Nov 30, 2025 10 min read

Cowper’s Cut 404: 2025’s Catch-22 of English health policy and politics - action on fiscal balance, or the RTT backlog?

“After last year’s general election was called, one hedge fund commissioned detailed research on Labour … who Labour’s MPs and ministers would be, what policies they would have, and how effectively they would deploy them … The research, according to a person familiar with the report, said, “There is no plan, there is no vision, and they’re not going to succeed because they don’t have the talent.” The fund decided to take a short position on UK gilts, effectively betting that Britain’s borrowing costs would rise. They made a lot of money on that bet.”

‘Meet The Bond Market Vigilantes’, New Statesman

“Other spending risks include: the impact on the NHS budget of further strikes and negotiations over NHS pharmaceutical spending … July and November five-day resident doctors’ strikes are estimated to have cost £0.5 billion, and there is a risk of further strikes.

“In addition, there is a risk of higher spending on drugs depending on the outcome of negotiations over branded medicines. The Spending Review assumed that spending on branded medicines (around 7 per cent of NHS RDEL) would rise by 25 per cent (£3.3 billion) between 2025-26 and 2028-29. A 5 per cent larger rise in spending on branded medicines over the Spending Review would cost £0.7 billion by 2028-29.”

Office for Budget Responsibility November 2025 report (released early)

“For our National Health Service, I will reinvest all of these (efficiency) savings back into the care that people rely on … more nurses, more GPs, more appointments … and investing in the future of our NHS.

“And today I’m announcing a £300 million of investment in technology to improve patient service, and 250 new Neighbourhood Health Centres, expanding more services into communities so that people can receive treatment outside of hospitals and get better, faster care where they live: over 100 of these will be delivered by 2030, including in Birmingham, Truro and Southall.”

Chancellor Rachel Reeves, November 2025 Budget statement to the House of Commons

When Chancellor Rachel Reeves announced in this week’s Budget speech that “former Heath Secretary Alan Milburn will review the causes of rising youth inactivity”, it’s theoretically possible that she was not alluding to the, erm, limited practical impact to date of Young Master Wesley Streeting’s tenure in office as Health But Social Care Secretary.

She should have been, though. Because Young Master Wesley does not seem interested in the main policy dilemma obviously running through English health policy and politics in 2025: the Catch-22 tension between NHS England’s pro tem boss Interim Jim Mackey’s insistence on financial balance at all costs; and the need to get convincing action under way on the English RTT backlog such that Labour’s ‘return to 18 weeks’ manifesto commitment may be met by 2029.

In the interim

Interim Jim has form on financial retrenchment: it was one of his key drives when he was interim chief executive of NHS Improvement. In November 2016, he asserted that the provider sector’s finances were “back on track”, and indeed the financial year ended with providers apparently within the £800 million overspend contingency set by NHS England - but as the Nuffield Trust’s Sally Gainsbury later showed, a substantial deficit of around £3.5 billion was being hidden by the fine tradition of NHS financial lying: a topic about which ‘Cut’ has quite often written.

(It’s well worth revisiting this Commons Public Accounts Committee evidence session on NHS financial stability, from January 2017.)

As I wrote in ‘Cut’ two weeks back, there is increasing anecdata that the 2025-6 situation of general English NHS financial balance in Q1 and Q2 is already slipping quite fast in Q3, and winter is yet to fully hit.

Waiting list revalidation (again)

If we wanted to feel even more reassured, what better than the announcement of a waiting list clean-up validation initiative? Again? Health Service Journal’s hardy FOI work revealed that NHS England has a £30 million fund for this validation, although past validation exercises have led to concerns about perverse incentives.

Here’s a point I have made previously: what was the point of NHS England’s regional presences, if not to be all over trusts’ waiting list data quality and revalidation? Once Interim Jim’s former fiefdom NHS Improvement got folded into NHSE, this was literally NHSE’s job. Clearly, it’s one that it preferred not to do: the Bartley The Scrivener of NHS organisations.

How to reduce a backlog: expensive, not complicated

Can backlogs be cut?

Absolutely. The English NHS knows how to reduce a backlog, as it showed in the 2000s. It isn’t complicated.

We also know how it’s done: the Kings Fund published this definitive report on ‘Understanding New Labour’s Market Reforms of the English NHS’ many years ago, in 2011. Setting aside the faffing around at the margins of patient choice and independent sector treatment centres, what you do is pay existing NHS staff to work overtime sessions at evenings and weekends in existing NHS facilities. You back this with incentives for higher-performing NHS organisations to be able to keep their surpluses.

We know that this is what works. It is very expensive, and it’s quite slow and it requires some management resource and techniques - but the one thing that it’s absolutely not is complicated.

Here‘s the problem: Young Master Wesley’s attention to detail is notable by its absence.

The RTT backlog has remained broadly stuck for almost half of this year.

As waiting time expert Dr Rob Findlay patiently chronicles in his Health Service Journal column, “if the English NHS were broadly keeping up with elective demand, so that the referral-to-treatment (RTT) waiting list neither grew nor shrank over the year, then in a typical September, the list would shrink seasonally by around 28,000 patient pathways.

