Road less travelled – What will fix the NHS

Rajan Madhok

There is an old, but very relevant, story from USA, about a man called Paul O’Neill who became the CEO of aluminium giant Alcoa in 1987. At his first public appearance after appointment, he said: “I want to talk to you about worker safety.” “Every year, numerous Alcoa workers are injured so badly that they miss a day of work. I intend to make Alcoa the safest company in America. I intend to go for zero injuries.”

The audience, expecting to hear about profit margins, new markets and “synergy” or other business buzzwords were confused. On being pressed further he said:  “I’m not certain you heard me.” “If you want to understand how Alcoa is doing, you need to look at our workplace safety figures.” Profit, he said, didn’t matter as much as safety.

The markets reacted badly and, so the story goes, one investor called his 20 largest clients and said: “The board put a crazy hippie in charge and he’s going to kill the company,” and ordered them to sell their stock immediately.

Within a year of O’Neill’s speech, Alcoa’s profits would hit a record high, and by the time he retired in 2000 (and went on to higher offices, and worked on health matters), the company’s annual net income was five times larger than before he arrived, and Alcoa became one of the safest companies in the world.

DOGE

Fast forward to 2025, when Donald Trump unleashed Elon Musk to wield the chainsaw to cut waste under DOGE. The conflicting reports of actual savings are neither here nor there, what is more noteworthy is the toll it has already taken on workers, and communities, and beyond, and will continue to exact in the years and decades to come.

What have these stories got to do with the NHS in Wales? Everything, as it happens. Because given the current failings of the NHS and state of society, the latter scenario is a distinct possibility. Crises bring out that sort of reaction. I have also advocated a focus on Waste recently. But I do not have the Musk approach in mind – that has never worked and never will.

The NHS is too complex for such simplistic solutions; reducing waste and increasing efficiency and performance are not new challenges – there have been many attempts in the past. In the English NHS there was the Gerry Robinson and later Lord Carter’s reviews and now the ongoing Lord Darzi review, and here in Wales we have had the report on Waste by the Bevan Commission and we wait to see what happens with the more recent Ministerial Advisory Group report. The clues to why these attempts have limited success, or indeed how they might succeed, lie in these stories.

There was a clearly stated goal, a compelling vision, well thought through plan led by a committed and humane leader; unlike chaos, slash and burn, no follow through plan, ‘chainsaw’ – the imagery speaks volumes – of Musk’s approach. Things are for a reason, and good leaders try and understand this, and then fix it – it is easier to destroy things than to build them, and some things once lost cannot be regained.

But what about the former scenario? What are the chances that an ‘O’Neill’ will appear? Of course, we have already had our own Nye Bevan, long before Paul O’Neill, who showed the necessary leadership at a time of great need, and surely, there is another Nye; we do not need to learn from these two scenarios. Actually, we do.

At its core, the difference between O’Neill and Musk is about the ultimate question for any business or organisation – the reason for their being. And which was Worker Safety for O’Neill – he wanted to save workers, and Money for Musk, who wanted to save Government spend, and these became the touchstones for what followed. What you aim for is what you will get. Both went at it, full steam, using whatever they had. Of course this is simplistic, as there are other factors, not least the background and character of the leader.

Tredegar Medical Aid Society

We also need to learn from our own history. Most people do not understand or remember what happened with Nye. His genius was to recognise the value of Tredegar Medical Aid Society (and by the way, there were many other such societies at the time) and use his position as the local MP to scale it up. His commitment, and of course his political skills, carried the day, despite massive opposition especially from the medical profession.

However, even he was not enough, because the year after the NHS was established, the plans to introduce prescription charges were agreed, and by 1951, charges for dental and optician services were introduced. The principles of Comprehensive and Free at point of Use NHS were breached. Being who he was, Nye resigned. As an aside the other reason for not allocating the money for these services during the parliamentary debate when Bevan argued against the charges was the need to allocate money for rearmament! Sounds familiar, and worrying?

I am not a politician, and much as I wish that the NHS could be freed from the political process, it won’t happen. Nothing is sacrosanct in politics (sic), things can and will change, unpredictably. As Rousseau said in his ‘On the Social Contract’: “The (English) people think they are free. They are badly mistaken. They are free when they elect members of parliament; as soon as those are elected, the electorate is enslaved; it is nothing. “ No judgement is intended here, it is merely an acknowledgement of the reality – being a (good) politician is a tough gig. I was a medical bureaucrat for a long time, and we had a saying: one should not watch how policies and sausages are made – both involve messy processes. Things are never neat, the ideal gets diluted and we can end up with the lowest common denominator, unless….

In any case, the battle for the NHS is not technical, rather it is philosophical, and is about ideology. The genius of Bevan was that he created a Rupture with the past – his was not a transactional intervention – it was not more of the same; he changed the rules of the game. It was a road less travelled. And that is what is needed now. But underpinned by an ideology, and which is the protection of all when they are most vulnerable and removal of fear; Nye did not divide society. He realised that illness, birth and death respect no boundaries, and people need help in these times. We are either all winners or all losers, we sail or sink together on the NHS ship.

Organising principles

But, what should be the organising principles for the new NHS is the challenge. The original three principles: Free at point of use, comprehensive and tax funded were a good attempt at that time, but sadly, the first two have not been followed since 1951, and the third was breached with Private Finance Initiative (PFI) introduced under Blair/Brown Government.

Those who make it a party political issue need to remember that the underlying neoliberal ideology has been the same, at least since Thatcher introduced her NHS reforms in England, regardless of party in power. We are fortunate in Wales, in that we did not go as far as them – we did not ditch unified health boards or introduce commissioning/contracting or Foundation Trusts, and private sector involvement is limited, for example, so we have the basis to build on.

The one learning from the NHS, when it was set-up, is the need for checks and balances, and recognition that it must be a dynamic, evolving system. The NHS had a very difficult birth, after a long gestation, with much opposition especially from the medical profession, and right thing to do would have been a very explicit arrangement for an early, and periodic, review. After all, it was an experiment.

National psyche

The fact that it has worked for so long is due to Nye who managed to weave it into the national psyche, and that is why, despite attempts to break it up over the years it has survived. This is what we need, this ideology at the heart of any proposals.

But this does not mean everything for everyone at all times, some may need more and some will need to contribute more, and that to me is as it should be. Equal treatment of unequals is not fairness. This will not be an easy conversation, especially in today’s polarised society, but it is something that must be done.

So, it is time to be bold, for a more humane and inclusive leadership, and one that meets the criterion that Carl Sagan set out:  “One of the criteria for national leadership should therefore be a talent for understanding, encouraging, and making constructive use of vigorous criticism“.

Rajan Madhok is a retired Public Health Doctor. You can read more of his work here, www.ramareflections.com