A new Labour government has taken power amid record levels of NHS dissatisfaction, with pledges to turn it all around. This is the story of 2024, but it was also the story of 1997.
Today’s government points to this proudly, claiming that Labour has fixed the health service before and therefore can do it again. In reality, however, the 1997 government brought nothing like the miracle turnaround that is sometimes remembered. After Tony Blair’s first year in office, approval for the way the NHS ran improved for a couple of years, but then it slumped back, and by 2001 dissatisfaction outweighed satisfaction. It was not until 2003, six years into their rule, that the New Labour governments were delivering enough improvement for public satisfaction to begin to rise to record levels.
The new government of today, with work underway on a 10-year plan and its external audit proceeding quickly, has the chance to learn from what worked before—and maybe get there faster. But it will need to do that at a time when the vast funding deployed during the noughties is less of an option.
The first lesson is to use targets judiciously. The 1997 government had the very modest goal of removing 100,000 people from waiting lists, around a tenth of the total. That proved fairly unambitious. The costed and perfectly realistic 2024 pledge to deliver two million additional appointments a year is again pretty modest; it is only a small fraction of what the NHS does each year.
There is an immensely bold aim to get back to meeting headline targets by 2029, but just having big targets is not what the 2001 and 2005 governments did right. Today’s NHS is massively overloaded with targets that never get met. Later New Labour governments learned to use ambitious waiting times targets that were matched to the money they put in, and to realistic assumptions about efficiency. This was not just a question of lobbing in ever more funding. The government was actually disciplined in setting priorities. While oversight could be intensive, there were feedback loops where NHS trusts could be honest about what was, and was not, deliverable. New Labour didn’t promise 18-week waiting times until 2004, when they pledged to deliver them by 2008. By the time of that assurance, marked improvement was already well underway.
Labour is now in government with no clear calculations about whether its waiting times commitments are possible, and the party will need to resolve this quickly. The NHS is already stuck in a cycle where ministers demand the impossible and insist that they be lied to as to whether performance and financial targets are, in fact, achievable. Objectives are then not achieved. This, in turn, leads to demoralisation and public discontent, and makes it genuinely difficult to hold anyone to account.
The second lesson is about where to spend money. The 1997 manifesto showed Labour had little interest in where funding was going beyond pledges to cut managers, who were, as ever, hardly financially significant. But in the 2001 manifesto Labour committed to raising investment in buildings and equipment, which would eventually bring the UK up to normal levels for a developed country. In 2005, the party promised an expansion of community hospitals and general practice.
Over the last decade, the cycle of overpromising and disappointment means the overspending hospital sector has to be bailed out from other funds, or suck in new cash from the Treasury. Capital spending, and other parts of the NHS, often get raided. This results in an ever better-funded service on paper having ropey equipment, sluggish computers, collapsing buildings, and difficulty finding anywhere outside of its hospitals (rehab units or care homes, for instance) for patients with serious needs.
The 2024 Labour government has a pledge to increase spending on general practice and out-of-hospital care, which is a step forward. This should be complemented by trying to match the achievement of the 2005 Labour government in finally increasing levels of capital spending.
This will not be easy given a tight yet poorly controlled budget, but there will be an opportunity. At some point, as the party has acknowledged, Labour will need to revisit the unrealistically low amounts of NHS spending in its manifesto. When Labour does so, it will need to try to set a steady course where money goes where it is supposed to.
The third way in which New Labour fitfully learned to be more effective was to focus on long-term improvement plans with incentives around them, not either small pots of money or endless restructures. The 1997 manifesto presented a sizeable restructure away from competition in the NHS. It was implemented at considerable effort, then dropped more or less immediately. Labour, from 2001 to 2010, reversed this, and then set multi-year objectives supported by financial incentives, transparency against new metrics and large-scale changes to staffing.
The objectives now need to be different: New Labour used financial levers to ramp up hospital treatment, but other areas have been left behind. Cutting down infections from the potentially deadly bacteria MRSA, a huge drive based on transparent data, various incentives, long-term workforce changes and finally legislation, worked so well that it is now less relevant.
The new 10-year plan needs to focus once more on giving local trusts and boards reasons to make the right decisions across years, remodelling things on several different levels. This will be difficult: the media, and politicians’ career hopes, always push for “quick wins” and single solutions rolled out from Whitehall. A major reorganisation could waste years.
Apart from tight Treasury commitments, Wes Streeting and Keir Starmer face problems that have worsened since 1997. General practice still enjoyed high satisfaction in the late 1990s, but today it is visibly under huge pressure, which is a major problem for a system assembled around it. New Labour set up a commission into social care that told them it was due for reform in 1999. The party ignored it. Now social care has had a quarter century of neglect, causing huge problems for people who need support, their families and the NHS.
The new government’s one great advantage is that it can learn from its own party’s past successes in fixing the NHS—and also its failures.
