When it comes to politics, we have a tendency to see the presentation of policy as somehow disreputable, even dishonest. We talk about ‘spin’ and ‘lines to take’ as if they automatically equate to deception; but this is to forget that politics is not just the business of ideas and administration, but of persuasion. Having a brilliant idea is only the first stage, after which any government must show the electorate why it is a brilliant idea.
The recent succession of minor-to-moderate political crises lapping around Downing Street – political appointments to civil service positions, generous donations to the Prime Minister and his wife as well as other ministers, the role and remuneration of Sue Gray, Keir Starmer’s chief of staff – have demonstrated that the current administration has a very shaky grip on media handling. It lacks a figure like Peter Mandelson or Alastair Campbell, often reviled but brutally effective at presentation and controlling the public narrative.
Yet persuasion is going to be central to the Labour Government’s prospects of achieving radical reform. Take its vision for the National Health Service, which Starmer sketched out earlier in September. Following the publication of Lord Darzi’s review, the Prime Minister argued that the NHS was ‘broken’ and ‘at a fork in the road’, and that it had to ‘reform or die’. He warned, however, that ‘reform does not mean just putting more money in’, but that the provision of healthcare would require a fundamental change in emphasis.
The Government is developing a 10-year plan for the NHS which will be published next year, but the Health Secretary Wes Streeting has alluded to three main areas in which there must be ‘strategic shifts’: from hospital to community, from analogue to digital and from treatment to prevention. These are noble enough, insofar as they have much meaning at this stage. However, combined with the Prime Minister’s emphasis that there will not simply be an influx of additional resources, they will require significant changes in policy which will not be instantly popular with the public.
It is more than 30 years since the former Chancellor Nigel Lawson encapsulated the relationship between public perception of the NHS and the challenge of making significant change. In his autobiography, ‘The View from No. 11: Memoirs of a Tory Radical’, he wrote:
The National Health Service is the closest thing the English have to a religion, with those who practise in it regarding themselves as a priesthood. This made it quite extraordinarily difficult to reform.
Two of the changes of emphasis that Streeting outlined, from hospital to community and from treatment to prevention, make sound clinical sense but, in circumstances of financial restraint, do not bring immediately visible benefits and will entail painful choices. Starmer noted that ‘the share of the NHS budget spent on hospitals has actually increased’, but added that ‘this Ten-Year plan has to be the moment we change this’.
Think about that for a moment. He is saying only what is inevitably true, but the Prime Minister announcing in a major speech that his government will stop increasing resources given to hospitals is a hugely significant political signal. If the overall NHS budget is finite, then of course ‘shifting’ focus from inpatient care to outpatients, and for strategies to prevent disease rather than interventions to treat them, will mean spending less on acute care. But how does that look?
NHS England has a budget of around £200 billion and employs 1.3 million people. Metrics for its effectiveness are incredibly complex and varied, and become more so if you attempt to measure the success of disease prevention. Politicians have always known two things: that the electorate understands headlines like the Johnson government’s New Hospitals Programme, which in 2019 promised billions of pounds to build new facilities and modernise the existing estate; and that these eye-catching figures are inadequate measures of the overall success of the health service. This simply reflects common sense. It is far easier to trumpet the spending of a 10-figure sum of money than to explain how a dozen incremental projects have obviated the need for that spending. Give ’em the old razzle-dazzle.
As the current Government has told us again and again that, in effect, there will be no razzle-dazzle, it has a huge presentational task on its hands to explain why it is not, and should not be, increasing NHS spending by substantial amounts. It then must show a sceptical and often hostile public that its alternative of ‘reform’ will improve the nation’s health without requiring simple injections of capital, and that people’s lives will be made better by a system of healthcare which keeps us healthy and stop us becoming sick, rather than waiting until a crisis and dealing with its consequences.
Some of the tasks Starmer faces are among the most difficult to communicate to the electorate. Democracy is a process of persuasion, and the most fundamental changes, such as to the way we deliver healthcare, can be the most challenging to present positively. Whatever else you might think of the government’s approach to the NHS, if it does not get better at telling its story, it will struggle for public support and risks condemning its 10-year plan to failure.
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