New year, old issue: how do you solve a problem like those facing the National Health Service? That is the question which the Prime Minister chose for his first set-piece speech of 2025.
It’s risky territory to march into, given the sensitivities, but he is doing so because the scale, reach and popularity of the NHS is so great that failure to shepherd it successfully would threaten his entire Government.
In Monday’s speech, he described success on this front to be the “cornerstone” of his mission to “rebuild the country”. There’s no doubt that the stakes are extremely high.
It was striking that the Labour Party itself went so far as to describe the NHS as “broken” in 2024, on the campaign trail and after the general election.
To an extent, that was about setting expectations. Just as we were told that the economy had “crashed”, and that there was a £22bn “black hole” in the public finances, campaign mode saw them rolling the pitch to attribute blame for bad news to their predecessors, and to lower the bar by which the public might judge their own performance.
But it was also about laying a rhetorical case for reform. Mending something necessarily requires an acknowledgment that it is in some way malfunctioning.
In his speech, Starmer further developed that case. After kicking off with the customary plaudits for the service as “the embodiment of British values and humanity”, he was refreshingly blunt about some of its challenges.
Speaking to an audience of NHS staff, he warned that “productivity can’t bump along 11 per cent lower than it was before the pandemic. Working people can’t be expected to subsidise the current level of care with ever rising taxes”, and even raised the fear that without “top to bottom” reform, the health service would “become the national money pit”.
He’s right, of course. The stubbornly persistent fall in productivity is a massive challenge, particularly in such a gigantic organisation. There is no sustainable future in paying more but seeing no improvement in care levels.
With a budget approaching £200bn, getting less for each pound you spend causes problems on multiple fronts. Though he didn’t say it in so many words, by implication, failure to address this would not only let down patients, but it would also threaten other public services by consuming an ever larger share of spending.
The most notable thing about Starmer’s speech is that he is able to say this at all. Can you imagine a Conservative saying even half of these things without inspiring heckling in the room and some rampantly unhinged hashtag campaign online?
They would be accused of insulting NHS staff, of talking down the health service, and of doing so in order to pursue some nefarious, albeit incoherent, plot to sell the NHS to Donald Trump, Vladimir Putin or maybe Elon Musk, the bogeyman of the hour.
Starmer is powerful enough to reform social care - he's choosing not to
Read MoreIt is Starmer’s Labour identity that gives him room to make reasonable but still controversial speeches acknowledging that the NHS faces difficulties, and to propose that changes are required to resolve them.
But it’s more than that: while Conservatives accurately argue that they have safely overseen the health service for the majority of its history, the fact remains that it is still a weak spot for them reputationally. Meanwhile, Labour can – and regularly does – lay claim to founding it in the first place.
His party’s brand gives the Prime Minister a head start in being able to make the case for NHS reform. It’s positive that he has done so, and is talking not just about new structures or more money, but about harnessing new technologies to deliver better services and empower patients, and working with the private sector to improve services.
But that head start does not make him immune from opposition. The fear-mongering which has tarred “reform” itself as a dirty word was built up over many years, and will not vanish overnight just because the speaker stands in front of a red backdrop instead of a blue one.
There are sizeable vested interests which are able and willing to dig in their heels – even to the point of harming patient care – if they see change as a threat. Most notably, the doctors’ unions have developed a taste for strike action, and an imperviousness to concerns about the impact on the public.
The Prime Minister evidently knows there will be battles ahead: “I know some people won’t like this, but I make no apologies. Change is urgent. I’m not interested in putting ideology before patients and I’m not interested in moving at the pace of excuses.”
There, too, he is correct. A government which rejected new technology, new ways of working, and private sector partners on grounds of dogma, even at the cost of poorer care for sick patients, would be letting down the public, and damning itself to a vicious circle of higher taxes, worse services, and rising discontent.
It is revealing that his goal now is to “unite the NHS behind a plan for reform”. It will not always be possible to serve patients and satisfy unions – and the government and health service exist for the former, not the latter.
The previous government sought to protect patients by legislating a requirement to maintain minimum service levels during strike action. Starmer’s own Employment Rights Bill intends to repeal this protection, which he may yet come to regret. If diplomacy fails, he will need steel – and political power – to get his way.
Mark Wallace is Chief Executive of Total Politics Group
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