A new government and health after the general election: part 2 – with Hannah White and John McTernan

Jennifer Dixon:  

As the dust settles after the general election, what can we expect in these early days on health? What will a mission-led government really mean in practice? And where is the money going to come from? Well, with me to discuss all this, I'm delighted to welcome two very seasoned guests. John McTernan, who is Senior Adviser at BCW, a global communications agency, and former director of political operations for the Labour government in 2005 to 2007. Now, John is a regular commentator on national politics and policy in the national media.

And Hannah White, who is Director of the Institute for Government since 2022. Hannah previously worked across government supporting select and legislative committees among other things, and 2 years ago published her first book, called Held in contempt: What's wrong with the House of Commons? Welcome both.

I think the first question is, landslide, feels momentous, doesn't it? I just wondered, given that you both are such seasoned people close to government, what you have made of the last few days since the election result?

John McTernan:             

I think you see Keir fulfilling his promise to govern as he campaigned, which is being straightforward, opening up about the problems. He was asked by The Sun newspaper at his first press conference, what do you think about the idea your prisons minister thinks a third of people aren't in prison? Instead of doing what a previous prime minister had done over the last 14 years, banged on about law and order, he said there can't be into court loads of times. I've seen many, many people who shouldn't end up in prison. They should be diverged earlier on. And actually he framed the whole issue without passing off responsibility for the prisons over credit crisis to the Tories, he framed the issue as a different one, a different approach to criminal justice.

And I think that emphasis on prevention and diversion and intervention is probably going to be a tone and a style and an approach that this government will use more and more. So I think they start to govern as they intended. Keir has put an emphasis on meeting the first ministers in the devolved nations. He's going to meet the mayors as well. He's aiming all the time to be inclusive rather than divisive, and I think that's a pretty good start off for the whole process of a new government.

Jennifer Dixon:                

Yes. My takeaway from that press conference, one of them, was his response to the question about Amanda Pritchard at NHS England and just said, look, it's not about the Chief Executive of the NHS. This is about the previous government's record. So he was already just thinking in a wider context and not a sort of blame you kind of way. Also, the word straightaway seemed to come across quite a lot in the press conference, so it was really sort of action oriented, wasn't it?

Hannah White:               

Yeah, I agree with that. It feels very much like this is an action oriented government. It's all about first steps being taken as quickly as possible, whole cabinet appointed on Friday, a real sense of purpose getting on with the cabinet meeting. I slightly differ from you John in the sense of I think the first appearance of Starmer in public now, he feels like a different man to me than to the one who was campaigning. He feels much more comfortable in handling the sorts of questions and giving the answers he now feels able to give in a way we can really see how constraining the [inaudible 00:31:18] was.

John McTernan:              

Yes.

Hannah White:                

Yeah, during the campaign and now he's just, it's a much straighter bat and that it feels like we're seeing more what he will be like as a prime minister. It's very interesting.

John McTernan:              

Yeah, definitely relaxed and definitely his authority derives from something different from hectoring rhetoric. His authority derives from comfort he finds of being in charge of a complex bureaucratic organisation, a complex system, but he's managed complex systems before and he's actually transformed complex systems before. So I think that's a very fair assessment of him. He just looked at a different kind of leader, but a natural leader and that does give him a different kind of eloquence in answering questions.

Hannah White:                

I guess one of the interesting things now is whether he really does what I think was the reflection of people coming in '97, whether he really makes the most of his moments of maximum power to make some of the difficult decisions he might want to make, whether those are about personnel, whether those are about structures, whether those are about priorities. This is the moment when he really has all the power in his hands across the government system, but also with his cabinet. So it's going to be interesting to see what those initial few sorts of decisions are.

John McTernan:              

I totally agree. I totally agree with that, Hannah. I always say to leaders in any organisation when I do work with a one induction, you have more authority than you think you have when you come in, but less time than you think you have as well. So you really have to act.

Jennifer Dixon:                

I think it was Gus O'Donnell I heard saying get some rest, don't sort of go straight at it, which they've obviously ignored and gone straight at it. And we published a book a while ago where we invited all former Secretary of States for Health to just say, what word advice would you give to a new Secretary of State? They all said, don't do things quickly. Have a good think. There are some stuff you have to do quickly, and as you said John, don't just hit the ground reviewing, hit the ground running. But there is a bit of a tension there, to try to get the short-term things right, but not cut off possibilities for the future by getting some early stuff wrong.

