The Punishment Model of Government
League tables, political cruelty and the quiet fear spreading through the NHS this winter.
Disclaimer: This piece reflects my personal views based on my professional experience in the NHS. It does not represent the views of any employer or organisation.
Flu has come five weeks early.
A reasonably innocuous sentence that. Just six words, not one of them over five letters long.
And yet, when I heard those words spoken by a virologist colleague a few weeks ago, I felt my stomach drop - because those six words were the sound of a bulkhead completely buckling under strain.
It’s not just the flu itself - though flu arriving earlier, harder and alongside a recent October peak of COVID infections and a growing RSV outbreak is a big enough knock on its own - but because of the impacts that will follow in the health service.
I’ve never professionally known an NHS not on the back foot - I joined the service in 2021, smack bang in the middle of a lockdown, which meant that “normal” was already the emergency footing. Daily crisis calls. A backlog that felt almost mythical in size. Fires getting put out on a near constant basis. I have no nostalgic golden era in my career on which I can look back - the baseline has always been barely controlled collapse.
And yet, stepping into this winter feels even worse than that. Even worse than in one of the most acute moments of the pandemic we all recently lived through. Not just clinically or operationally either - but to a very large extent morally.
I would like to go into this piece acknowledging something - I realise that the current government didn’t cause the issues we are now faced with. I get that. The Tories shredded the NHS to within an inch of its life, and there will be many, many years of repairing the damage that was caused. This is true.
But, it’s also true that the Labour government’s approach to the health service so far has been nothing short of disastrous - and, most importantly, punitive.
For those not in the know, the NHS has started with a trust league table recently - a public place that underperforming trusts can be “highlighted”, along with a lovely new implicit threat - “Fall down far enough into the rankings, and you’ll get a turnaround director.”
And you may be asking, “Turnaround director? It sounds like you’ll have support coming!”
Oh, my sweet, summer child.
While that may sound like support, what it means in reality is that someone arrives with a clear and unambiguous mandate to cut. To cut posts. Rationalise services. To strip back whatever is left of the trust in question to bones that will rattle around ineffectively1.
And that sword of Damocles currently swinging above multiple trusts head is creating fear. An electric current of it running through meetings. Not a fear of embarrassment - no, no. A fear of what that means for not only your job, but the community that you work in and the impact that this will have on them.
And there’s a lovely little caveat within this league table - that regardless of how well you perform, if you are running at a deficit, Finance being one of the five domains being measured, you’re automatically placed in league three which is classed as “Underperforming and / or Financial Deficit”, which puts you in below average.
It doesn’t matter if you score “High Performing” or “Above Average” in any of the other four measurements2 - if your trust is overspent, BANG! Down the league table you go, and straight into touching distance of having a turnaround director foisted upon you.
So even on the basis that your clinicians are literally pulling miracles out of their scrub pockets - no matter how hard they hold the line, how far they go to ensure patient safety, or how thin they spread themselves to ensure access, a deficit is the measure that will ultimately decide whether or not your organisation gets a turnaround director.
It all feels genuinely deranged. Utterly incoherent. Because a trust that’s running a deficit is no longer a sign of unsustainable pressure - it is the judgement, and the metric itself has completely swallowed the meaning.
You can have an ED that consistently meets its four-hour performance target, urgent referrals getting definitive diagnoses within the four-week cut off, community teams that perform minor feats of alchemy to ensure that their local residents can access the services that they need and surgical teams sweating blood to get elective activity back to pre-pandemic - and not a single one of those things matters. Not. One. Bit.
Finance is the trapdoor, the scarlet letter, the factor that can turn an otherwise well-performing trust into “Below-Average” and one, single missed target away from going into “Low Performing” and nudged straight into the Recovery Support Programme segment of the league table - and once that happens, a turnaround director somewhere starts sharpening their spreadsheets.
And it doesn’t take much, just a few missed targets, and you’re there.
Higher than average sickness rate? An increase in MRSA, C. Diff or E. Coli infections above the baseline? An increase in the number of days between “discharge ready” and “discharge actual (a metric that is heavily dependent on social care capacity which trusts can neither control or fix)?
These are just some of the things that can push what is a reasonably well performing trust over.
If it were just the league table, I think there is a way it could have been justified - but it’s not. This league table is happening in an ecoystem that’s collapsing not only in the NHS itself, but outside of its walls, because the other wheel that has come off completely and is gleefully winging its way down the motorway is social care.
The conversation around winter-pressures are sometimes framed as meteorological, but they’re not, they’re social care shaped, and every single winter that I’ve been with the NHS has had one constant hum in the background, one that tells you that regardless of the rate of flu or COVID or RSV, if you can’t discharge patients safely, the whole system backs up like a blocked drain.
And while in 2024 and 2025, the picture became marginally better for social care as a sector, they were still disastrous.
Recruitment is still struggling while retention remains low. This is causing the social care providers that the NHS depends on to keep patients flowing to simply shut entire services down because they just cannot staff them.
