Wes Streeting is taking lessons straight from the Donald Trump playbook

Two men, two very different ways of ‘doing reform’: as the health secretary unveils his plans to shake up the NHS, Sean O’Grady says that it’s a Trump move with one key difference – it might actually work

In the headlines today: two wildly different ways of “doing reform”. In the crazy world of Donald Trump, we find him dropping Elon Musk like a failing SpaceX rocket onto the federal government to see what happens.

Musk will be given the newly created Department of Government Efficiency, or Doge, the name being a wearisome and suitably juvenile cryptocurrency in-joke. Yet because of his vast and multiple conflicts of interest, it isn’t actually a government department or agency at all – but will sit outside official structures.

So, Musk and his sidekick – a former presidential candidate who makes Trump look cautious, Vivek Ramaswamy – will only have advisory roles, to “drive large-scale structural reform and create an entrepreneurial approach to government never seen before.” Musk claims, with zero evidence, that he can carve $2 trillion out of the federal budget, from a total of about $7 trillion (give or take a few billion).

With that much cash swilling around the system, it’s hard not to find some waste and inefficiency; but two amateurs blindly slashing the government by a third with no effect on people’s lives and no political backlash from the states and Congress? Well, we shall soon see…

Then there’s Wes Streeting. Much the most impressive figure in Keir Starmer’s cabinet, Streeting is a man who can not only enter the BBC Today programme studio to deliver his key messages with force and grit – but actually seems to have a plan to begin with the “reform” we hear so much about.

He will bring back league tables for hospitals, so that patients, their families, and dedicated staff can see whether the institutions they all depend on are doing their job. If they are not, and they are underperforming, then there are fair questions to be asked. It’s perfectly possible that in some NHS trusts, there are acute demographic pressures or historic underinvestment – no one works well under a leaky roof.

Having a poor rating doesn’t mean you sack the healthcare assistants and interrogate the path lab. It means people at the centre – watchdogs and the health department – finding out what’s going wrong and fixing it. The trust managers, invariably very well paid, have to play their part in reforming things and showing results. They are the ones paid the big bucks to perform, and they have to be accountable.

If they don’t improve matters then they shouldn’t get a pay rise; if they do – without some other detriment – they deserve a bonus, as does everyone in a hospital or clinic that has turned itself around. More than in most places, health workers have to work as a team, and their collective effects should be materially rewarded. But there should be no hiding place for duff managers or board members, and, as Streeting is at pains to ensure, no big payoffs and a new job at some other complacent trust.

Obviously, no one likes league tables and they’re a crude way of measuring excellence, or lack of it, just as they are in schools. But they are also inevitable in systems that are funded by the taxpayer, and where people feel they have a right to know how their hard-earned money is being spent on their behalf.

If voters don’t have faith in the system and assume that the extra taxes they’re paying are just going to be wasted, then that fatally undermines their faith in the whole NHS system and the principle of social insurance. League tables constructed and used intelligently, are, if you like, the price that NHS professionals pay in order to help carry the trust of the general public – as well as the sometimes world-class care they receive when they do eventually get into the hands of the professionals.

The NHS has its faults. Many of them are purely down to past neglect and a simple lack of staff and facilities (and money). It has had to learn to make the most of every pound and is actually more efficient than many comparable systems elsewhere. It is already value for money for those of us – a vast majority – who’ll never be able to fund complex treatments administered by world-class medics.

However, like any other organisation, those at the top have to be driven through a system of clear financial incentives and penalties to get the best out of it. To make that happen, I’d trust Wes over Elon every time.