Jun 15, 2025 11 min read

Cowper’s Cut 380: Will Taylorism do?

We can too easily forget people’s contributions to the English NHS and health system. One of the first people who helped me a lot in understanding this world was the patient and public involvement advocate and policy entrepreneur Bob Sang, whose work I used to publish on various media platforms that I edited, including Health Policy Insight.

Bob had a good grasp of management theory, and because I was remembering things that he’d said about Taylorism, I was drawn back to his last article on health policy and politics, which I published in 2009. In it, Bob quoted the management thinker Russell Ackoff‘s line “Quality is a term so general and ambiguous as to be almost completely meaningless … Use it as often as you can!”

For ‘quality’ in the late 2000s, read ‘integration’ in the mid-2010s, and in 2025 ‘The Triple Shift’. “The Triple Shift is a term so general and ambiguous as to be almost completely meaningless … Use it as often as you can!”

Taylorism is also known as ‘scientific management’: its aim was to analyse and synthesise workflows, in order to improve economic efficiency and labour productivity. Taylorism was one of the earliest attempts to apply science to business processes.

It could scarcely be more timely, as the English NHS awaits the 3:7 Forward View (also known as the NHS Ten-Year Plan), the core aim of which is to deliver The Triple Shift’ (from treatment to prevention; from acute to community; and from George to Ringo).

The Chancellor this week delivered 3% real-terms growth for the NHS over the three-year period of the Comprehensive Spending Review. This was above the 2.8% figure most recently briefed to The Times, but below the 3.5% previously briefed to the same publication that 10 Downing Street would impose to stop rows (see last week’s ‘Cut’). It was also above the fantasy 0.7% pencilled in by Jeremy Hunt when Chancellor; but crucially, it is below the NHS’s long-run average growth of 3.6%.

Unfortunately, the Chancellor was unable to deliver the NHS with any growth on capital, and it now appears obvious that the only route to what is necessary to fix the huge NHS capital and maintenance backlog is going to involve private sector borrowing. This week saw a timely Guardian piece on thousands harmed and 87 dead as a result of equipment failures in the English NHS.

It is reasonable to point out that below-trend funding matters. It is equally reasonable to point out that £204 billion a year ought to be able to deliver a better service than is currently on offer to citizens, voters and taxpayers. In both cases, we are starting from where we are.

The NHS: not Portugal

At the NHS Confederation’s conference this week, NHS England interim chief executive Sir James Mackey compared the budget of the NHS to the annual GDP of Portugal. Various other speakers picked up on that point. This is curious, as the point is the equivalent of comparing people’s salaries to that of the Prime Minister: only of interest to people who are incredibly stupid or wilfully naïve.

The population of Portugal is just over 10 million: the UK’s population is just under 70 million. Portugal’s nominal GDP is $321 billion; the UK’s nominal GDP is $3.84 trillion. The analogy is, at any meaningful level, pointless.

This is a pity, because much of Sir James’ speech (delivered ahead of the CSR announcement) was fine. He hammered the importance of redesigning care processes, with particular attention to outpatients. Mackey is also, rightly, winning admiration for his refusal to tolerate the culture of toxic bullshit and mendacity that has long prevailed among several NHS England directors.

On the 3:7 Forward View, Mackey told delegates that “we’re just about to start the process with government. These things always dilute as you go through the process – you get more and more frustrated as you go on, and it gets challenged and it gets sorted and diluted”. This remarkable piece of honesty about the 3:7FV’s tortuous gestation to date, and upcoming trial by Number 10 fire, hasn’t had the attention it deserves. Apart from here.

I mentioned the Ackoff line about quality, and Mackey said, “the focus on quality again, I think it’s really welcome and we have lost our way a little bit coming out of Covid”. This is glossing over the well-known utter, and longstanding failure of the Care Quality Commission to do its job of quality regulation. It was good to see that Mike Richards lost scant time in utterly renewing the CQC board, as announced this week.

Mackey also gave what may be an important heads-up to further management redisorganisation in the 3:7FV, with his phrase, “let’s not turn that into something that becomes a tribal thing where we all argue about who’s in charge of what”. Clearly one to watch.

