I joined the NHS as a pre-registration “houseman” in 1979, and finally left in 2017. I lost count of the number of reorganisations I lived through. It seems to me that these reorganisations had much in common with the children’s game of musical chairs. In the NHS version there are more and more players running round the chairs, as the number of elderly people in Britain has steadily increased, and old people are medically expensive. But all our politicians have done in recent years – with the exception of the New Labour governments – is regularly alter the music and musicians, with little real change in the number of chairs.
You can stretch the analogy further by saying that the music played has got faster and faster, with demands for “efficiency” recommended by management consultants, so that many of the children start tripping over each other as they hurry to find an empty chair when they fall ill. As a result, ever more of us are turning, if we can afford it, to the private sector for treatment. The NHS is not being privatised – it is withering, and private health flourishes in its place.
The problem is compounded by steady progress with medical technology that has enabled us to treat the multiple morbidities that accompany old age. New drugs and chemotherapy, and safer, minimally invasive surgery keep us alive for much longer than before. Many acute illnesses that once killed us have been converted – at great expense – into chronic illnesses. “Frailty” is a new and important diagnosis, often accompanied by dementia. And it is a world-wide phenomenon, not confined to the NHS. In almost all countries, healthcare costs are growing faster than the underlying economy, meaning an increasingly large proportion of national wealth and income must be devoted to healthcare. And this, of course, is a political problem.
Isabel Hardman’s Fighting for Life is a kaleidoscopic history of the NHS, subtitled “Twelve Battles That Made our NHS and the Struggle for its Future”, published to coincide with the organisation’s 75th anniversary in July. She tells us that “the history of the NHS is the history of British society” and explains that the book is necessarily selective. She focuses on the politics and politicians of the health service, interspersed with accounts of clinical developments such as heart transplantation, in vitro fertilisation and joint replacements. She also describes the Covid pandemic and some of the scandals, such as the one at Stafford Hospital over geriatric care and those at several maternity units. That the NHS now spends more than twice as much on litigation and compensation over obstetric negligence claims than on maternity care itself is proof that something has gone seriously awry with at least one part of the NHS.
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We learn of how the NHS was not entirely Aneurin Bevan’s creation but originated with people and organisations now largely forgotten, such as Dr Edith Summerskill and the Socialist Medical Association, and of course William Beveridge, a Liberal. It was fiercely opposed at first by the British Medical Association (BMA), which regularly appears throughout the book as a major thorn in the flesh of the politicians trying to change things. We also learn how the much-reviled Enoch Powell was an effective health secretary, and largely responsible, alongside the chief medical officer George Godber, for building the many district general hospitals that became the backbone of the hospital system.
[See also: The sick society]
From the very start, funding was a problem. As Hardman points out, creating the NHS had been about improving not the quality of healthcare, but access to it. It was rapidly swamped by the large numbers of people previously unable to afford healthcare and Bevan was quickly embroiled in arguments with his Treasury colleagues over money. This problem has continued ever since, driven by demographic change and the expense of ever-improving medical technology. With the exception of the New Labour years, the UK has consistently spent less on healthcare than countries we would like to consider equals, such as the Netherlands, France and Germany. By the time Margaret Thatcher became prime minister in 1979 the service was dilapidated and severely overstretched.
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Thatcher’s solution was to introduce management, as recommended by the Griffiths Report of 1983. Before Thatcher the hospitals had been run by “consensus” – essentially a senior doctor, a senior nurse, and perhaps a manager of some kind. Roy Griffiths, a director at Sainsbury’s, famously observed that if Florence Nightingale went with her lamp into an NHS hospital, she would have difficulty finding anybody in charge. The report, Hardman tells us, had “a huge cultural impact on the NHS… not all of it was positive”. Thatcher enthusiastically claimed, showing an ignorance about healthcare that I find painful to contemplate, that these reforms would make the NHS so good that nobody would seek private treatment. The wishful thinking that management, with the later addition of competition and the internal market, would turn everything to gold reached its apotheosis with the coalition government’s Health and Social Care Act 2012, led by the Conservative health secretary Andrew Lansley, which contained reforms generally regarded as little short of disastrous.
The Labour governments of Blair and Brown did not entirely reverse the move towards competition, but they greatly increased expenditure on the NHS and introduced performance targets. In 2000, Tony Blair bounced Gordon Brown on the David Frost TV show by unexpectedly announcing this increase without telling Brown in advance. “The New Labour era,” Hardman tells us, “led to huge improvements… [but] also contributed to a bullying culture that still hangs over the health service like a bad smell today.” The NHS had the best overall score in an international comparison of healthcare systems published in 2014 by US think tank the Commonwealth Fund. It has been a story of terrible decline since then, exacerbated by the pandemic. As the NHS struggles with 14 years of austerity, the talk now is of integration and cooperation rather than of the market-driven incentives and efficiencies of competition beloved of economists, that apply poorly to health and social care.
If Isabel Hardman’s top-down view of the NHS at times feels a little like Hamlet without the ghost, Phil Whitaker’s What is a Doctor? remedies the absence with a powerful account of what has happened to the bedrock of the NHS, the GP system. Hardman recounts battles, Whitaker – a novelist, GP and the New Statesman’s medical editor – gives us a series of subtle and graphic stories that illustrate the complexity of the doctor-patient relationship and of modern medical practice at the ground level. He decries the transformation of evidence-based medicine – an undoubted good – into evidence-dictated medicine, where guidelines morph into targets and polypharmacy (individual patients taking multiple medicines simultaneously). He shows how the algorithms of the emergency 111 telephone advice line are a poor substitute for an actual doctor and have led to a flood of unnecessary referrals to A&E departments.
There are many further such examples that demonstrate how cost-cutting reform without extra investment easily leads to greater expense. The book is essential – and highly readable – for anybody who wants to understand what has gone wrong with the national GP system, and what can be done to renovate it, with a return to the “family doctor” who knows her or his patients. An extraordinary recent study from Norway has shown that patients who have been cared for by the same doctor for many years have a 25 per cent reduced mortality compared to those who do not.
The way the NHS is funded means that there is a simple trade-off between low taxation and quality of healthcare. Politicians are loath to explain this to the public, and all too often promise to improve healthcare by reform without raising taxes. It is nonsense, for instance, for Wes Streeting, the shadow health secretary, to claim as he did recently that the NHS will die without reform. The NHS will not die or collapse, nor will any government ever seek to “privatise” it. Politicians of all persuasions know that it is far too popular with the public, despite its present failings. The lesson from these two books is that reform without investment will only lead to further deterioration and the exacerbation of the great inequalities in health that are already such a problem in Britain.
Fighting for Life: The Twelve Battles that Made Our NHS, and the Struggle for Its Future
Isabel Hardman
Viking, 384pp, £20
What Is a Doctor?: A GP’s Prescription for the Future
Dr Phil Whitaker
Canongate, 320pp, £16.99
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[See also: How to save the NHS]
This article appears in the 21 Jun 2023 issue of the New Statesman, The AI wars