When it was revealed this week that Elon Musk had sent an email to tens of thousands of US federal workers asking them to list five tasks they completed this week or effectively resign, one senior Pentagon official described it as “the silliest thing I’ve seen in 40 years.”

This latest twist in the Trump presidency came after Musk was granted authority to root out wasteful government spending through his Department of Government Efficiency (DOGE).

In the midst of the furore and fear that followed the billionaire Tesla founder retorted that he was simply eager ‘to see who had a pulse and two working neurons’ amid concerns that some government workers have it so good that they don’t even check their emails.

Whilst this may not be an entirely constructive approach to people management, Elon Musk’s action has attracted a lot of sympathy from ordinary Americans who have become increasingly frustrated with the state’s lack of ability to solve even the most basic and urgent of social and domestic issues. In 2023, around 19.58 million people were working for state and local governments in the United States, or around 5% of the country’s population. Not surprisingly many Americans feel this is a ridiculous waste of taxpayers’ money which ought to be spent on actually providing public services rather than administrating them.

The debate around administration vs provision is common in many areas of public service, but has gained a new urgency in a world that is suddenly changing, and especially one where overpopulated bureaucracies have long been the object of public public scorn and concern.

It’s a debate we’ve had here for many years now relating to the NHS, which has seen a progressive decline in the number of patient service providers and a worrying increase the number of administrators. Medical staff at all levels have long complained that the ever-increasing burden of paperwork, form filling and general bureaucracy is having a highly negative impact on service provision and the NHS’s ability to treat patients.

Just last Saturday an Ipsos poll for the Daily Mail and The Guardian revealed that patients no longer have faith that the NHS will be there for them when they need it. The bombshell study exposed a critical ‘public confidence crisis’, with the once-treasured icon of British success now evoking a sense of fear and waste. More than half the people questioned by Ipsos made the point that despite the new Labour government injecting an extra £25 billion into healthcare at last year’s budget, it’s still no easier to get an ambulance, find a hospital bed in A&E or access a GP. There were also widespread concerns that many critical areas of healthcare, such as cancer and social services, were being cut at exactly a time when they were needed most.

Last week the then chief executive of NHS England, Amanda Pritchard, admitted that a lot of the extra government cash had not even reached front line care, but rather had been swallowed up by ‘inflation and pay rises’. Naturally this wasn’t what a Labour government committed to rescuing the NHS wanted to hear, so yesterday it was announced that Mrs Pritchard was quitting as NHS chief executive, leaving the way clear for Health Secretary Wes Streeting to parachute in and begin tightening his control of our ailing health service. Mr Streeting has made it very clear that he wants a far greater involvement in the day-to-day running of the NHS and the word in hospital corridors is that swathing staff cuts are lurking just around the corner.

In a farewell letter to Mrs Pritchard delivered yesterday, Mr Streeting said that said there was a need for a ‘new relationship’ between the Department of Health and Social Care (DHSC) and NHS England and that he intended to deepen the ‘one team’ culture that had been much discussed following Labour’s general election victory last July. Whilst this may not exactly result in ‘five tasks this week’ memos being circulated to NHS staff, Mr Streeting has already made it clear that he will be targeting and seeking to reduce the huge areas of duplication and conflicts of priorities that have dragged down the health service over recent decades.

He also flagged up that whilst “the NHS is full of extraordinary people, who do extraordinary things every day”, the nationwide wave of support for nurses and other health staff during the recent Covid pandemic actually masked the reality that the NHS was woefully unprepared for such an event. Whilst this is true it was not the NHS’s response to Covid that caused the public disconnect, nor was it even was it necessarily the high profile breeches of Covid restrictions – rather it has been the subsequent revelations that some individuals in positions of power took appalling advantage of the crisis to corner lucrative NHS contracts and add significantly to their already obscene wealth.

If Mr Streeting does manage to prise open the complex administrative structures of our health service no-one will be in the least bit surprised if he discovers numerous other instances of undue self-interest at work.

All of this is a great sadness, and a very long way from July 1945 when the Second World War was crawling to its end and the British people brought Clement Attlee’s Labour Party into power with much the same kind of landslide that brought Keir Starmer in some 80 years later. When Attlee appointed Aneurin Bevan as Health Minister, the dream of free health provision for all, regardless of wealth, seemed like a perfectly reasonable ambition – especially as the anticipation several years earlier of massive air raid casualties had led to the creation of the Emergency Medical Service, which had effectively placed all of England’s hospitals under one umbrella organisation anyway.

