In January, Dr Phil Whitaker made an open offer to politicians on the New Statesman Podcast: “Come and spend a day with me in my practice.” The health service was overwhelmed: ambulances were fatally delayed, patients were crammed into hospital corridors, and millions were waiting weeks for an appointment at their local surgeries.
Whitaker, a GP since the mid-Nineties, argued that those tasked with fixing the NHS should see the crisis up close. That crisis has persisted: the waiting list for hospital treatment has now reached a record 7.22 million.
On a sticky Friday in early June, Wes Streeting, the shadow health secretary, took Whitaker up on his offer. Dressed in the uniform of the MP-at-large – suit but no tie, polka dot socks, fresh trim – one of Labour’s most influential shadow cabinet members arrived at 7.45am at Westfield Surgery, a low-slung redbrick building bordered by allotments in the old pit town of Radstock, north-east Somerset.
The surgery, owned by three GP partners including Whitaker, serves a small but relatively deprived community of 5,225 patients. It has an in-house pharmacist provided by the local primary care network, the model for linking GP surgeries with community services introduced in England in 2019.
At 8am the phone line opened, and the incessant beep of calls began. Streeting sat behind the receptionist, upright like an eager prefect, watching her update a mind-bendingly complicated multicoloured calendar. Streeting’s stepmother works on a reception desk at a surgery in Hornchurch, Essex, and he has heard her stories about the job. Feeling grouchy through lack of sleep, he joked: “If you have any difficult customers, put me through to them – I’ll tell them to get lost!”
Streeting was born in London’s East End to teenage parents and raised by his mother in a council flat. As a gay man with working-class roots and Blairite politics, he could almost have been lab-grown as a rising star in today’s Labour Party: its modern, centrist sheen underpinned by the pursuit of a more activist state. He is also one of the Labour front bench’s few straight talkers, which helps.
For Streeting, the health of the NHS is both a political and personal concern. While on the campaign trail in Bury two years ago, he received a call from a urologist who was treating him for kidney stones: he had kidney cancer. It was caught early. A couple of months later, he returned to Westminster, one kidney down but with new ideas about fixing the stretched service he’d experienced.
Since Keir Starmer appointed him shadow health secretary in November 2021, Streeting has been a prominent commentator on the state of the NHS. His plan is to expand training for tens of thousands more NHS staff, and to double the number of medical school places (which Labour intends to fund by abolishing non-dom tax status). He would also create mental health hubs in every community and secondary school (paid for by closing private equity tax loopholes and charging VAT on private school fees).
Streeting is an unashamed proponent of his party’s most controversial idea: paying for independent healthcare to treat NHS patients quicker. He has riled some colleagues by straying beyond plans agreed by the shadow cabinet, such as suggesting they “tear up the contract” with GPs and make them salaried NHS employees. Last year, ahead of strikes, he offended the British Medical Association trade union by implying it wasn’t putting patients first, and warning that Labour wouldn’t tolerate a “something-for-nothing culture in the NHS”.
Visiting the surgery a month before the NHS’s 75th anniversary, Streeting listened to patients’ stories in telephone consultations and face-to-face appointments. There was a tense investigation into why one middle-aged man had started collapsing, methodically traced back to an unusual side-effect of medication Whitaker had prescribed weeks before (“I’m afraid your doctor has been poisoning you!” Whitaker said, as relief filled the room). There was an anguished call from a young woman who had lost her job, after waiting months for a hospital appointment for a frozen shoulder.
Later, in an upstairs meeting room crammed with medical textbooks and a bereft-looking CPR dummy, Whitaker asked Streeting how a Labour government might improve the NHS for his colleagues and patients. Over a box of Morrisons finest chocolate biscuits – “We have fruit as well as biscuits at shadow cabinet meetings now, but apparently I eat apples too aggressively!” Streeting said, tucking in – they politely clashed over the future role of GPs, but found common ground on the existential threat to the NHS posed by this government.