(Matthew) Taylorism

NHS Confed chief executive Matthew Taylor’s speech picked up on Jim Mackey’s comments about the worrying findings of the latest British Social Attitudes survey on health.

Looking all the way ahead to 2029, Taylor warned delegates that “the next general election could see one or more major party with a credible chance of forming the next government openly sceptical about the NHS. Their leaders may make the judgment that voters are so despairing of the service they are willing to see it become a mere safety net, perhaps by incentivising even more people to do what many are doing already, buying medical services from the market ... we are fighting for the life of the NHS as a universal service available according to need.

And it is a daunting challenge … As far as we can see into the future, we face a tough financial environment”.

I mentioned the Milburnian “really retail” comments about 3:7FV draft discontentment a few columns ago, and Taylor also said, “while satisfaction with the service declines, public expectations rise. From weight loss to cancer, people want access to the new treatments they read about daily. They experience the best the retail sector has to offer in speed, personalisation, reliability and they ask why the NHS lags so far behind.”

Um. Do they? The majority of heavy NHS users are, as they have long been, the elderly comorbid. I’d be interested to see the evidence that they are particularly grieved by NHS sub-retail personalisation and responsiveness (particularly as they may well have spent time on the phone to call centres, and the wonderful world of retail has now made unavoidable). I suspect that their complaints may be more about lack of easy access to primary care (despite that sector’s huge and unsung success at expanding access with declining resources); poor record-sharing; Winter crises meaning that for a third of the year, urgent and emergency care access is bad; and long waiting times once it is decided elective care is needed.

None of these problems is new or recent. None of them are much like retail: a sector that ruthlessly segments and selects its customer base and does not have a universal access obligation. I do wish that people would stop using retail analogies that add no value.

Taylor also announced that NHS Confed and NHS Providers will be working more closely together. The deal is evidently not yet done on a merger, but this is simply recognising the reality that there is not the money or space for two NHS representative organisations. Indeed, it may become questionable whether there is space for one, given that funding constraints will not be going away.

Lord Adebowale’s opening speech was a rousing and heartfelt effort, with welcome emphasis on workforce wellness and on culture. He gets it.

Black and white

Nor did the Confed’s chair shy away from the NHS’s racism problem: “my mum, who worked for many years as a nurse, died earlier this year at the age of 92. It was difficult, it was not the dignified death that we would have wanted for her. It wasn’t the death she deserved. So it makes me clear about the need to address the inequity. I think she got a black service, not an NHS service.

“So I have to address the inequity that still exists within the NHS, in terms of the experiences that people who look like me continue to receive. It just hasn't got any better. It is not acceptable that someone who looks like me, on average waits 20 minutes longer in A&E than white patients.

“To achieve an inclusive, equitable NHS we need an inclusive equitable culture from top to bottom.”

Streeting speech

There was also a speech from Health But Social Care Secretary Wes Streeting (although due to arsehole behaviour from members of Team Streeting towards the hosts, there almost wasn’t). That came on top of Streeting’s speaking appearance not being confirmed until ultra-late in the day: Confed should probably have stuck with the offered Karin Smyth, who as a former career manager, knows a lot about the NHS.

The Streeting speech … existed. The irony of its title ‘Our vision for a new model of NHS care’, and its being delivered with the 3:7 Forward View just about to go into battle with the Number 10 process, was not lost on the sharper people observing it.

Mr Streeting set out his stall to “have a health geekout, set out what the Spending Review means for us, trail some of the reform agenda in the 10 Year Plan and then spend most of the time we have answering your questions. I apologise in advance to our friends in the media, who might not be as excited as the rest of us by the prospect of a discussion on the NHS operating model”.

Some of the media, Wes. Some of them.

He made a point of thanking ‘Brains Trust’ WhatsApp group member Matthew Taylor “for the leadership you are showing and the ideas you are bringing to the table. They are critical in shaping the 10 Year Plan and developing a new model of care.

“I really enjoyed reading your speech yesterday and I want to rise to the challenges you set for me, as well as the challenge you’ve set your members today. You were absolutely right to warn in your speech yesterday about the jeopardy facing the NHS.”

