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Robert Ede is Head of Health at Policy Exchange and Sean Phillips is a Fellow at Policy Exchange.

A much-anticipated speech on reform, delivered at the Royal College of Physicians earlier this week, was designed to set out what Sajid Javid intends to achieve whilst in post as Health and Social Care Secretary. Did it succeed?

Javid has been Health and Social Care Secretary for 256 days. His initial tenure has been consumed by responding to the pandemic: first taking the country out of lockdown in July, then supercharging the booster rollout and successfully persuading the Commons to accept ‘Plan B’ restrictions last winter, as Omicron reached these shores.

Up until now, his stated priorities have been Covid, recovery and reform. Broad, right? So this speech was billed as the chance to provide the detail to underpin a vision for health and social care.

“I’m mindful I’m not the first Health Secretary to stand in front of an audience and propose reforms” Javid said in opening the hour-long address. However ,this was a fundamentally different speech to ones given by his most recent predecessors, Jeremy Hunt and Matt Hancock, in setting out their own visions.

Central to his pitch were three difficult ‘home truths’:

1. There won’t be more money for the NHS. Javid highlighted that the healthcare budget is now bigger than the GDP of Greece. Reflecting on his experiences leading six departments, including the Treasury, he highlighted the “serious trade-offs” that accompany healthcare taking up an ever-greater share of national income. April’s Health and Care Levy – raising £36 billion over the next three years – will be a line in the sand, Javid said. He didn’t want government to “have to keep going back for more tax hikes” with a proportionately smaller working-age population bearing a bigger burden.

2. The state should get smaller. Javid said that the NHS continues to spend too much on the symptoms rather than the causes of ill-health. He wants to see citizens with more power to determine their own health – and a greater focus on the role of families. He reiterated that he was a small-state conservative. The word ‘freedom’ was mentioned more than 17 times.

3. The NHS should not hold out for a fully funded workforce plan. The sector has been near-united in calling for a comprehensive solution to the workforce shortages – mobilising an effective campaign to have independently verified modelling of workforce need baked into the current Health and Care Bill.

The workforce concerns are genuine – with 110,000 vacancies split across core specialisms, and reports of burnout. It is also a key factor in delivering transformation: as Javid himself acknowledged, healthcare suffers from ‘Baumol’s cost disease’, with lower productivity for the workforce than a sector like car production, where robotics and technology have made production both faster and cheaper over time. In response to questions from the media, Javid said that any recommendations to increase staffing levels would need to be funded from within existing budgets.

The response in the room was flat. Telling producer interest bodies (Royal Colleges, NHS trade associations and healthcare charities) that more money won’t come is a difficult message to land.

But this speech was clearly aimed at a wider audience. Despite the war in Ukraine raging, it was notable that a number of Conservative backbenchers trekked across from Westminster to sit in the front row. Javid should also be heartened by his rising stock amongst Tory members; the February poll of ConservativeHome members put him sixth in the cabinet, with a net positive satisfaction rating of +49.4.

This should signal that Javid will push back against suggestions that he may ‘go native’ – a common criticism of Conservative health secretaries who arrive at the department full of ambition, but get sucked into the day-to-day issues and spending negotiations with the Treasury.

Was there any hope to accompany this dose of realism? Javid’s reforms are based around three Ps: Prevention, Personalised and Performance. A fourth – People – appears to have been added at short notice. The priorities themselves are sensible. Prevention, technology and workforce were so from Hancock, too. As were Hunt’s priorities of quality of care, long-term conditions, dementia, and boosting survival rates in key disease areas.

Whether the three Ps make an impact will come down to the execution. Perhaps the most concrete offers at this point relate to ‘personalisation’. Making the NHS App a front-door for accessing services will require significant improvement, but 25 million of us have grown accustomed to using it to show our vaccination status. We need to sweat that asset.

Expanding the ‘Right to Choose’, including amongst independent providers, is a strong message for patients – so too is the extra support and information for those who have been waiting the longest for routine treatments (something Policy Exchange has called for).

But anyone familiar with healthcare policy will legitimately point to initiatives under Tony Blair and Alan Milburn, and argue that seeking to achieve something similar with more modest budgets (in the mid-2000s the NHS budget grew by 7.5 per cent each year for five years) will lead to mediocre results.

A baseline assessment for prevention spend will be overlooked, but is significant. Too much of the current NHS budget remains under the control of secondary and tertiary hospitals. And if you visit any hospital, two thirds of the people in the inpatient beds will be there due to preventable ill-health.

Yet despite successive attempts by policymakers in Whitehall, GPs and community care – the best means of delivering population health and preventative initiatives – lack the firepower to fulfil their potential. An assessment can signal the first stage of a broader rebalancing of the NHS; in practical terms, it might mean prescribing ‘game-changing’ anti-obesity medication in primary care, in an attempt to intervene before co-morbidities lead to hospitalisation.

It is great to see prevention back in vogue. But we have been here before, and expectations must be balanced with a recognition that the quality of housing, schools, and work opportunities are just as important as the NHS in shaping the health of the nation.

Some exciting ideas were held back. These include possible reforms to primary care – the Secretary of State provided a foreword to Policy Exchange’s recent report on general practice which called for a shift to a predominately salaried model – and expanded autonomy for NHS trusts.

As others have observed, the integration agenda which Javid inherited only received a passing mention, and he himself has hinted at going further than the current reforms in the Bill. It would be wise to not delay bringing these collective conversations out into the open.

In his speech, Javid evoked both Tony Blair and Margaret Thatcher. It was the latter who told one of Javid’s predecessors, Virginia Bottomley to “never turn down the opportunity to explain the government’s case, because nobody else will.” This week, Javid took that chance. He set out a clear Conservative vision for the NHS – indeed, for public service spending more broadly. It included some difficult things that he wanted the NHS to hear. The ideas and policies must now follow.