John McTernan:              

People voted for change, they need to see change. So I think Rachel Reeves’ announcement of the framework of the planning review reform, that's really interesting because that should be the deputy prime minister, the secretary for [inaudible 00:05:48], Angela Rayner, elevated to the Chancellor. It becomes, it's a down payment on growth. It shows the intent, it shows the intention. I think that sense of setting as much of the framework out as soon as possible in a strategic way to the five missions, we know the top mission is growth. We know that growth contributes to all the other missions. Everybody who's ever worked in and around health learned a lot from the Lansley reforms.

Jennifer Dixon:                

Hopefully.

John McTernan:              

And the desire to never ever be put in that situation again, I think has been burnt in not just in the NHS England and the people that run the trusts and all the people in the health service. I think it's very clear that Keir understands that and that Sue Gray understands that and that Wes understands that. So I think one thing that there has been done well and badly under previous Labour governments, it's whether you bring the health service with you, one sector state, however many junior ministers got, how many advisers he has, cannot change a complex organisation. So bringing people with you, letting them have their say. The one thing that I'll learned from David Plouffe who was Obama's strategist, he took Obama to the presidency twice, David said, you do need to spend a lot of time on strategy and make sure you get everybody's views, everybody's voices, and when you get your strategy, stick to it because a day or a dollar off strategy, it's wasted. Let everybody contribute but never let the monkeys in the cheap seats throw you off your stride.

And I think that's an important thing. You do need to take time, but you do need to be clear. I think Labour's approach is going to be this. We've got a mandate, it's not as a mandate for change, it's a mandate for change in particular key areas. We are willing to talk to anybody about ways to get this done faster, but we're not going to be diverted from our mandate to build more houses, to sort out the backlog in the waiting list, all of those things. So it is tight on objectives but more open on how to get to there, which I think is probably going to be refreshing for people.

Hannah White:                

I think it also depends a bit on the exact circumstances in which you come in, say, as health secretary. Wes Streeting has had some time to think, to build relationships to form his thoughts. It's not the same as coming in as we've seen so much in recent decades, mid-governments to reshuffle or at a snap election or something like that. So I think that that balance between intention and moving quickly and talking to people and bringing them with you is slightly different in this circumstance.

But the thing that's been interesting for me with Wes is how much his key message is around the NHS is broken. And obviously that is both understood by lots of people across the NHS, but also a difficult message when people are there and working extremely hard and doing their best. And it's clear that he feels that that has to be a message which is understood in order to move on and to find the ways in which it can be solved.

But I think what's going to be interesting is how the NHS and others respond to that. Do they kind of continue to say nothing to see here in a sense, there's no problems, it's all going as well as could be expected with the money we have available or is there more of a sense that that opens up a space for discussion about what needs to happen, which maybe hasn't been there as much? I'm interested in what you think about that Jennifer.

Jennifer Dixon:                

From the manifesto, we had a sort of shopping list. I sort of likened it in a blog to a sandwich with a filling, but the bread bits were missing. The two bits of bread were the investment levels promised and the other bit of bread was the reform programme. Clearly they've got some must-do asks that everyone realises they need to show progress on so you maybe get cred for the longer term investment. But in terms of the reform itself, what is the guiding star here for reform is just murky.

John McTernan:              

I think there's a real tension in the health agenda if I'm honest, which is missions are the end of neoliberal approaches to governance. It's a fundamental break with the past. [inaudible 00:10:06] the question, we have a problem, we've got challenge, we've got an issue, what are we going to do about it? And the language of reform, however you use it, is not the language of transformative missions. The language of reform is I've got something and I'm going to do it to you. And until that language issue is resolved, I don't think it'll become clearer what the actual health agenda is.

Labour has relied actually on its advisers, Simon Stevens as an adviser eventually became chief executive is the greatest example, but advisers have driven a lot of health policy as opposed to Department of Health or even NHS England, or NHS England adapted itself to include some of the people who been key advisers for Labour.

But in that sense, we're in a funny situation where it's not clear what the Labour agenda is for health, but it's clear what the public's problems are. And within that, the language of reform does occlude, it is murky and the making a mission into reality in the mission board may well be the process whereby you start to see how is a complex system going to change. Because nothing in the end can be solved on its own. You cannot fix trusts. You cannot fix waiting lists if you don't deal with social care. You can't deal with social care if you don't deal with local and government finance. You can't deal with local government finance if you don't deal with the council tax in the end. And so the interconnectedness of it makes it quite difficult to show much of the entire strategy. This is going to be emergent I think.

