This is a summary of the meeting, sponsored by Richard Burgon MP, held in the Houses of Parliament on Tuesday 4 March 2025.

Present from Parliament were Richard Burgon MP, Baroness Virginia Bottomley, Ian Byrne MP, Baroness Hilary Cass, Ellie Chowns MP, Neil Duncan Jordan MP, Staff of Baroness Finlay, Imran Hussain MP and Luke Myer MP. Also present, as well as the expert panel and Mark E Thomas, were representatives of the Unions and other health campaigning groups.

Richard Burgon opened the meeting, welcomed the new report, explained the importance of rebuilding the NHS as a crucial part of national renewal, and introduced Mark E Thomas.

Here is an approximate transcript of the formal presentation; we will add a summary of the Q&A next week.

Thank you very much Richard, and Good Afternoon, everyone.

As Richard said, I’m going to talk for about 20 minutes and then leave plenty of time for discussion, but before that, let me introduce our very expert panel.

The expert panel

I expect you know Polly Toynbee as a political journalist and author – her most recent book, The Only Way is Up sets out her hopes for the UK between now and 2030. What you may not know is that she is also a member of the NHS Assembly. Polly’s depth and breadth of experience will help us assess the extraordinary challenges we face.

Professor Patricia Murray began her career as a nurse and is now Professor of Stem Cell Biology at the University of Liverpool. Trish has personal experience of what works well in healthcare innovation as well as the potential for abuse. She was awarded the Healthsense 2024 award for her work on scientific integrity. Trish is also a current cancer patient.

Doctor John Puntis worked for 40 years in the NHS, latterly as a Consultant Paediatrician; now he is Co-chair of Keep Our NHS Public. John’s practical experience of what works and what does not work in terms of private sector involvement with the NHS is unmatched.

Chris Banks has been – among other things – Chief Executive of the Northwest Anglia NHS Foundation Trust, Chief Executive of NHS Cambridgeshire and Chief Executive of Tower Hamlets GP care group. He has 30 years’ experience of the practicalities of managing the NHS through good times and bad.

Before we give them a chance to answer your questions, let me quickly run through the key points of our new report, the Rational Policy-maker’s Guide to Rebuilding the NHS.

Summary

I am going to cover three main topics:

1. The turnaround in NHS performance between 1997-2010 – and what caused it;
2. Some choices made then, that we should be careful not to repeat;
3. The importance of getting the big picture right.

And I will conclude with some key points that this government must take to heart if it is to succeed.

The improvement between 1997-2010

There is no question that the 1997 to 2010 government dramatically improved the performance of the NHS. I should first explain what it is that citizens want – and can reasonably expect – from a high-performing health care system.

In essence, there are three things:

1. Effectiveness –  when we are ill, we expect our healthcare system to provide us with high quality care;
2. Efficiency –  efficiency is defined as output (that is the healthcare provided) divided by inputs (which are all purchased with money). We want value for money;
3. Equity –  we want the system to be fair. When we are ill, we want to be treated according to our needs rather than according to the size of our bank balance or whether we are perceived to be in some sense ‘important.’

That is all we can reasonably expect our healthcare system to provide, but it’s not all we care about. We care very much about things like life expectancy which are not entirely under the control of the health care system. In the US for example, which has very low life expectancy for a developed country, the main causes of that low life expectancy are drug overdoses, gun-related deaths and automobile accidents. A healthcare system cannot pick up the pieces of a broken country. Context matters.

Here are some of the key statistics summarising outputs over time. Unfortunately, the data do not go back to 1997, but you can see enough of the picture to get an idea. Waiting lists fell dramatically to the year 2010 and have since been worsening. The percentage of patients seen within 4 hours at A&E rose to over 95% and has since declined dramatically.

Patient satisfaction reflected those statistics: satisfaction which had reached an all-time low by 1997, rose to an all-time high by 2010, and has since declined.

And that level of satisfaction was recognised by international benchmarking which looked at all the factors I described the beginning. This chart is from the US-based organisation, the Commonwealth Fund, who produce one of the most comprehensive of the international benchmarks and describes their assessment of the NHS in the early 2010s.

As you can see, the NHS scored extremely well overall as well as for efficiency where it was cheaper than the systems in all our peer countries, effectiveness and equity. It did less well on outcomes, because of the context of still high levels of inequality and poverty by international standards.

