What is the politics behind who runs the NHS?

After blistering criticism from MPs, Amanda Pritchard has quit as chief executive of the NHS in England. She had been in the post since August 2021. James Mackey, the national director of elective recovery, will serve as interim chief executive.

Wes Streeting, who as health secretary is the political chief of the NHS, is planning what he says will be an essential period of major reform; he said there must now be a “new relationship between the Department of Health and Social Care and NHS England”. Given the NHS is one of the most pressing voter concerns, the health of our health service is as crucial for the government as it is for the nation’s quality of life… and therefore is an obvious priority for the Starmer administration and the ambitious Streeting.

Relations between Streeting and Pritchard were reportedly cordial and correct but, perhaps inevitably, there were tensions about NHS funding. A more fundamental problem was attacks by two parliamentary committees on her performance, rendering her position quite untenable. The public accounts committee and the health and social care committee pointed to complacency and a lack of dynamism within NHS leadership.

If the NHS doesn’t improve, the Starmer government will fall. The job of chief executive could hardly be a more important one: the NHS is one of the largest employers in Europe, with around 2 million employees, an annual budget of almost £200bn, and a vast number of contracts with private suppliers and GP practices. Even those with private healthcare will come into contact with it, and the vast majority of the population depends entirely on it.

Yes, and some chief executives, such as Duncan Nichol (1989-94) and Pritchard’s predecessor, Simon Stevens (who lasted more than seven years) left with their reputations enhanced. The NHS is not a public company, and being at the top exposes someone to a highly political environment, but it’s not beyond a human.

“Help Streeting win the next election” would be a candid way of describing the role, and the key to success. There are obviously arguments about the relative roles of cash and organisation in securing the success of the NHS, but Streeting has made it perfectly plain he places reform first precisely because the NHS is “dying”, needs to be saved anyway and money is short, as is time.

Maybe better than might have been thought, given pessimistic noises from Streeting about the state of things – amply reinforced by the daily experiences of patients awaiting treatment – and the chancellor’s equally downbeat assessments of the overall state of the public finances. The Darzi report set out the challenges facing the service, and the 10 Year Health Plan to take matters forward is being written now. More concretely, Streeting has been given a big boost by the delivery of more than 2 million extra NHS appointments seven months earlier than pledged in the manifesto. With some luck from relatively mild weather, the hospitals have so far escaped another terrible winter crisis, albeit by very slim margins with the “quad-demic” of seasonal colds, flu, Covid and respiratory disease.

The NHS is never going to be a winner for the Tories, fairly or otherwise. Some months ago, while still a candidate for the Tory leadership, Robert Jenrick called for Pritchard to be sacked, but shadow health secretary Edward Argar hasn’t commented; indeed, it’s fair to say he has been a rather low-profile opponent of Streeting.

Liberal Democrats have made social care a theme of their campaigning, but it’s Reform UK who have presented the more radical alternative to the present NHS: a “French-style” system of private insurance for the better off and public support for those on low incomes to access healthcare, free at the point of delivery. The quality of such care is not specified, and Labour has identified it as a weak point for Nigel Farage. But if Streeting doesn’t make the NHS feel tangibly better for those using it, Labour will lose support regardless.