Wes Streeting – 2024 Speech on the Reform of the NHS

The speech made by Wes Streeting, the Secretary of State for Health and Social Care, in Liverpool on 13 November 2024.

I’ve come along today to lay down some direction.

Not just to make the case for reform, which I’ve done before, but to spell out how we’ll do it and what I need you to do with me for us to collectively succeed.

When it comes to the condition of the NHS today, the Darzi diagnosis is clear:

• the NHS has not been able to meet its most important promises to patients since 2015
• A&E waits are causing thousands of avoidable deaths
• 50 years of progress on cardiovascular disease has gone into reverse
• 345,000 people are waiting more than a year for mental health treatment – that’s more than the entire population of Leicester
• as the performance of the NHS has deteriorated, so has the health of the nation
• adults are falling into ill-health earlier in life
• and children are less health today than a decade ago
• Ara’s [Lord Darzi’s] conclusion was that the state of the health service is heartbreaking

And I’m yet to hear anyone seriously contest this analysis, which was entirely based on the data.

In my experience, not just as a patient, but in the last 3 years talking to frontline staff and NHS leaders – most people appreciate the honesty and recognise that the biggest barrier to patients accessing care is long waiting times.

As I’ve argued before, a culture that puts sparing political blushes or protecting the reputation of the NHS above protecting the interests of patients is one that stifles inconvenient truths being spoken to power, that silences whistleblowers and that ultimately puts patient safety at risk.

In the last few years I’ve come to know many of you in this room and in the last 4 months I’ve toured the country talking to leaders and frontline staff, so I think I know you well enough to know that you share my view that honesty is the best policy, you agree with the Darzi diagnosis and that you share my optimism that the NHS is broken, but not beaten. Every day there are outstanding episodes of care being delivered, by dedicated people working with some of the best science in the world. As Ara put it: “The NHS is in critical condition, but its vital signs are strong.”

Our collective challenge is to take the NHS from the worst crisis in its history, put it back on its feet and make it fit for the future.

The budget was important. The Chancellor gave us the investment we need to arrest the decline, begin fixing the foundations and start turning the service around.

The NHS was the standout winner. We’re the biggest cash uplift in day-to-day spending of any government department.

There have been 2 predictable reactions to this: the first says that the NHS is getting too much money. That this is a black hole that consumes ever-increasing amounts of taxpayers’ cash and that the NHS will complain it is never enough.

So right on cue, some NHS leaders popped up in the newspapers, aided and abetted by the health think tanks, to complain that this isn’t enough.

One of the luxuries of leading a think tank is that you don’t have to engage with the choices and trade-offs that government does.

The Chancellor had to raise more than £40 billion to plug not just the £22 billion black hole we walked into in July and to fix the foundations so that our economy and our public services can recover.

When the Chancellor announced the settlement for my department, she joked about how unpopular it would make me around the cabinet table.

The truth is, at the cabinet meeting in which she set out the contents of her budget, I did feel uncomfortable.

Not because I was worried about the opinions of the people in the room – because they support the NHS and the investment – but because I am worried about the jobs they have to do. As I look around that cabinet table I see a Justice Secretary who inherited overflowing prisons. A Work and Pensions Secretary who inherited more than 4 million children living in poverty. A Defence Secretary charged with securing our nation, at a time when there is a ground war in Europe, as well as the constant threat of cyber warfare in a more dangerous and unpredictable world.

Every penny of extra investment that goes into the NHS was a penny that didn’t go towards child poverty reduction, extra prison places, or bolstering our armed forces.

More than that, every penny spent on treating sickness is a penny that doesn’t go on preventing illness. You know as well as I do, that around only 20% of the nation’s health is affected by the NHS. The rest is dictated by the poverty we live in, the damp on our walls, the food we eat, the air we breathe and so on.

So, you can’t pretend to care about the social determinants of ill-health if you only ever ask for more money for the NHS.

So then, the argument goes, we must do both.

Of course that’s right, but the choices and trade-offs aren’t just about spending money but raising it. The tax burden in this country is at record levels. We chose, rightly in my view, not to hit working people in their payslips. The extra investment in the NHS, as well as other public services, meant asking employers and the wealthiest to pay more.

You will have seen in the past few weeks, that there are those who disagree with the Chancellor’s decisions. That’s the nature of tough choices.

We stand by our decision to prioritise the health service: healthy businesses depend on a healthy workforce and a strong economy depends on a strong NHS.

But if you want to know where the average taxpayer stands on NHS spending it’s quite straightforward: they welcome the investment, but they worry it won’t be spent wisely.

They agree with the central argument we made at the last general election that investment must be matched with reform.

Tight fiscal constraints mean that reform needs to do a lot more heavy lifting.

We would still need to reform our public services because we are in the foothills of a scientific and technological revolution that is changing the world around us.

Citizens are used to choice, voice, ease and convenience at the touch of a button. We expect everything faster.

Unless our public services are modernised to meet the needs of our people, they’ll become increasingly redundant and irrelevant to people’s lives, unable to meet their needs.