Hannah White:                

Yeah, I think, it feels to me that the sort of incremental set of steps that need to be taken across those complex interconnected systems, which John describes, in order to deliver long-term productivity gains across services. Point of the mission is that it should be about outcomes rather than inputs. That has been a bit contradictory I would say in what we've heard from Labour across the piece. We've heard 6,500 teachers still talking about front-line numbers, when actually at the same time the point of a missions-based approach is about saying what is the longer term outcome? We don't know yet what the right way is to get there. There is going to need everyone to work together across a system to deliver that outcome, and maybe frontline numbers will be part of the answer, but that is more like the old approach we've seen in recent years and maybe that's inevitable. Maybe that's just a function of how you have to campaign, where Streeting talked about numbers and scanners and so on and capital investment is going to be a priority and is going to be a thing that people notice. So I think there's going to be a constant set of tensions to be negotiated and maybe that's why we can't see an overarching organisational sort of narrative in the way that you're sort of looking for.

Jennifer Dixon:                

Is Stammer going to really chair these mission boards or would it be Wes Streeting was more likely to take risks and want to do something bigger, how far could he prevail? Do we have any inkling of at the moment?

John McTernan:              

I always use the role that Keir played in changing the RUC into the PSNI, the Police Search in Northern Ireland, as the most interesting way of thinking how he'll deal with changing government in one sense because it shows you how he managed, how he led. And I think taking an institution which was distrusted by one community and turning it into an institution which is making his way and building trust. Keir actually is the first Prime Minister I've seen for a very long time who's got a theory of change. And his theory of change is that you do need to change culture. Everybody says that, right? But you only change culture by making structural changes. The organisational form embeds behaviour and embeds ideology. I wouldn't say that, yeah, because this wide is saying it, but he has a theory of change which you need to change the organisations if he wants to change the outcomes.

I think the missions appeal to him for that same reason. If you'd simply run things the same way we've always run them, then it's less likely that you'll have changes. Now, how that then takes you into the health service given that, he doesn't say this nor does Wes, but the dominant political discourse mediated through lobby journalism in the UK acts as though we have one health service. We don't, not even in England we have one health service, really. I think the management of complex systems and changing complex systems is something that he has a theory of approaching. And I think one of the things about the way he will approach it.

Jennifer Dixon:                

We've seen a lot of structural reform over the years. I started in policy in 1990. There's been so much. And I'm not convinced that any of it really made a massive difference to be honest. And I think other things do make a difference more. Science, technology, data, the development of medicine, communications, rather than structural organisational change. If that's what you meant there, John.

John McTernan:             

Crudely, and it is crude to say, since 1948, the majority of productivity improvements in health services have been in terms of treatment, biosciences, machine learning, just take those two, can assist with detection, prevention and cure. So suddenly you're in a situation where there's productivity achievement on the horizon and you can see it in bits and pieces. And I think the way that Keir explained they were going to implement the policy on appointments was to get people who are already doing it in parts of the health service to go to other people.

Now it seems simple and straightforward, but it's an observation, which is the William Gibson, the science fiction writer's observation, which is the future's here already, it's just unevenly distributed. And so again, it plays to, he's not the flashiest of political figures, but we've tried flashy and that was a disaster. So there's something about using the missions, having the modest targets, admitting that we are living within constraints, accepting that there is a productivity issue, but it's not a product thing that we solve by [inaudible 00:16:27] this to you. It's a productivity issue that's handled by us all working together. I think ideally they'd like to tidy up post-Lansley problems, but they're also very aware that overlapping the structural reform is the way to get everybody's backup in the health service, waste time and not deliver anything.

Hannah White:                

I do think structural change in the NHS may well not be the answer, and you two are much more expert on that than me. But I do think a change in the way structures work at the centre of government is going to be really essential if missions are going to work. And we've heard Keir Starmer at his first press conference say that he's going to chair these mission boards that most of the actual, those sort of policy and delivery focus is going to be within departments rather than held at the centre so much. But if missions are actually going to be a different way of doing government, then DHSC is going to have to work better and more closely with other government departments, the departments that actually have a massive impact on population health. That's DfE, that's DWP, that's MOJ, that's home office. They all have areas of policy which are really, really important. And working together means not just talking to each other, but it means a real change in the way money works in Whitehall. That is the fundamental thing. If the missions-based approach is not reflected in the spending review, then it's not going to make the difference it could make. Yes, it's about culture but it's also about Whitehall processes as well.

Jennifer Dixon:                

So Hannah, just as we're on missions, could you just say a little bit more as to what you understand how they would work? So you've said Keir Starmer would chair, there'd be a board. We understand the board would be some external experts brought in amongst others. So you've got them sitting in the centre of government, but then also there's a department that leads, so in the case of the NHS, obviously a department of health, but how would it work in practice then? And would the mission have a budget? How would that work?