And the care workers who are still around - mostly women, a large proportion migrants, all of them chronically underpaid and structurally ignored - doing the job? They’re being treated like a political chew toy by this current government, many of them being branded as part of the “post-2021” cohort of migrants, or in Reform language, the “Boris Wave” - also known as the people who came to prop the social care sector when we needed them most acutely.
There are many of our care workers who were told in a speech by Shabana Mahmood that they are right at the back of the queue3. People who are being flattened into “lower-lower qualified workers who entered the country, along with their dependents, through the health and care visa” and will now have to wait 15 years before being eligible for settlement in the United Kingdom.
A group of people who are doing the most physical, intimate labour for the least reward already are being used as red meat to try and win over voters that would never vote for Labour anyway.
That alone is a dagger strike to the beating heart of the social care system and something I find utterly unforgivable.
But, I hear you say, there is an independent commission that’s looking into adult social care as we speak, so it should be fine!
Except there’s one problem - the first phase of that commission isn’t due to report until 2026 at which point we’ll be told “yes, indeed - things really are a bit troubled, aren’t they?” and only in 2028 will there be any sort of long term strategy in place.
2028!
That is winter 2025, 2026 and 2027 that we will need to get through before there is any sort of solid plan that’s set in place. Three winters! I have to spell this out very clearly now, because there is no minister available that seems able to do so:
The NHS cannot survive three more winters without meaningful social care reform. It cannot happen. It cannot happen operationally. It cannot happen clinically. It cannot happen morally.
The NHS will not bend some more, or buckle in places we pretend not to see - it will break. The people who sit with me in the NHS know this. The GPs, the porters, the nurses, the community teams, the mental health networks - all of them. And the moral injury of that knowledge - of seeing exactly what sits on the horizon and being utterly powerless to do anything to prevent it - is absolutely enormous.
And it’s at this point that the politics of this all should snap into focus for everyone, because the most galling part - the part that keeps me awake at night far more often than I’d like to admit - is that none of this is inevitable.
None of it.
Not the blockages, the burnout or the looming feeling of collapse. These are choices that are being made by our current government - policy choices. They are being made right now, in real time, by a government that seems far more terrified at being called soft by Camilla Tominey than they are of presiding over what has the potential to be a humanitarian disaster in its own hospitals.
Instead of urgently stabilising the NHS while the social care commission does their thing in a committee room somewhere, they’ve chosen this moment to tighten the financial screws by introducing a league table that punishes the sickest areas and talking tough about migration as if scapegoating the actual workforce that keeps elderly people alive and in comfort will magically free up beds.
It is poor, shortsighted and ultimately idiotic strategy to go about things like this.
And the cruelty of this - the feeling I wish that every single MP could experience for just ten minutes - is knowing that it’s coming, and knowing that there is pretty much nothing you can do to stop it.
Knowing that a patient in a hospital bed today may very well be in that hospital bed a week or a month from now because the care package that should have picked them up is simply not there.
Knowing that your trust - no matter how brilliant its clinicians and its services - could be one spike of sickness or an E. Coli infection or worsening of its discharge targets away from being sanctioned.
Knowing that “efficiency” now translates even further into “do the impossible, but do it even faster, with even fewer people and don’t you dare complain.”
That is moral injury. That is what large swathes of the NHS are carrying going into this winter.
And none of this has to be that way, because Labour has it in its power to stabilise things. They could announce immediate stabilisation funding for social care. The league tables can be set on hold until after the winter has brought its worst. They could actually follow the Darzi recommendations and give hospitals the capital funding they need, that would avoid them dipping into their operational funding to cover things like broken MRIs or infrastructure falling apart.
What have we got instead? Gestures. Warnings. Vilification.
Flu is here five weeks early this year. The politics are decades out of date. Unless something changes very soon - loudly and unapologetically - this winter will not be the worst we’ve ever seen. It will be the winter that snapped the NHS in half.
Further reading from on the same subject:
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A minor caveat here - turnaround directors are personally not villains, they’re just operating within a framework that’s specifically designed around cutting rather than recovery.
The other measurements are: Access to Services, Effectiveness and Experience of Care, Patient Safety and High Performing.
All the way behind anyone paying the top rate of tax - a cohort that will be eligible for settlement after three years. If that’s not a tiered system of value, I don’t know what is.
It’s utterly terrifying isn’t it? When you look at the alternative to a functioning health and social care system it would seem to be a no-brainier, but not to policy makers; oh no. And this attack on low-paid migrant workers like they were somehow a drain on the system - have our ministers not eyes to see who’s employed in care homes and hospitals? What the hell do they think will happen without them? When my dad was in a specialist care home most of his carers were migrants. When my partner was being treated for cancer, ALL the nursing and personal care staff were migrants. The same will of course be true for every family accessing the NHS & social care in the country, including those who think migrants are the problem and will vote Reform whatever Shabana Mahmood or Keir Starmer or Wes Streeting says. I’m going on for a small op at my crumbling local hospital (Whipps Cross) next week. I hope not to be a drain on the system. Wish me luck.
oh heck.
I've shared this with my (Labour) MP, but he's stopped answering emails recently.
I suspect he's as horrified by what's happening as I am, but not allowed to say so.