next Health Secretary, Wes Streeting has made a point of ‘talking tough’ on NHS performance. Streeting said that we should treat the NHS as a health service, not a shrine. That we risked killing the NHS with kindness. That we cannot just keep throwing money at it. He even went on a fact-finding mission to Australia and Singapore to learn about other health systems.
Now, I don’t want to dismiss Streeting’s statements as mere abstract waffle of the above variety. I don’t want to say that talk is cheap, because this is a case where talk is not cheap at all. When it comes to the NHS, talk can actually be quite expensive.
Until very recently, saying anything about the NHS other than showering it with love and affection was extremely controversial, even if it only happened at the most abstract level. It still triggers a lot of hysteria in some circles today.
Pointing out weaknesses in NHS performance is an easy thing to do if, like me, you are a Tufton Street villain, and everyone assumes that you have worst possible motives, because you will only come under attack from people who hate you anyway. But if, like Wes Streeting, you are on the centre-left of politics, it takes some genuine courage, because you will upset people who might otherwise be broadly on your side. On Twitter, Streeting is constantly under attack from high-profile NHS cultists who accuse him of secretly plotting to destroy the NHS from within. One of his most vocal opponents is a former Labour shadow health secretary, Diane Abbott.
So, kudos to Wes Streeting for challenging his own side! But I nonetheless never expected him to become much of an actual health reformer. His reform rhetoric has always been too general, and too abstract. What does it mean, in policy terms, to stop treating the NHS like a shrine? What would a non-shrine health policy look like? What is the point of travelling to Australia or Singapore, and pointing at shiny hospital buildings, if you are not actually interested in the features of those health systems that make them outperform the NHS?
And indeed, we are now beginning to see the limits of ‘Streetingism’. The government has just thrown another £22.6bn at the NHS in the latest Budget, on top of the spending injections that already happened under the previous government. Nonetheless, a survey among NHS providers shows that they are still not expecting the NHS to meet its waiting time targets by the end of this parliament.
Streeting is now reportedly considering a series of interventions to improve cost-effectiveness in the NHS. He wants to block pay rises for senior NHS management if the organisation they manage is underperforming. He wants to block NHS trusts from using agency workers – who are typically more expensive – to fill recruitment gaps. And he wants to block a kind of reverse fire-and-rehire practice, where NHS employees resign, and then try to get re-contracted at a higher rate via an agency.
All of these may sound like sensible cost containment measures, but it is also very much business as usual. This is micromanagement from the centre. It is reminiscent of the famous quote from Aneurin Bevan, the ‘founding father’ of the NHS, that the sound of a dropped bedpan in the hospital at Tredegar should reverberate around the Palace of Westminster.
The question that Streeting – and not just him – should be asking instead is: why is it not in each NHS trust’s own best interest to avoid unnecessary costs? Why does a cabinet minister have to force cost savings on them? In most organisations across most parts of the economy, there is no obvious potential for large cost savings, and no obvious potential for major performance enhancements. Why not? For the same reason that there aren’t many £50 notes lying in the streets: because somebody would have picked them up already.
Political pressure on NHS management can sometimes lead to some improvements: it did under Blair in the early 2000s, a period which Streeting’s interventions seem to be modelled on. But if we want lasting improvements without ongoing political micromanagement, we will eventually have to bring healthcare into line with most of the rest of the economy.
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