What drove this success? The Office for National Statistics provides a data set on healthcare efficiency  –  the amount of healthcare provided per pound spent. And we know how many pounds were spent in each year, so this enables us to separate the additional outputs caused by increasing efficiency from those caused by increasing funding. The picture is remarkable.

The improvement in healthcare output between 1997 and 2010 was overwhelmingly due to the increase in funding. Efficiency rose by about 1% per year, which is lower than the normal rate of efficiency growth. In other words, all the initiatives which were intended to improve efficiency, collectively failed to do so. Conceivably, none of them were successful; far more probably some of them were quite successful and others were extremely unsuccessful. It is vital that policy makers understand which were which  –  with everything else that is happening now, we cannot afford mistakes this time.

Some questionable choices

There are three areas in which there is already considerable evidence that suggests  –  to put it mildly  –  a need for caution:

• the private finance initiative –  while, in terms of short-term accounting and fiscal rules, this may have looked tempting, the government can always borrow more cheaply than the private sector, and it always makes sense to borrow at the lowest possible rates;
• Clumsy use of targets –  all organisations need targets to run, but over-focus on a small number of targets risks counterproductive behaviours –  some of the world’s most admired companies were brought down by over-focus on earnings per share, for example. Last time we saw serious problems caused by ‘gaming’ in order to obtain Foundation Trust status, and today there is evidence of unanticipated consequences of waiting list targets in ophthalmology;
• using public money to build private sector capacity – there is considerable evidence that this is both uneconomic and produces worse clinical outcomes.

We have institutions which could be used to prevent errors of this kind: we could commission our universities to set up a task force to do a rapid assessment of previous policies, and NICE, the National Institute for Health and Care Excellence and the NAO, the National Audit Office could do pre- and post- assessment of proposed policies. We should be making full use of them to ensure sound policy-making in these areas.

Getting the big things right

If the 1997 to 2010 government did make mistakes of this kind, how was it so successful? Very simply, it got the big things right.

The first big thing is funding. The Conservative government repeatedly claimed that it was ‘spending more than ever before on the NHS,’ but that was true only if you ignored the impact of inflation, a growing population, an ageing population and a population with increasing rates of ill health. Of course, £1 in 2010 went much further towards meeting the needs of the UK population than £1 does in 2025. A rational policy maker would not ignore those other factors.

If we focus on the bottom line in the chart, the line which does take these factors into account, we see that whereas we had been increasingly able to meet need until the Global Financial Crisis struck, the NHS has been decreasingly able to meet need since then. And the results since 2010 reflect that.

The second big thing is context: the 1997-2010 Labour government tackled many of the social determinants of ill-health.

Here, for example is poverty – which you know from the work of Sir Michael Marmot and others is one of the key causes of ill-health because it affects diet, housing, stress and other lifestyle factors which determine health.

The third big thing is prevention, which was in reasonable shape then, and is not now, having suffered from repeated reorganisations and cost-cutting.

When you look at health systemically, as part of the wider economy, it turns out that these are three key things to get right.

Let’s start by looking at healthcare capacity.

• Chain 1: the Capacity Loop:
  • Number of healthy people of working age drives economic performance;
  • Economic performance enables economic decisions to fund;
  • Funding drives capacity to treat;
  • Capacity to treat (staff, technology, hospital beds, etc) drives treatment provided;
  • Treatment provided drives rates of recovery and hence number of healthy people;
• Chain 2: the Poverty Loop:
  • Economic performance enables economic decisions to address deprivation;
  • deprivation drives lifestyle factors which cause illness;
  • ill-health drives demand for treatment;
  • Excess demand causes untreated illness;
  • Untreated illness drives (negatively) number of healthy people;
  • Reduced number of healthy people of working age decreases economic performance;
• Chain 3: the Prevention Loop
  • Spending on prevention reduces illness;
  • Reduced illness reduces need to treat;
  • Reduced need to treat reduces funding requirement for treatment capacity;
  • Reduced funding requirements facilitates adequate spending – according to WHO, every £1 on prevention saves £4 on cure.