The failure to reform the state to meet the needs of the people is one of the fertilisers of populism we see across liberal democracies. The other is failure to ease the pain in their pockets. We need to address both – with NHS reform that delivers better outcomes for patients and better value for taxpayers’ money.

By now you will be familiar with the 3 big shifts that will underpin our 10-year plan for health:

• from hospital to community
• from analogue to digital
• from sickness to prevention

These shifts are not radical new ideas, but delivering them truly would be.

They’re necessary to tackle the challenges of our growing ageing society, rising levels of chronic disease and rising cost pressures; as well as to seize the opportunities of a scientific revolution in which AI, machine learning, genomics and data offer us the chance to transform our system of healthcare to one that can not only diagnosis earlier and more accurately and treat more quickly and effectively, but also predict and prevent illness.

But we’re not waiting for the 10-year plan in May to get cracking with reform.

Over the last few years, I’ve regularly heard the criticism of the top-down nature of the NHS. It can be a difficult criticism for those at the top to hear, but for the last 4 months I’ve found myself at the top of the system – at the peak of the mountain of accountability – and I not only recognise the criticism, I agree with it.

The NHS in 2024 is more hierarchical than almost any other organisation I can think of. Even our armed forces, as the Messenger Review argued, is less locked into centralised command and control.

Those of you who have studied the birth of the NHS will know that there were vigorous debates within the Attlee government about how the new NHS should be organised. Given the vital role that a strong state and central planning had played in Britain’s success in the Second World War it was perhaps inevitable that Nye Bevan’s centralised model won the day, albeit with concessions to the doctors to overcome opposition from the British Medical Association. But Herbert Morrison and others in the Labour movement had argued strongly for a municipally based model, with power and control exercised locally.

Attlee and Bevan could scarcely have imagined in 1948 that the single payer system they created would make the NHS ideally placed to seize the opportunities of data, genomics, AI and machine learning. The ‘N’, the national, in NHS is important. It should be the guarantee that patients everywhere are treated according to the same values and the same standards.

The framework I’m setting out today is based on triple devolution: with power shifting out of the centre to integrated care boards (ICBs), to providers and, crucially, to patients. I want to lead an NHS where power is moved from the centre to the local and from the local to the citizen. Morrison meets Bevan.

It starts with clarity. The centre should be deciding strategy, policy and clear objectives for the system to deliver on behalf of patients. We should allocate resources against those objectives and provide the overall accountability framework for improving performance. We should ensure the same standards of care in every part of the country and we should unlock the unrealised potential of the NHS as a single payer model by making the NHS the best partner in the world for the development of new treatments and medical technology and to make the most of our collective purchasing power to deliver value for money.

And the centre should be smaller.

As power flows from the centre over time, resources should flow with it. Otherwise it will keep swamping local services with diktats and demands that distract them from the job of meeting patients’ needs and improving the communities they serve. We need more doers and fewer checkers and the centre needs to learn the words ‘stop’ and ‘or’ after years of ‘start’ and ‘more’.

Clear priorities mean a few, not 50 different targets. So the instructions coming out in the forthcoming NHS mandate and following planning guidance will be short. I want to see waiting times cut, urgent and emergency care when people need it and improved access to primary care. The shift from hospital to community needs to start now.

Amanda set out yesterday that NHS England, not ICBs, will be responsible for managing performance of trusts. When I talk to ICB leaders I hear mixed views about where they should be focusing their efforts. There is no uniformity and too much confusion.

So let me be clear: I want to see local commissioning back and I want to see ICBs leading it.

ICB chiefs, I am talking directly to you: you will lead the transformation of care – the pioneers of reform. Your organisations will play a critical role in doing what we’ve never pulled off before.

I want ICBs to focus on their job as strategic commissioners and be responsible for one big thing: the development of a new neighbourhood health service. It will focus on building up community and primary care services with the explicit aim of keeping patients healthy and out of hospital, with care closer to home and in the home.

All the evidence suggests that 1 in 4 patients in hospital should not be there and that 1 in 5 emergency hospital admissions are preventable – so long as earlier diagnosis takes place. There’s your challenge.

We need to design services around people – particularly more than 15 million people with long-term conditions who are too often passed from pillar to post, from one service to another. Fragmentation needs to give way to integration and that is the job of ICBs.

That will leave providers – whether NHS foundation trusts or regular trusts in mental health, community or acutes – to get on with the job of improving frontline services for patients, including restoring the 18-week waiting time standard.

Over the past decade, provider freedoms have been curtailed. I view that as a retrograde step.

Starting with the best performing trusts, providers should be given greater freedom and flexibility to innovate, run community services and manage their own house to meet the needs of their patients.

Our long-term ambition is that all providers should enjoy the same freedoms as foundation trusts so long as they deliver improved performance.

Critically, those ICBs that perform best – particularly in developing neighbourhood health services – should also enjoy greater freedom and flexibility.

We will no longer treat all providers and ICBs as if they’re all performing equally, when you and I know it’s a mixed ability class.

We’ll assess systems against a set of criteria and publish the results, starting from next year.

