It is now more than a year since Wes Streeting entered office promising not merely improvement but transformation, not incremental repair but structural renewal, and not managerial drift but muscular democratic control, and yet the uncomfortable verdict emerging across hospital corridors, primary care networks and community services is that what was trailed as a revolution has felt, in practice, like an administrative reshuffle layered upon a system already fatigued by a decade of austerity, a pandemic shock and a workforce stretched to its limits.
The abolition of NHS England was heralded as the defining act of this new era, a decisive move to end duplication, restore accountability to ministers and cut through the fog of semi-autonomy that critics claimed had blurred responsibility, but the months that followed have been characterised less by clarity than by re-centralisation, transition costs and uncertainty about who, precisely, holds which lever at what moment, while integrated care boards have been variously empowered, trimmed and reimagined in a sequence that has generated more organisational anxiety than operational gain. What was presented as a clean sweep has, in effect, re-routed authority back to Whitehall without demonstrably increasing the capacity of frontline services, and in healthcare capacity is the currency that ultimately determines whether patients are treated promptly or left waiting.
The much-heralded 10-Year Health Plan, launched with language that evoked renewal and long-termism, spoke eloquently of prevention, neighbourhood care and digital acceleration, yet read to many experienced leaders as a compendium of aspirations insufficiently anchored in delivery mechanics, workforce modelling and capital realism, because shifting activity from hospital to community requires not merely exhortation but buildings, clinicians, data interoperability and contracts that align incentives over years rather than quarters. The persistent invocation of artificial intelligence, genomics and other transformative technologies has suggested that the next leap forward might be achieved through innovation alone, as though algorithms can compensate for shortages of district nurses or outdated estate, when in truth technological adoption in healthcare is cumulative, complex and dependent on painstaking implementation rather than ministerial enthusiasm.
Performance, which has a stubborn habit of ignoring rhetorical flourish, offers a bracing counterpoint to the narrative of grip and momentum, because elective waiting lists have declined more slowly than required to meet publicly stated milestones, accident and emergency performance has improved from its post-pandemic nadir without approaching historic standards, and 12-hour trolley waits have reached levels that would once have provoked national alarm, while ambulance response times have edged forward only for patients to encounter bottlenecks inside hospital walls. Mental health, repeatedly described as a priority deserving parity with physical health, continues to face demand growth that outpaces funded expansion, and the much-discussed left shift to community provision remains constrained by workforce supply and capital budgets that do not yet match the scale of ambition.
Underlying these outcomes is a more fundamental tension between political tempo and clinical reality, because healthcare reform unfolds over training cycles measured in years and infrastructure programmes measured in decades, whereas political narratives are shaped by annual budgets and media cycles measured in weeks. Real-terms funding growth of around 2.2 per cent, while not negligible, sits below the historic average required to absorb demographic pressure, technological advance and rising public expectation, and yet the repeated assertion that the service has been given what it needs has created a narrative of sufficiency that jars with frontline experience. When ministers imply that inputs are adequate, any shortfall in outputs is easily framed as failure of management or effort, rather than as a mismatch between demand and funded capacity.
The instinct to question managerial numbers has played well with sections of the public long sceptical of bureaucracy, but the arithmetic of the modern NHS is not so easily reduced, because the service now employs hundreds of thousands more clinicians than it did a decade ago while the growth in management posts has been modest by comparison, and productivity in a system of this scale depends as much on coordination, data, scheduling and logistics as on clinical headcount. To treat management as an indulgence rather than as infrastructure is to risk compounding the productivity challenge that reformers claim to address, particularly at a moment when industrial relations have been strained and morale remains fragile after years of pressure.
There is, too, a question of tone that matters in a service whose effectiveness depends on trust between national leaders and local operators, because impatience may energise a speech but can corrode collaboration if it translates into an atmosphere in which targets are proclaimed without the accompanying resources and constraints are acknowledged only privately. The suggestion, sometimes implicit and sometimes explicit, that the NHS has been over-funded relative to its performance ignores the long tail of capital backlog, social care fragility and workforce pipeline gaps that cannot be closed within a single Parliament, however determined the secretary of state may be. Things take time in healthcare not because of complacency but because of complexity, and any reform that neglects that truth risks mistaking motion for progress.
A longer historical view reinforces the pattern, because successive health secretaries across parties have discovered that the NHS absorbs structural upheaval slowly and often at significant transitional cost, and that promises framed in the language of revolution tend to encounter the stubborn realities of demography, workforce training and fiscal constraint. The experience of Andrew Lansley, whose sweeping reorganisation through the Health and Social Care Act 2012 promised liberation through competition and commissioning yet left a legacy of complexity that required years of stabilisation, remains a cautionary tale about the unintended consequences of structural zeal. Jeremy Hunt pursued seven-day services with an emphasis on patient safety but collided with workforce resistance and financial limits; Matt Hancockchampioned digital transformation and prevention only to see the pandemic dominate his tenure; Sajid Javid and Steve Barclay grappled with elective backlogs and industrial unrest that proved resistant to rhetoric; and now Streeting, armed with the language of renewal, confronts the same structural constraints that humbled his predecessors.
The following table summarises six recent health secretaries, including the current incumbent, alongside their headline ambitions and the areas where delivery has fallen short, drawing on departmental announcements, NHS performance data and independent analyses.
What distinguishes the present moment is not the existence of under-delivery, which has become almost cyclical, but the dissonance between the scale of promise and the modesty of measurable change after a year in office, because abolishing a national body, publishing a long-term plan and proclaiming a new era do not in themselves create the additional theatre sessions, community teams, social care placements or diagnostic capacity required to alter the lived experience of patients waiting in corridors. If the revolution promised has so far amounted to a reshuffle of structures and slogans, then the question for ministers is not whether they possess conviction but whether they possess patience, because without a candid reckoning with time, trade-offs and fiscal limits, the risk is that the NHS will continue to cycle through reforming secretaries of state while the fundamentals remain stubbornly, and expensively, unchanged.