Hannah White:                

The answer is we don't know yet and we're waiting to see. And those are all the really key questions. And the important thing to bear in mind is that although the missions are broad, they don't by any means cover everything that the government will do. There's huge amounts of government which won't be covered by the missions. And actually in fact, the health one I think is the one that sits most squarely within a single department. As you say, it's enormous arm's length body.

But there's a danger in that. There's a danger in thinking this is something that the NHSE is going to be responsible for delivering a loan. So we need to see, we don't yet know the answer to how the spending review is going to be handled, whether there's going to be a 1-year and then a more in-depth longer 3-year one. We've heard both things very firmly stated in recent days since the election. So that will be a really core thing. But yes, I think driving departments to put in joint bids into that spending review process has got to be a core element of making missions real.

John McTernan:              

Between 1997 and 2010, the Labour government halved child poverty and it ended pension poverty. And what is really interesting to reflect back on the last 14 years is ending pension poverty became a bipartisan consensus, and for all the railing, it's a triple lock. It actually has been a good thing to stop the state pension becoming nougatry, in the words of Michael Portillo when he was in the Thatcher government and becoming something that's a base on which people can live with dignity in retirement.

But there was no political cost to the conservative party actually increasing rates of child poverty really substantially. Working parents, kids with parents of work, they're in poverty. So there's something around establishing a framework that is robust and bipartisan and can carry on beyond the government. And for me, that leads back to the point, the point of the missions. And there's an openness about the missions because that's how mission-driven government should be, that people should be contributing to the debate about whether there should be a 1-year spending review followed by a 3-year one.

And the political logic of it is you definitely should do a one-year spending review because if it's going to be a spending review, it needs to allocate fresh spending, and it cannot be a cuts review. If the Labour Party has a cuts review and this is a one-term Labour government, there's no doubt in my mind about that. If the fiscal rules don't bend, then the government will break.

There's something about accountability, responsibility, delivery as well in all of this, which should be open to a broader conversation, because as you said, the National Health Service is part of a system which it can't determine the life opportunities of working-class kids. The tone of Keir, the way he talked about policy should be a way that people are keying into, well, if that's how he talks about prisons, what does it mean for health? How should the missions work? And if he talks about devolution the way he does, well, what does that then mean about the mayors? What does it mean about local government? It's going to take a long time for us to realise we're free to think out loud. And that should be liberating.

Jennifer Dixon:                

One of the big mission hopes through is technology. And there, I'm not sure a gradualist approach is necessarily going to be the right one. And I noticed what Tony Blair Institute is quite techno-ecstatic about technology and it's a big hope. Are we really set up to take some risks here, which we will have to? And that leads to the spending review because in a sense it does take time to feel confident that you can take those risks. It's taking them within a year with a one-shot spending review done this year or later this year is difficult because a lot more thinking needs to be done. I'm talking about technology that can sustain public services through service transformation as opposed to medicine or science.

John McTernan:              

A lot of health service internal administration is trying to get people, patients, to clinicians or clinics to slots matching a moving target, changing pressures on the individual to make things. And there's a sense in which there must be a transformatory internal admin solution by using machine learning. Patient transport has a first mile, middle mile and last mile, and we know the machine learning and AI have assist algorithms basically have helped deliveries that come to our houses. There are new systems that have been built on [inaudible 00:23:18], and I think this is one of the tensions, which is retrofitting existing institutions and systems is a lot harder, but there are productivity improvements, service improvements. We look at just the application in vaccines. And so again, it feels as though the knowledge and the practice are there. And so how do you get that out and how do you spread it?

And I always caution politicians who talk about risk, and civil service too, because the one thing there's never any risk in doing in government that's failing. As always as we're failing in the same old way, no one cares. What always gets focused on is failing in a new way. If you share an open this about what's really the problems are, the challenges are, then you can start to go, well, what could we do about this? And then it opens up a space where if we're failing already, it's less of a risk to try something new.

Hannah White:                

The depressing reality when you think about technology and government is that there are lots of existing really safe, really well understood technologies which are being used to maximum effect already in the public sector before you get to much more cutting edge sort of risky type technologies. So I was very struck by a piece of work we did here at the IfG where one of our findings was that GPs should be making better use of the telephone, which is not exactly a forefront technology. Is a lot of stuff around legacy IT systems and obviously that's not cost free and there's lots of complicated, boring contractual issues around updating those. There's a lot that can be done without getting into the very forefront technologies.