And, like the economy as a whole, the NHS is driven by its people, so there are other important issues that are not part of these three loops, for example, the overload loop:

• Having less capacity than needed to deliver the treatment required results in
• staff overload; which damages
• Morale and retention; which affects
• Workforce capacity and productivity.

The 1997-2010 government addressed this big picture; subsequent governments ignored it.

As our previous report showed, that is simply not sustainable. And recent data have confirmed our findings.

Now, imagine, just for a second, if what has happened to NHS dentistry were to happen to the rest of the NHS.

Regional health inequalities would worsen, in parts of the country people would be unable to get treatment for non-emergency procedures and A&E demand would rise correspondingly, medical bankruptcies would become more common, and many people would postpone getting medical attention or resort to do-it-yourself treatments which can lead to life-threatening conditions – and ill-health and avoidable mortality would rise.

The health consequences are obvious, and morally unacceptable. The economic consequences would also be dramatic. The former Deputy Governor of the Bank of England, Andy Haldane, estimated  that the cost to the UK economy of ill-health is already £150 billion per annum. But that is nothing compared with the cost of such an NHS failure: as our previous report  showed, if the NHS were allowed to fail like that, the UK economy would fail with it. There would be no chance of any kind of national renewal.

The long-term consequences for the UK of such a failure would be unthinkable.

Conclusion

So we have seen that there was a huge improvement under the last Labour government, that they did not get everything right, but that they did address the most important issues – the big picture.

So what should we do now?

Joined up government

We saw that getting the big picture right was key last time, and it will be even more essential this time. Countries like China and Singapore have departments which produce integrated long-term plans for their countries, using a range of systems thinking and other techniques to assess the trade-offs involved. They have been remarkably successful in achieving their aims. Every major business has a strategy department. The UK, however, does not have  a department responsible for  making sure that we think long-term and keep the big picture in mind. So a first step should be the creation of a Department for National Strategy. Importantly, this should not be part of the Treasury.

Learning from what works

And of course, as we have argued repeatedly, we should learn from what works. This is intellectually obvious, but politically difficult, because it means accepting that not everything did work. But there are ways of doing it. We are used to the idea of evidence-based medicine; now we need evidence-based policy.

Determination to succeed

Most importantly, when failure is not an option, governments find ways to succeed. Even if that means scrapping what had been ‘red lines.’

Before the Second World war, the idea of a British government introducing a compulsory lending scheme, driving debt up to over 250% of GDP, and introducing a top rate of income tax of over 90% would have been inconceivable. But after Churchill’s famous “we shall never surrender” speech, the question was no longer, can we afford to win the war? but how shall we pay for it? Without taking these actions, it is unlikely that Britain would have held out against the axis powers.

After the Second World War, Attlee’s government would have had plenty of excuses for non-delivery: nevertheless in 1948, at a time when the ratio of government debt to GDP was still over 200%, Attlee’s government founded the NHS. Also in 1948, it passed the National Assistance Act, which abolished the poor law system and established a social safety net to protect the poorest and most vulnerable. Attlee could have said, “I love this Beveridge report, but right now it is simply unaffordable” – instead he committed to delivering it and with it, the most successful period of our economic history. Without this, the conditions of the poorest and most vulnerable in the UK would today be at best like the poorest in the US – and probably worse.

Although the Johnson/Sunak government handled the pandemic badly, they got at least one thing right. Once ministers understood that without a lockdown, hundreds of thousands of UK citizens would die needlessly, they found a way to fund a furlough scheme. At that time government debt stood at around 85% of GDP. From Cameron onwards, Prime Ministers had been arguing that such debt was dangerously high and there was “no magic money tree,” so there was no way of funding UK public services adequately. Surely, then, it would be impossible suddenly to find a spare £70 billion to pay for a furlough scheme? In fact, no: the UK became the first country to use money creation by its central bank to finance the scheme directly.

All those governments did extraordinary things in the face of exceptional crises.

More recently, in the US, the Biden government also faced an extraordinary threat, and it tried to relieve the US cost-of-living crisis and uphold the rule of law, but only within the normal conventions of politics; it took no extraordinary action – and now we see the consequences.

Extraordinary challenges demand extraordinary responses. We face extraordinary challenges. We should model our thinking and actions on Attlee, not Biden.

Thank you. I’m sure you’ve all got lots of questions!

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