Former health secretary Jeremy Hunt has urged Andy Burnham to consider radical structural reform of the NHS if he becomes prime minister, arguing that the health service's productivity crisis stems from excessive centralisation and bureaucracy.
Productivity puzzle
Writing in the Guardian, Hunt noted that the UK now spends the fifth most of any OECD economy on government health spending as a proportion of GDP. Despite a 20% increase in NHS England staff since 2020, activity has only risen by 10%, leaving waiting lists stubbornly high. Progress in reducing lists has largely come from "list cleaning"—removing patients no longer needing treatment—rather than actual increases in activity.
"Getting to the bottom of this matters because there isn't likely to be a lot of extra cash soon," Hunt wrote. He highlighted poor IT as a key inefficiency, referencing his 2024 budget that allocated £3.4bn for a productivity plan including joined-up medical records and AI adoption. However, he argued that this alone would not tackle the root cause.
Centralisation and bureaucracy
Hunt described NHS England as "the most centralised and bureaucratic healthcare system in the world," with 1.5 million people micro-managed from London via 18 monthly operational targets for hospitals and 44 QOF targets for GPs. He argued that this leads to "learned helplessness" among local managers, who focus on delivering "improvement trajectories" rather than innovation.
"As mayor, if Burnham needed money for a big infrastructure project, he had to bang on the door of No 11 and get in a Whitehall queue," Hunt wrote, linking Burnham's experience in Greater Manchester to the NHS's daily reality.
Proposed reforms
Hunt proposed two major changes: scrapping all national targets and devolving NHS responsibility to locally elected mayors across England. He pointed to Sweden and Denmark as examples of universal systems with better outcomes, and to England's education system, where school heads have high autonomy but accountability through Ofsted and exam results. "England now has the highest reading standards in the western world," he noted.
"A hospital in Barrow-in-Furness faces different challenges from one in central London," Hunt wrote. He advocated for national standards, including maximum waiting times, but maximum autonomy in delivering them.
Devo Manc unfinished business
Hunt acknowledged that Manchester's "Devo Manc" experiment in 2016 fell short because national targets remained, and hospital bosses remained accountable to NHS England rather than the mayor. He called for completing that job and also handing social care to mayors where not already within their remit, which could help reduce "bedblocking" by enabling prompt hospital discharges.
"Governments have been trying to break down the barriers between the two services for years. Now it might finally happen," Hunt wrote, though he conceded it would not solve social care funding problems.
Common ground
Despite disagreeing with Burnham's "soft-left worldview" on many issues, Hunt expressed hope for agreement on NHS reform. "Both of us have sat on top of the pyramid as health secretaries and seen how difficult it is to make an enormous system responsive to patients," he wrote. "Both of us have wanted to be the health secretary who finally 'fixed' the NHS from the top—and found we could not."
Hunt concluded that as prime minister, Burnham could turn the NHS "from the world's most bureaucratic health service into its most innovative one"—and asked, "What other options are there in a world where there is no extra money?"