A lovely love-in. And it’ll all be OK, apparently, because, of the fight for the NHS’s future, Mr Streeting thinks that “nothing I have experienced in my first 11 months in office has shaken my conviction or confidence that this is a fight we will win.”

Mmmmmmm.

He added, “reimagining the NHS over the next decade demands a mammoth effort from all of us. So, I want to give you this assurance, as you carry out the difficult tasks I’ve set for you: I’ll have your backs.

“… as we deliver the transformational shifts in our 10 Year Plan, from hospital to community, analogue to digital, and sickness to prevention, it will have radical implications for services.

Much of what’s done in a hospital today, will be done on the high street, over the phone, or through the app in a decade’s time. So if you need to reconfigure services to cut waiting times, modernise, and improve productivity, you will have my support … This is a team effort and I trust you to deliver. That is the only way we will succeed”. Words to bookmark.

There were more bold claims: “you are worried that a top-down reorganisation would make it harder to deliver. So let me assure you all on this too - we are not embarking on another top-down reorganisation. Changes to the organisation of providers will be evolution, not counter-revolution.”

Um. I mean, technically, it’s true: the top-down redisorganisation to ICBs and ICSs and NHS England has already de facto happened, well in advance of the legislation that is required to do it.

There was also assertion that “Government no longer attempts to control public services or industries from Westminster. Except when it comes to the NHS.” This is quite something, coming from the man who just abolished the arms-length body allegedly running things. One must have a heart of stone not to laugh at his claim that “with the publication of our 10 Year Plan, we will bring this era of top-down control to an end”. By abolishing NHS England, Mr Streeting has ‘taken back control’ in the most maximal way possible. Its ramifications will become clear to him in time.

FTs to be reborn for these financial times

In a long dose of unadulterated Milburn, Mr Streeting also said that “the introduction of foundation trusts was one of the most successful NHS reforms in the last 25 years. The philosophy behind it holds true - earned autonomy, greater responsibility for boards and the freedom to innovate is still the best way to drive up standards.

“This has been lost over the last decade, as the bureaucratic culture of excessive micromanagement took over. So we will reinvigorate the foundation trust model. The 10 Year Plan will introduce incentives, freedoms flexibilities, and freedom from central control for local providers delivering a quality service.

“Starting with the best performing foundation trusts, we will restore the powers they once enjoyed.” Re-earned autonomy, anyone?

“This will be a reinvention of foundation trusts for the modern age. We will also change the financial rules of the game … so foundation trusts can only succeed if they collaborate with community and mental health providers and GPs, focus on outcomes not activity, drive the left shift, and help to improve population health.

“Where providers are underperforming, we will step in and support you to turn it around. If services are simply configured wrong, we will empower you to change. Where there are failures in leadership and culture, the leadership will be replaced, with bonuses to attract our best leaders into our most challenged trusts.

“Where there are repeated financial problems, the failing provider may be placed into administration and taken over by another provider.” This, of course, already exists.

In a sign that someone who knows where the NHS’s biggest problems are had a hand in the drafting, Streeting announced that this “decade-long project of improvement … will start in working class, rural and coastal communities”.

Less reassuringly, he added that “this year, we will require regions to begin drawing up plans for failing providers and begin the process of turnaround”. Sorry: this year? When you have massively re-centralised power? For this to be done consistently and well, it will have to be done a) nationally and b) urgently.

The Axel accelerates into Number 10

Axel Heitmueller, alumnus of the Blair-era 10 Downing Street Policy Unit, associate of the Tony Blair Institute and former AHSN boss, was this week announced as PM Sir Keir Starmer’s Expert Advisor on Health. This is not a civil service role.

Axel will be comfortably the tallest man in Number 10, and probably in the whole Government. And if he so chooses, he can make his own headroom and space for manoeuvre within the political set-up, now he has momentum on his side. He is bright, experienced and focused.

And his introduction into the 10 Downing Street set-up is, to put it very mildly, not a vote of confidence in the performance of Wes Streeting as Secretary Of State For Health But Social Care. Sir Keir is not famous for lacking the ability to be ruthless when he so wishes.