[See also: The NHS’s decline will have political consequences]
Phil Whitaker Wes, thank you very much for coming. What impressions have struck you this morning?
Wes Streeting Firstly, it’s been great getting a warts-and-all view – not literally, I’ve not been watching examinations! I’ve seen how a surgery should work for everyone. Where people can see the same family doctor, if they’ve got ongoing conditions, or where you’re still trying to suss out what’s going on, as I saw this morning.
You’re also part of a primary care network, so a small practice like this benefits from having a wider range of roles coming in: the clinical pharmacist, for example, managing prescriptions and taking the pressure off you. This is not necessarily representative of general practices across the country, but it’s a lot closer to what general practice should be.
PW At this point of our NHS history, ours is the minority experience. Lots of practices are really struggling. We look after about 1,600 patients per GP [partner]. When I started in the mid-Nineties, I had a list of 1,800. That’s the right direction of travel. If there’s any number I’d love you to walk away with today, it’s 1,600.
WS Some of your GP colleagues will be spitting out their tea, “1,600? God, I’d love that!” It’s always a political minefield for me, because we know patients are not happy with access issues around general practice, and I’ve got to give voice to that without making poor old GPs feel like I’m beating them up. My argument isn’t that we’ve got GPs who don’t like seeing their patients: quite the opposite, we don’t have enough GPs – and that is why people are finding it hard to see one.
Anoosh Chakelian You’ve had some backlash from GPs about your plans to absorb them as NHS staff. Can you elaborate?
WS The GP – the front door to the NHS – is broken. It’s bad for the patient, but it’s also more expensive for the taxpayer. If one of this morning’s patients hadn’t spoken to Phil, I’m in no doubt she would have ended up in A&E. That appointment cost the NHS about £40; if she’d gone to A&E, it would have been £360.
So I want to see a bigger role for GPs, and certainly more GPs. That’s why Labour is committed to the biggest expansion of the NHS workforce in history. And we want a greater incentive for continuity of care within the GP contract.
Where I have definitely hit a nerve is around the future of the GP partnership model. The number of partners is going down and within the next few years, salaried GPs – those directly employed rather than running their own partnerships – will be the majority. I’ve seen examples where partnerships have folded and no one has come to take them over, which leads to thousands of patients without a GP.
The Conservatives misinterpreted what I was saying, and suggested I wanted to nationalise all GP partnerships – that was never the plan. We’re genuinely open-minded about the model. We will probably end up with a mixed economy in primary care. I have to plan for a future where lots of people coming into general practice don’t want to be a partner.
[See also: NHS gridlock: facing the crisis in emergency care]
PW In the earlier part of my career, practices never folded, and when a partner retired or left, there would be a queue of people taking over. I challenge slightly the idea that the partnership model is not attractive. It isn’t at the moment, because it’s not been supported. Last year, Jeremy Hunt, as chair of the Health and Social Care Committee, came out with a report praising it.
WS Do you know, I don’t know what’s happened to Jeremy Hunt, the excellent chair of the Heath and Social Care Committee, but Jeremy Hunt, the Chancellor, behaves like he’s never met him!
On the workforce generally, he actually praised Labour’s plans to double the number of medical school places. Now that he is literally able to, he’s still not doing it.
PW Well, quite. There is also a lot of unused GP capacity at the moment, because they’ve voted with their feet and either left or reduced their hours in order to survive.
WS A whole bunch of people have left the NHS feeling really sad about how it ended, and fearful about its future. If we get this right, we can inspire some to come back, particularly to help train the next generation. It’s Labour’s responsibility to give people a sense of hope and belief that things can be better.
For all my anxiety about the state of the NHS today – it will be one of the hardest jobs in government – I really think this is not only salvageable, but there is a bright future.
AC How would Labour “inspire” them to return? Would you incentivise them, or hope a warmer atmosphere around the health service would be enough?