On 5th July 1948 the NHS was born, much to the chagrin of many in the government, as Bevan was adamant that, where medical need existed, medical care should follow and budgets should be of secondary importance. This may seem like a rather utopian view of what is in many respects a huge commercial operation, but many in business today share Bevan’s take on how to run such a complex business. Increasingly, a budget is recognised as a safeguard, a guide and an analysis of business activities, but should it inform the confines of day-to-day needs and activities? Many think not.

It might actually benefit those who currently claim to control the NHS to consider the Bevan view – after all, the root of the NHS is the human person, whose needs must always come first. Which brings us back to those clogged up A&E departments. Ask any GP and they’ll tell you that, whether it’s an aspirin or a decision to send a patient down the line to A&E, there are few decisions today that genuinely and cleanly rest in their hands. Far worse, more and more are telling us that they no longer feel like doctors at all, but cogs in a much larger, industrialised process that sees us, the public, not as a cherished asset but as an unwelcome drain on central resources.

Shortly after taking power, Sir Keir Starmer declared that the NHS was broken but “not beaten” – but equally warned that there wouldn’t be any additional funding without reform. Quite what shape that rescue plan will take is still very uncertain, but it can hardly focus its attention on frontline service provisions which have already been depleted far beyond reasonable levels. That really only leaves the organisation behind the service, and making any meaningful changes here – especially if seeking cash savings is a factor – is going to be a monumental task.

Ironically, when Bevan presented the idea of a single, unified health service to parliament in 1946, many Conservatives in particular were sceptical about his proposal – not in the concept of free healthcare for all, but far more in the means of delivering it from one centralised organisation. It was felt strongly back then that the strength of any service provision lay in a small-scale, dispersed operation that was primarily community, rather than nationally, based. Much of the language of opposition used at the time was steeped in nostalgic memories of cosy village surgeries and tweed clad GPs but – with the current deterioration of British identity – it’s a strain of thought is now seems to be gaining renewed currency.

Over the coming months don’t be at all surprised if you keep hearing mention of ‘The Wigan Deal’, a ground-breaking project started in Wigan in 2011 in which Wigan Council embarked on an informal agreement with its citizens to commit to their health. The council worked with local NHS and other services on a preventative approach which gave local medical staff great freedom to make decisions affecting patient care within the community. Outcoming evidence has suggested that this scheme not only worked extremely well and efficiently, but has even increased life expectancy in the Wigan area.

This may seem like a new innovation, but in many respect it’s a health strategy that has its roots in public service communities of the medieval period such as the Order of St John and the Knights Hospitaller movement, where dedicated health professionals with a profound Christian commitment to person-centred care established localised solutions and services in response to localised health issues. More than 1,000 years on the modern successors to these knightly health workers continue to provide highly flexible, focussed and effective care services in countless places around the world where urgent healthcare solutions are needed.

It may seem like a profound reversal of ethos but if we are to save Bevan’s – and the country’s – longstanding dream of universal free health care for all, the government will need to begin as soon as possible a long and difficult process of dismantling the current unfit single edifice of the NHS, and reshaping it into a nationwide network of separate, devolved but robust and responsive health care provisions.

Pope Francis summed up the required objectives perfectly in his Message for the 31st World Day of the Sick, 11th February 2023.

“These past years of the pandemic have increased our sense of gratitude for those who work each day in the fields of healthcare and research. Yet it is not enough to emerge from such an immense collective tragedy simply by honouring heroes. Covid-19 has strained the great networks of expertise and solidarity, and has exposed the structural limits of existing public welfare systems,” said Francis.

“Gratitude, then, needs to be matched by actively seeking, in every country, strategies and resources in order to guarantee each person’s fundamental right to basic and decent healthcare.”

Given the incredible care and support that Francis is being given right now by the hard-working staff of Rome’s Gemelli hospital, it seems an appropriate time to reflect on the fundamental importance to the common good of free universal health care for all. Please do also keep the Holy Father in your most fervant prayers.

Joseph Kelly is a Catholic writer and public theologian