And then I guess the other point is just about piloting and trialling things, but as John was saying, working out how to work out what's working where and then scaling it rapidly. And I think that is part of the mission's approach.

Jennifer Dixon:                

There's one approach to tech which is just free up innovation grassroots and it's an American approach. You just let 1,000 flowers bloom and the good ones will pass them, but etc, etc. But there's another approach also American actually, which is national demonstrations, bigger bets because time is short because the morbidity wave is going to hit the NHS and demography is against us, etc. How bold are people going to do to grasp all of this stuff and say, we don't know if it's going to work, but let's try it because time is short and-

John McTernan:              

It's really important. It's not just the time is short, it's the patients untreated are living in misery sometimes and at the end of this whole process, there's real people. And I think if the Labour party does anything in health, it needs to keep putting people and their stories at the centre of it. That's one element to my thing. I think when Hannah mentioned the telephone, we still not fully exploited the benefits of telephone technology, and that comes in the 19th century. There's a great book by a UK academic, which is, The shock of the old, that actually old technology still has a lot to help us with and we should never disdain old technology.

The third element, which I think is really interesting is, I read a great piece by a colleague of mine who was saying you can use synthetic data to create synthetic profiles of individuals and that that has quite high rates of accuracy. Now it made me think we do, in the private sector, use digital twins of organisations look at supply chains. To then I know people are working on doing a digital twin, the personnel side to look at the human element to it. And I just think a really practical use of investment in AI, it's not all the money that's being spent in Silicon Valley, but actually what if you took some of the ideas that Hannah was talking about, the ones that are working that you could scale up. OK, what about using a digital twin of particular parts of the service or particular regions or sub-regions, cities, to then look what are the bridges and barriers? What are the blockages? Just run simulations. What if we could use run simulations to see into real time what a four or five year rollout might look like? And then it's between your national demonstration projects and your let 1,000 flowers bloom. What about let 1,000 models bloom? That kind of opportunity, that openness might be helpful.

Jennifer Dixon:                

There's so many more questions I want to ask you both, but I've pressed on your time enough I think. Thank you so much. Is there anything burning that you wanted to add at the very end?

Hannah White:                

When you were saying, John, earlier, and it's a really interesting point about how abolishing pensioner poverty had become kind of a shared consensus. And all the evidence in the work that we've done at the IfG on long-term policymaking is that the golden thread that the thing that really makes a difference in terms of long-term sustainability of government moving towards a goal is that trying to achieve cross-party consensus.

And I was reflecting as you were talking, John, that obviously for pensioners that was a policy which came from a Labour government but then was sustained by the Conservatives. And maybe electorally that's very explicable because the Conservatives could see that for them appealing to pensioners was also something that they wanted to do, because that's where their voter base is. Some of the narrative now around the Conservatives is actually what they need to do to rehabilitate themselves in the eyes of the electorate is to appeal to younger demographics. And maybe a smart new conservative leader might think that actually picking up on what you say around your child poverty and working age, that might be quite an interesting way to build a coalition with a new conservative administration if that were ever possible.

John McTernan:             

And it fits with Conservatives presenting themselves as the party of the family. There's so many ways in which they've taken policy positions over the past period I’ve wondered about. Why would you oppose equal marriage or sole partnerships, gay relationships, when actually marriage is a foundation of family, and families are a foundation of our society. You made me think was Labour does need to think in some of the reforms that are going to come, whether the [inaudible 00:29:36] to become the proper taxation of domestic housing wealth to fund local government social care. There's a whole set of areas where labour should seek to entrench as much cross party support for it. Being the government is no longer being an opposition. Not everything is about doing down the other guy. The other guy's record will live for a long time. People will not forget Liz Truss or Partygate for a very long time.

You can remind people about that, but it doesn't stop you making sure you get their votes for some big [inaudible 00:30:09] of changes, which can then be the welfare changes that create the new frontiers in the 21st century. I think it's, for me, my final thought would be there's such a huge amount of possibility for health in our country and the health service in our country, and it's not simply having a change of government, but that does create a change of context and we should never forget the freedom to dream. And I think we should all dream of a better health service.

Jennifer Dixon:                

So we must leave it there. Thank you very much to Hannah White and John McTernan for their really interesting insights today. Have a look at the show notes. We'll stick a few interesting links in there of writings by Hannah and John on the subjects we covered today. And not least the fabulous IfG report which is on the centre of government, how it should change to achieve more progress. In the meantime, thanks as ever to Leo and Sean at the Health Foundation, to Paddy and Jack at Malt Productions. And it's goodbye until next time from me, Jennifer Dixon.