WS We need to think carefully about practical incentives, not least because – this is a very common refrain – all our policies will be fully costed and fully funded, and we’re not going to make promises we can’t afford. I think people will be willing to come back if they’re walking into a system where they can feel part of rebuilding the NHS they believed in when they first signed up.
PW It isn’t just about people at the end of their career. A fifth of doctors under 30 who have trained in general practice left last year.
WS Having got into medical school, they’re clever people – as doctors regularly remind me! – and highly employable. They’re not just going off to work in Australia, Canada and Ireland; they’re going to work for PwC, KPMG and McKinsey. In the past, they would have been kept on the basis of goodwill, and the government’s spent all the goodwill.
PW It’s sometimes wryly amusing reading political initiatives. In one briefing, you talked about creating a new “care coordinator” role. We’re here already, doing it. In the Department of Health and Social Care and at the top of NHS England, there is a lack of understanding of what GPs do, and a belief that the role can be atomised. I would make a plea not to invent further fragments of the GP.
WS I sometimes feel, in reaction to some things I’ve said, that GPs think I want to do away with them full stop. We’ve committed to doubling the number of medical school places – which wouldn’t just be GPs, but a large proportion would be. When we talk about other roles, it’s not to devalue the GP or supplant it – it’s to reduce some pressure.
Finding your way around the NHS can be really hard, and I’m not sure the GP has to do that bit. GPs have become the customer service department of the NHS. I often see people asking their GP: “Can you write to the local hospital to chase up my appointment?” As if the practice doesn’t have enough to do without asking secondary care why it’s not doing its job.
How do we make sure GPs have time for what only they can do? A lot of that is about other roles that don’t require the expertise and medical training you guys go through.
[See also: NHS gridlock: facing the crisis in emergency care]
PW There’s a death-spiral that general practice gets into, which is that NHS England and the government say: “We want instant GP access, that’s our priority.” So practices are pushed towards that, at the expense of continuity of care. There’s a seductive idea I’ve seen in Labour briefings on health policy, that there are two bits to general practice: the complicated, multi-morbid, often elderly patients who need and want the continuity, and then everybody else who gets an urgent problem and just wants a quick diagnosis, for whom continuity doesn’t matter. It’s wrong, if you don’t mind me saying.
WS I’m feeling gently told off. Carry on!
PW I call it the dark magic of healthcare. Where patients know and are known by their clinicians, they develop a relationship of trust. If I speak to a patient who smokes, and I’ve known them for ten years and happen to ask, “Have you ever thought about giving up smoking?”, they’re much more likely to take that seriously. Whereas if it’s somebody they don’t know, it’s just: “Bloody doctors, having a go again.” Continuity matters for everybody.
WS That’s a well-evidenced point. I’m thinking more from a patient perspective. Given my general health, at this moment in time at least, touch wood, what I would prioritise is the fastest and most convenient access, ideally over the phone, so I don’t have to take a morning or afternoon off work. I’m not bothered about whether I speak to my GP or any of the other GPs at my local practice.
When I was going through kidney cancer, I felt differently: those relationships meant more. It’s about what patients value and why patient choice really matters.
PW My plea is that we don’t build this structure that splits primary care into chronic and acute disease.
WS That’s a fair challenge. We are thinking deeply about what primary care provision looks like. We can free up some GP capacity by creating more front doors into the NHS. Our commitment to mental health hubs in every community, and mental health support in every secondary school, could have a transformational impact both on people who need those services, but also by reducing pressure on GPs.
AC To take pressure off GPs, you need to fix hospitals and social care, too. Tell us about Labour’s plans in those areas.
WS Like the saying “Only Nixon could go to China”, only Labour can reform the National Health Service. The Tories dare not touch it. For them, reform is charging people to see a GP, as [the former health secretary] Sajid Javid floated. It’s Rishi Sunak saying, if you don’t turn up to your appointment you should be fined. When the Conservatives say what they think NHS reform should look like, they realise how politically toxic it is, and stop.
But the NHS does need to change, and if the answer is only more money, we are going to fail because there isn’t a great deal of it going around. Even if the money were there – and even if the NHS weren’t in its biggest crisis in history – we would still need to change the way we do things.