Those systems and providers that are in the middle of the pack will get support to improve to bring them to where the best are now.

Those ICBs and providers that are doing well will be rewarded with greater freedoms over how to spend their capital, with fewer ringfences for example.

Those that demonstrate the best financial management will get a greater share of capital allocation. We want to move to a system where freedom is the norm and central grip is the exception to challenge poor performance.

So improving services for patients should be rewarded. The quid pro quo is that there will be no more rewards for failure.

The work you do couldn’t be more serious. When you get it right, lives are saved. When you don’t, the consequences can be tragic.

If performance dips, I reserve the right to take those freedoms away.

For those judged to be persistently failing, we will act. We will go from zero consequences for failure, to zero tolerance.

Our new pay framework for very senior managers (VSM), which I know has been long awaited in the system, will be published ahead of the next financial year and will set out substantial reforms.

It will drive consistency, increase transparency and limit VSM pay inflation whilst giving sufficient flexibility to attract talented candidates to the most challenging roles and providers. It will also ensure that those who are in charge of organisations that persistently fail to provide decent care or fail to keep a grip on their finances, do not receive annual pay uplifts.

Failure to have appropriate regard to the framework will be considered a governance issue and therefore be backed by the full range of regulatory levers at NHS England’s disposal.

Failing integrated care systems will not have access to capital flexibility, and neither will trusts, including foundation trusts that have the badge but don’t meet the mark.

Turnaround teams will be sent in to diagnose the problem and help fix the problem, financial controls will be imposed if necessary and where leadership is found lacking, they will be removed.

But there is one thing I am sure of over the last few months – one person behind a desk in Whitehall cannot deliver the mammoth task ahead of us. Taking the NHS from the worst crisis in its history and making it fit for the future will require first class leadership at every level of the system. The journey of reform is one I am determined to take with you, not impose upon you.

And that’s where you can expect a grown-up break from the past. No more manager bashing for manager bashing’s sake.

Lord Darzi’s investigation into the NHS concluded that the problem is not too many managers, but too few with the right skills and capabilities.

And let me tell you, that is not the most convenient conclusion for a politician to receive. I could be no more popular than announce the sacking of lots of managers, but that would not be the right thing to do.

I am prepared to make an unpopular argument with the public about the value of good leaders. The NHS is one of the biggest organisations in the world. We should be competing with global businesses to attract top talent, and for that we need to attract and retain the best.

So we will invest in you and support you. Yesterday, Amanda laid out our plans to develop a new NHS management and leadership framework with a single code of practice, set of competencies and national curriculum to help develop essential leadership capabilities.

And today I can announce that we are establishing a college of executive and clinical leadership, to help train and develop excellent NHS leaders. Non-clinical leaders should be working in lockstep with clinical leaders and that’s why I want this resource to be available to every type of leader in our NHS.

And I have asked Sir Gordon Messenger, to help us develop and attract the talent we need to develop our 10-year plan.

The most important person in all of this is the patient. Since we launched the national conversation on the future of the NHS with the Prime Minister a few weeks ago, I’ve been struck by how loud the patient voice has been during the exercise. It’s almost the inverse of my experience in my average working day.

Popular and familiar ideas – like allowing patients to choose where and when to be treated, making it easier to rearrange appointments and grouping tests and scans together in one visit to save time – rarely pass the lips of most people of the people who walk through my door with something to say to me.

I said in opposition I would be the patients’ shop steward. Now I’m in government I’m here to be the patients’ champion.

They will be at the heart of the 10-year plan next year, their priorities will be reflected in a new NHS mandate shortly and when the elective recovery plan is published in the coming weeks you’ll see that greater choice and control is at the heart of it.

We start from a low bar and we’re not going to change the experience overnight, but the direction is clear: patients should be able to choose where we’re treated and when. The ease and convenience with which we organise most of our lives – and the best performing providers allow us to organise our health care – should be available to everyone, in every part of the country. That’s why I welcome Amanda’s announcement yesterday about the new ‘ping and book’ service for breast and cervical cancer checks.

Power to the patient is my mantra and it needs to be yours, too.

Finally, right now, I know that many of you are feeling battered and bruised.

I know it won’t be easy to turn the tide, but my message to you today is a message of hope.

The Prime Minister pledged the biggest reimagining of our NHS since its birth.

And it falls upon all our shoulders to deliver this – the jewel in the crown of this government’s decade of national renewal.

The challenge is huge. But the prize is enormous.

And the change has begun.

The package of reforms I’ve announced today is how we will get more out of the NHS for what we put in.

This is how we will make sure the investment announced in the budget delivers real change for patients.

This can only be a team effort, based on a shared national mission, to recover and renew our National Health Service.

You have dedicated your careers to public service and I know that, among you, I am not alone in the scale of my ambition.

To coin a phrase, we are in this together. The NHS is already living on borrowed time.

If we get this right, we can look back on our time with pride and say we were the generation that took the NHS from the worst crisis in its history, got it back on its feet and made it fit for the future.

Many of you in this room have done it before. We can do it again.

Thank you very much.