For months, an appearance of Work‘s past has traveled the corridors of the Ministry of Health and Social Affairs.

Alan Milburnthe most radical of Sir Tony Blair’s health secretaries, has at times been more visible in London’s Victoria Street offices than the current Secretary of State, Wes Streeting, for whom the former MP has been something of a mentor.

Streeting made it clear that Milburn would play a major role in helping him with his 10-year plan to the NHSbut the fact that Milburn’s job title still hasn’t been announced is a sure sign that trouble is about to break out.

Milburn was the man who played against the grain by kissing private health care providers, using NHS funds to send NHS patients to private hospitals for treatment where appropriate. It was a common-sense approach that reduced waiting lists and increased patient satisfaction, and the left, needless to say, hated it.

Between 1999 and 2003, Milburn also introduced trusts, allowing the biggest and best NHS trusts to operate independently and increase their budgets by providing private on-site medical care. He defended patient choice and rewarded the best hospitals by giving them more money than failing hospitals. Milburn made no apologies for pursuing measures that worked, regardless of political party, and believed that those who opposed his reforms were motivated by “some bizarre, Byzantine, outdated ideological reason.”

Two decades on, Milburn has unfinished business, as his reforms were watered down by his Labor successors and then replaced by the reforms of Andrew (now Lord) Lansley, the first Health Secretary of the Cameron years. Lansley created NHS England to run the health service, which some of his own colleagues saw as an ill-conceived attempt to avoid ministers being blamed when things go wrong.

“A willingness to take charge of the argument and win it”

The big outstanding question after Streeting this week announced a “national conversation” on the future of the NHS is whether Milburn’s market reforms will now be resurrected, and the answer, it seems, is yes .

Milburn, who worked as an advisor to a company that funds private health care, is not about to abandon his belief in making the public and private sectors work together for the benefit of patients. His appointment could well come to define Streeting’s tenure as current Secretary of Healthand it signals that Streeting is preparing for a battle with the unions and with the left of his own party.

“Alan has shown that it’s the combination of investment and reform that gets results,” says a Streeting ally. “He showed that you have to be prepared to face arguments and opposition to achieve reforms. Things like patient choice and reliance on the private sector were challenged when Alan brought them in, but there has to be a willingness to take on the argument and win.

Streeting has repeatedly made clear that he does not share the distaste of many on the left towards private health care. We can therefore expect a Milburn-style scale-up of NHS-funded treatment in private hospitals, with the NHS used to pay for it. health care but not necessarily to provide it.

A Whitehall source says: “There will be things we need to review, for example whether we want to use spare capacity in the private sector, and there will be ideological opposition to this from the left.

“Similarly, if we want to emphasize prevention, there will be opposition from the right (due to accusations of nanny statism).

“There will be a lot of resistance. There’s a reason no change has happened in the past: there are people who are very vocally opposed to it and if you’re not willing to oppose it, you’re going to avoid those fights and n ‘you’ll achieve nothing.’

If you think this sounds more like a Conservative speech than a die-hard Labor voice, you wouldn’t be alone.

Sir Liam Fox, who was shadow health secretary during Milburn’s tenure, said: “Alan Milburn opened the door to more private services in the NHS, and if the Conservatives are honest we should recognize that this is a good thing and welcome it. »

The main problem Streeting and Milburn will have is that Milburn has been accused of significantly overpaying private providers. This time, they will have to increase their use of private services while trying to pay public sector prices.

A health sector source says: “The private sector will turn around and say no thanks, because they have growing demand, more and more people are paying for private healthcare and they won’t make any profit by doing things at NHS prices. »

Streeting and Milburn are also expected to reintroduce payment for results, which Milburn has always seen as a driver of productivity. Hospitals that manage to reduce waiting lists will receive more money, thereby increasing their productivity (although this takes little or no account of the quality of care, but simply that a certain kind of care was provided). Again, this is not a new idea: the NHS has operated on a pay-for-outcomes model for almost 20 years, but it has largely collapsed during the Covid pandemic, and the Last year it was officially replaced by the NHS Payment Scheme, which aimed to encourage better cooperation between healthcare providers.

Lining up to oppose the Streeting-Milburn plan, health service leaders believe in NHS monopoly; medical unions, and almost certainly Angela Rayner.

There have already been rumors from the left about another Streeting appointment: that of Paul Corrigan, who was special adviser to Milburn when he was health secretary and who favored the private sector be authorized to take over the management of failing hospitals.

Corrigan, 76, was awarded a 12-month contract to work alongside Streeting on developing the 10-year plan, and has already rattled NHS religionists by saying it was “not feasible » that the health service receives more. money unless there is an increase in productivity.

Corrigan, a former Communist Party parliamentary candidate who took a turn to the right and never looked back, has been credited with coming up with the idea for trusts and will argue for hospitals to be run more. in the sense of business.

“It all depends on how you spend the money”

Streeting’s three main reform themes are: moving more care from hospitals to the community; a shift from treatment to prevention and a shift from analog to digital services.

Cynics point out that every health secretary for decades has said they would do the same, and Streeting’s team doesn’t deny that, but they are determined to be the ones to actually make it happen.

Where will all this leave Amanda Pritchard, chief executive of NHS England? Appointed by Boris Johnson in 2021, Pritchard is an NHS “lifer” who joined its management training program in 1997 and has held various senior roles since 2002. She was promoted to the role after serving as deputy Simon (now Lord) Stevens, who led NHS England for seven years, meaning she is vulnerable to accusations that she is part of the reason the NHS has failed to match budget increases with the reform. Under his leadership, the productivity of the NHS declined, despite an increase in staff and resources.

Streeting said she had his “complete confidence”, although there has been speculation about his future and that of Richard Meddings, chairman of NHS England, whose term of office runs until 2026.

One possibility is that Streeting replaces Meddings with a health minister in the House of Lords to strengthen ties between the government and the governing body. Names that have been mentioned in connection with the possibility include former Health Secretary Patricia Hewitt; Lord Darzi, the eminent surgeon who led a review of the NHS for Streeting, and Matthew Taylor, currently chief executive of the NHS Confederation.

One thing Streeting will not examine is the funding model of the NHS. Other countries are successfully combining private health insurance with taxpayer-funded national insurance to increase spending and create efficiencies, but Streeting’s allies say he doesn’t want to spend his time on able to focus on how the NHS is funded, believing that this can deliver a first class service with the funding model it currently has, and without a radical change in the level of money coming in.

“It all depends on how you spend the money,” said a Whitehall source. “It’s easy to see how wrong we are at this point, but also how it can be changed.”

Easy to see, but difficult to fix, as many of Streeting’s predecessors discovered.

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