Our outcomes aren’t good enough, relative to other countries. We’ve got an ageing population that is growing. The NHS must always be a publicly funded service, free at the point of use – that, for me, is non-negotiable. But the NHS has got to look a little less like the NHS of 1948 and a lot more like the NHS we’re going to need in 2048, or indeed 2088.
To all these people who say “Only more money, not more reform, is needed”, I say the government put £7bn into social care and it didn’t make a dent on the number of delayed discharges [from hospital].
We’ve committed to fair pay agreements to improve the pay of people in social care. For secondary care, we’re not just talking about doctors, nurses and midwives, important though they are. We’d double the number of district nurses, and have 5,000 more health visitors. Care in people’s homes is a really important part of the NHS’s future.
Finally, on reform, it’s perfectly achievable for this country to position itself as the number one place to trial new treatments and technologies. We should say: “You have a really big customer here in the NHS.”
[See also: Labour NHS mission: Will Keir Starmer’s plan work?]
PW My perspective is that, certainly since 2010, we’ve had a virtually exclusive concentration on technology – on drugs and tests – and really no focus on the socio-economic determinants of health.
WS We’ve got to be really hard-headed and clear-sighted, that the answer to depression and anxiety cannot simply be prescribing people antidepressants; the answer to obesity cannot simply be prescribing people an injection. It’s got to be about our diets, exercise, incomes, housing and well-being at work.
The Health Secretary announcing this new obesity drug is as good as it gets for this government. Under the last Labour government, that would have been a written statement at best and a page 14 nib in the Guardian, but for this government, it’s: “Wow, someone else has done something, we’d like to take some credit – quick, get the Health Secretary on the Today programme and hope no one asks about waiting lists!”
If our answer to obesity is simply pharmaceutical, we’re going to fail; we can’t keep prescribing our way out of these problems, which are preventable illnesses. It’s about the responsibility we take as individuals, and conditions we create as a society.
AC What role does private provision play?
WS This drives me bananas, because if I had a pound for every time someone accused me of wanting to privatise the NHS, I could fund the NHS personally!
We’ve just got to be pragmatic. The system is under enormous pressure, and there is spare capacity in the private sector: to get the backlog down, we should be using it, but we should be using it on the NHS. At the moment, we’ve got a two-tier system where those who can, pay to go private, and those who can’t afford it are left behind. I want to make the NHS so good that people never feel they have to go private.
PW Two years ago, there were no private GPs in Bath, now there are five. A yardstick for the success of a Labour government would be reversing that. If you have really good public services then everybody, apart from Lord Somebody-or-Other, will use that service, because why would you pay? And then you’ve got everybody, even the people with the least resources, getting quality healthcare.
If you run [the NHS] down, as we have over the past 13 years, the middle classes will take their healthcare elsewhere, and thatis happening in spades. The rump service that’s left is going to be like a Medicare in the US.
WS That is the existential risk facing the NHS with another five years of Conservative government, if the party gets back in. Whether through accident, neglect or design, they have created a two-tier system that will deepen, and there are people in the Conservative Party who genuinely think a desirable future for this country is to have an NHS for the poor and private healthcare system for everyone else. Over my dead body.
The great wisdom of the 1945 government was to build a framework that’s a public service, free at the point of use. In the 21st century, it’s the right framework for the world of artificial intelligence, genomics, life sciences and technology. The NHS model is one that could be enormously powerful, but it needs to be brought into the 21st century, and that’s something only a Labour government has both the desire and plan to do.
PW Thank you. Dr Whitaker is running late, I’m afraid, so I’ll get back to my patients. I’ll leave you to finish the biscuits.
[See also: How to save the NHS]
Patients’ details have been changed, and the Q&A has been edited for length. You can listen to the whole interview on the New Statesman Podcast
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This article appears in the 28 Jun 2023 issue of the New Statesman, The war comes to Russia