Optimism of the will

Evaluating Labour's plan for the NHS

At the launch of the government’s big plan for the NHS last week, media attention focused on whether Rachel Reeves looked cheerful and Keir Starmer giving her a hug. Which is a shame because the plan itself is an almost perfect exemplar of Labour’s first year in office and deserves proper analysis.

Like so much of what this government has done, it’s ambitious and full of policies, but largely undercut by a lack of coherence and a refusal to acknowledge reality. There are lots of long-term ideas, plenty of complex restructuring, but very little on how to get from where we are now to this desirable future state or how it will be paid for. Symbolically, a delivery chapter pencilled into earlier drafts never made it to the final version. As a result it contains far too little on how to deal with the most pressing problems facing the system right now.

There’s also a stubborn refusal to engage with the past. Ideas that have been around for a long time are presented as revolutionary. Schemes that haven’t worked when tried before are reinvented without any analysis as to what will be different this time. Assumptions are made that seem to have been disproved by the NHS’s history.

For instance, much of the plan focuses on shifting services out of hospitals into “neighbourhood health centres” that would bring together GP services, diagnostics, consultant-led clinics and other support services like housing and debt advice.

One purpose of these centres would be to reduce the number of outpatients being seen in hospitals, to take pressure off them. But pushing more healthcare into the community, and away from hospitals has been a theme of every NHS plan for decades.

The NHS 2000 plan proposed 500 “one stop shops” to see more outpatients outside hospitals. The 2006 plan proposed that 15 million outpatient appointments be done in community settings. The 2014 plan proposed “multispecialty community providers” that would allow the majority of outpatient appointments to be moved out of hospitals. The 2019 plan proposed shifting a third of all outpatient appointments out of hospitals via investment in “multidisciplinary community teams”.

The new plan is hamstrung by a failure to acknowledge or discuss this history. There is a lot more treatment happening out of hospitals than there used to be, because of all these previous reforms, and yet hospital activity has not fallen because demand has increased so much. Why will it be different this time?

Reading the document, with its lack of reflection and determination to wish away problems, reminded me a phrase made famous by the Italian Marxist Antonio Gramsci that Michael Gove used all the time when I was working at the Department for Education – “pessimism of the intellect, optimism of the will”. Or in other words: “stop giving me all the reasons this won’t work and get on with it”. I get the sense Wes Streeting, the health secretary, has a similar approach. There can be merit in this, complex bureaucracies are good at finding reasons not to do things: asking for unreasonable outcomes sometimes works. But there are obvious risks too.

So in the rest of this post I’ll look at the main barriers to making progress (pessimism of the intellect is my forte). First, money, an issue on which the plan is frankly disingenuous. And then at some of the big holes in the proposals that are going to make delivery so hard. I’ll finish with what I suspect will end up happening.