“But the NHS has bigger ambitions than steady-state: it aims to tackle the post-covid backlog and restore the “18 weeks” waiting times standard by March 2029. That requires a big reduction in the waiting list, with September’s share of the reduction being some 98,000 pathways.

“However, according to the latest data, the waiting list actually shrank by only 16,000 pathways in September, which is consistent with year-round growth in the waiting list, rather than recovery.”

The RTT action currently being taken under Team Milburn-Streeting is simply not working in ‘maintenance’ terms; nor is it adequate to the scale of the challenge facing the English NHS.

If you want to be the politician in charge of fixing and running the NHS, then you need to be able to do two broad things at one: the narrative and politics; and the operational oversight and strategy-setting. Young Master Wesley’s ambition is making him over-index on the politics: he shows no discernible interest in the latter areas, both of which matter greatly.

It was also interesting to note the recent appointment of former newspaper editor Gemma Aldridge to do a review over three months of the ‘integration’ of the Department for Health But Social Care and NHS England media teams. This is intriguing, as no contract to tender for this work was published by DHBSC or NHSE. Ms Aldridge (born 1983) studied at Selwyn College, Cambridge, which by a massive co-incidence is also where Young Master Wesley Streeting (born 1984) studied.

Surely Mr Streeting has not simply given this work to an old university mate?

The PFI comeback: it’s on

In one of the plethora of Budget leaks, this one being direct from HM Treasury, we learned last Monday that our beloved amigos the Treasury Munchkins were officially going to back private funding for 250 rebuilt, expanded and maybe a few actually new Neighbourhood Health Centres.

It announced that “the NHS Neighbourhood Rebuild programme will deliver the Neighbourhood Health Centres through a mixture of refurbishments to expand and improve sites over the next three years, and new-build sites opening in the medium term.

“The new Neighbourhood Health Centres will be delivered through a combination of Public-Private Partnerships and public investment to bring together infrastructure expertise from different sectors to deliver new facilities on time and on budget – so patients across England get faster treatment in new and convenient buildings. By delivering through a combination of private and public investment the government will be able to build further evidence and compare different models of delivery whilst updated accounting treatment will ensure these are recognised up front in public accounts.”

Mmmmmm. The accounting treatment proposal highlighted in the above quote is interesting … and may get more interesting still, once the details get made up as we go along.

Back in January of this year, I wrote a chunk of this column about capital - “the problems around capital and maintenance seem to me to be particularly ill-suited to management and delivery by a couple of hundred individual organisations.

“I’m not a person who philosophically suggests centralisation to a devolved body lightly, but on balance, the potential gains from a properly-led new organisation which has a tight remit around property asset funding and ownership could outweigh the very real potential to make very, very big mistakes.”

It’s likely to remain a pertinent observation. When we remember how bad the first wave of PFI deals were, to say nothing of the first round for ‘take or pay’ Independent Sector Treatment Centre contracts, it still seems like a potentially good idea to have a national body that is adequately staffed, led and incentivised to do good deals on behalf of us taxpayers once.

If anybody thinks that contracting for 250 NHCs is likely to be done well by either the residue of the regional presences of NHS England or the newly-halved Integrated Care Boards (who are, let us smile to remember, supposed to become strategic commissioners), then I have some wonderful and great-value real estate in Florida to sell you. It’s the greatest real estate the world has ever seen, possibly.

The BMA Resident Doctors 2008 Pay Differential Historical Re-Enactment Society rides again! (perhaps)

This week, to the considerable surprise of absolutely nobody, the BMA Resident Doctors committee leadership chose to re-ballot for an extended mandate for industrial action over pay and conditions. The new ballot will run from 8 December to 2 February.

This was accompanied by a further show of political immaturity on both sides, with the BMA GPC leader Dr Katie Bramall speechifying about the Government having lied to and betrayed GPs. In response, Streeting wrote to GPs, saying that Dr Bramhall had “accused the government of being ‘traitors’ to the profession and of ‘disingenuousness’, ‘duplicity’ and ‘gaslighting’.

“This speech was not just deeply unprofessional and unbecoming of a professional representative body, it was misleading. The BMA agreed these contract changes [on online access to GPs] in February 2025 and any suggestions to the contrary are factually incorrect.”

He added that the BMA was not displaying “mutual respect and professionalism” in its dealings with the government: “your union representatives are currently making it impossible for me and my officials to engage in good faith in the way we would all want.”

In consequence, Mr Streeting has removed the BMA’s exclusivity in negotiations over the new GP contract.

Petulant? Young Master Wesley? Who would ever say such a thing?

It’s always been hard to like the BMA: nor are Team Milburn-Streeting winning themselves too many stans, apart from among members of the Truly And Obviously Desperate Community. It was funny and telling to see former Streeting advisor and now DHBSC NED Paul Corrigan launching himself into battle on the HSJ message boards this week.

The NHS is not a golden cow to be put on a plinth, it seems. Thanks for clearing that one up for us, Paul: I can’t be the only one who’s often confusing the two.

In the interim

Waiting list revalidation (again)

How to reduce a backlog: expensive, not complicated

The PFI comeback: it’s on

The BMA Resident Doctors 2008 Pay Differential Historical Re-Enactment Society rides again! (perhaps)

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