Jeremy Hunt’s budget statement last week might calm markets. It is unlikely to calm its chief clients: the public services. Here, the best Hunt could claim is that they were warned. After 10 years of austerity and two of pandemic chaos, all sectors other than health now face real terms cuts. Hunt is not going to help them any more. They must help themselves.
The oddest contribution to this challenge was reported this summer from two health secretaries, Sajid Javid and Steve Barclay. Both said that their department could live within its budget, and that it should concentrate on efficiency. They were influenced by embarrassing figures from the Institute for Fiscal Studies showing that in the health service “extra resources are not being translated into more treatment”. Efficiency was the watchword, but then it had been for years. What was the problem?
Near the end of her reign, Margaret Thatcher was asked by a heckler if she was proud of fighting Labour’s trade unions, but ignoring Tory ones. When she asked what they were, the answer came “the professions”.
I recalled this answer when I recently heard two leading medics asked privately why the NHS was so resistant to reform. They replied, “because of us”. The NHS was built on a pyramid of professional protectionism, from consultants and GPs, to nurses, pharmacists and paramedics, all guarding their specialisms. Services left largely unguarded, such as social care and mental health, had no lobby and experienced constant humiliation and under-capacity.
Rishi Sunak has two years to run, nothing to lose and a golden opportunity to complete Thatcher’s challenge. He should take on the professions. He is having to disappoint the doctors in their hospitals, the lawyers in their courts, the teachers in schools and universities, and other bastions of restrictive practice. The least he can do is demand they reform themselves and their services to deliver value for money. No one else is going to help them.
Reforms in health provision in 2012 and again under the present Health and Care Act 2022 indicated some cracks in the professional boundaries. Yet none of these changes seem to stick. Nurses can be retrained to perform simple operations. GPs can order tests and scans. Pharmacists can give out prescriptions. Attempts are made to circumvent bottlenecks in A&E triage. But the fundamental structure of the medical profession remains archaic.
The structure of the law is much the same. The courts are reportedly close to collapse. They have a backlog of 60,000 delayed cases. They suffer a chronic shortage of barristers, prosecutors and judges. Trials are being halted, witnesses sent home and defendants let off. Yet any murmur that costs might be cut by merging the activities of barristers and solicitors is passionately opposed by the legal profession. Any suggestion that Britain might reduce, indeed abandon, the wasteful medieval jury system – as across the rest of Europe – is met with cries of magna carta.
Education remains resistant to reform. Despite a recent budget boost, schools are going to suffer a serious fall in income. Yet there is no sign of teachers succeeding in attempts to abolish the GCSE. There is little indication that the country will move away from its obsessive and costly exam regime towards a more relaxed or vocational approach to teaching, or accept the wider use of school assistants or evening classes. And there is no proposal to share facilities or teaching between the state and private sectors, to justify charity status for the latter.
Equal horror greets any suggestion that the higher education profession might improve productivity by shortening courses or lengthening terms, let alone doing less in research. The lecture was suspended during lockdown in favour of online, only to see a frenzied demand afterwards to restore “in person” teaching. As for the monastic tradition of most students studying away from home, it has become wildly expensive. Only 20% of students fully repay their loans, which amount to £20bn a year in England, about 70% of it going on rent. In total, taxpayers have guaranteed student loans of £182bn – not far off the cost of England’s NHS. The burden is forecast to rise to £460bn by the 2040s, which is clearly unsustainable. Someone has to reform Britain’s universities: will it be the professors?
The public sector has traditionally been a safe space for the professions. George Bernard Shaw declared them “conspiracies against the laity”. Liz Truss, as junior Treasury minister, savaged them as a “blob … constantly lobbying to put up barriers to new people joining them”, in her case women. To the legal pundit Richard Susskind, the professions are dead. Intelligent robots – assuming digitally literate clients – will need the help only of hand-holding “paraprofessional empathisers”.
I doubt it. There is a sense in which professional status does need protection. In the public sector, a classic case is that of a formal civil service empowered to resist authoritarian bullying by politicians. But the fact remains that professions underwritten by taxpayers must deliver value for money. This means leading the way to reforming themselves.