It is hard to know whether we are celebrating a birthday or conducting a wake. As the country prepares to mark the 75th anniversary of the NHS, public satisfaction has slumped to its lowest level (29 per cent) since the British Social Attitudes (BSA) survey began 40 years ago. The proportion of respondents expressing explicit dissatisfaction is also the highest it has ever been – 50.5 per cent – just pipping the previous record of 50 per cent in 1997, when the Conservatives were swept away by Tony Blair’s landslide election victory.
Yet the NHS’s current catastrophic collapse is not due to doctors, nurses, paramedics, physiotherapists, caterers, cleaners or porters having become lackadaisical in their duties. Nor is it Covid, which merely poured petrol on a fire that was already blazing. The cause of our crisis – and the suffering, disability and premature deaths that are the real-world consequences for so many – is politics.
The creation of the NHS was an intensely political act, a determination on the part of the postwar Attlee government to extend high-quality healthcare to every man, woman and child, free at the point of need. The prospect of a publicly funded health service was resisted by many in the medical profession at the time. Undoubtedly there was self-interest at play: what would be the impact on their earning power and standards of living?
Yet there was also a deeper fear, of the state interfering with the practice of medicine itself. Writing in the British Medical Journal in 1948, the then minister for health Aneurin Bevan assured the profession that, “My job is to give you all the facilities, resources and help I can, and then to leave you alone as professional men and women to use your skill and judgement without hindrance.”
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That sentence contains the twin clues as to the damage that politics has inflicted since. The question of resources is the more obvious one. Within a year of its launch, the cost of the new NHS was spooking some in government, and after bitter cabinet infighting, fees for some dentistry and optician care were introduced. Prescription charges followed in 1952, but despite certain exemptions they remained contentious, being first increased, then abandoned, then re-introduced with wider exemptions in 1968.
The battles and messy compromises involved in levying direct patient contributions have made this a no-go area ever since. Yet the early expectation – that once the new NHS had dealt with the pent-up need in the population, activity and costs would settle – was quickly revealed to have been very naive.
We are mortal biological organisms, and curing or controlling any of the myriad afflictions that can strike us simply creates the opportunity for others to develop. Meanwhile, medical science continues to advance at an astounding rate, generating ever more potential interventions, invariably with hefty price tags. Healthcare spending appears to have an inbuilt, irresistibly upwards momentum – something seen in countries around the world.
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With further direct patient contributions anathema to the NHS’s founding principles, political focus has for a long time been concerned with getting the most out of whatever budget the government of the day was prepared to allocate.
In 1983, Margaret Thatcher commissioned Roy Griffiths, a director and deputy chairman of J Sainsburys plc, to report on health service management. He found an NHS characterised by hospital fiefdoms competing with one another to accrue resources for their own departments, with no one setting or delivering objectives for the system as a whole. Griffiths’ pithy summation quickly became famous: “If Florence Nightingale were carrying her lamp through the NHS today, she would be searching for the people in charge.”
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The report ushered in a new era of professional management. From the outset, Griffiths insisted that senior clinicians be involved. Healthcare is highly complex and it takes practitioners many years to develop the knowledge necessary to make secure judgements. The new breed of manager would have expertise in running large organisations; but system improvements also had to take account of clinical imperatives.
It wasn’t enough for Thatcher. While acknowledging the political impossibility of replacing the NHS with a private model, she believed that competition would drive greater efficiencies. In 1990, her health secretary Ken Clarke legislated to introduce an “internal market”, in which “providers” such as hospitals would vie to win “business”. The “purchasers” would be GP practices, given control of their budgets to buy care for their patients. GP fundholding was introduced in waves, but even at its peak only half of practices had signed up. Fundholders wrought shorter waiting times for those requiring hospital care, and brought innovations such as in-house physiotherapy. Patients of non-fundholding practices started falling behind; the NHS was becoming “two-tier”.
Despite these radical reforms, the internal market failed to achieve meaningful results; when Tony Blair assumed office in 1997, waiting lists and public dissatisfaction were sky-high. He swiftly stopped GP fundholding and declared the Tories’ internal market dismantled. But the purchaser-provider split was maintained, and New Labour went further than Thatcher had ever dared.
Under Blair, the iconic blue NHS logo became a mere franchise. The private sector was offered lucrative contracts to set up treatment centres, and to take over community services such as district nursing and health visiting. Every local health area was compelled to host a “Darzi centre”, a new-model GP surgery with extended opening hours, funded by payments far in excess of those received by traditional neighbouring practices. When the 2004 GP contract transferred responsibility for out-of-hours services from family doctors to local health managers, the process of commercialising this huge swathe of primary care provision was set in train.
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The New Labour initiatives brought mixed results. The increased capacity for elective procedures played a crucial part in bringing waiting lists down to historically low levels, and the years immediately following the 2004 contract saw a renaissance in general practice. Both access and timely treatment improved, leading to unprecedented levels of public satisfaction (70 per cent) in the BSA survey by 2010.
Yet behind the scenes, competition centred on relentless cost cutting, and quality in many services began to decline. Frequent changes of contract-holder exhausted the goodwill of staff who for decades had been the NHS’s secret power supply. (The downsides of competition led eventually to the policy being abandoned in 2019, in favour of a return to collaboration between different parts of the system.)
Faced with upwards momentum in spending and the economic fallout from the 2008 crash, the Cameron coalition government looked for another way to square the circle. The answer seemed to be a shift away from hospital-based activity and a relocation of as much care as possible in the community. Not only would this reduce costs, it would be more holistic for the complex, multi-morbid patients who so frequently found themselves admitted to wards geared to treating single-disease episodes.
David Cameron tried to drive the intended transformation through resource starvation, anticipating that this would force the NHS to adapt. It was disastrously ill-judged. Capacity in primary care and community services withered as managers sought to find savings. The result was to send ever more patients into hospital, sucking resources into secondary care. The NHS was transforming, but in precisely the wrong direction.
This was compounded by a second, more subtle problem. Think back to Bevan’s promise in 1948, “to leave you alone as professional men and women”. That pledge was first subverted by New Labour’s 2004 GP contract, which began powerfully to compel the prescription of pharmaceuticals – with their associated on-costs of repeated testing, monitoring and clinician time – in the cause of disease prevention.
Increasing amounts of general practice are consumed in doling out pills, to the detriment of inexpensive lifestyle measures, and frequently against doctors’ better judgements. This trend has accelerated under Conservative-led administrations, with their ideological abhorrence of public health approaches to disease prevention, derided as “nanny statism”.
Meanwhile, successive Conservative governments have reneged on manifesto commitments to match GP numbers to the growth in population and medical complexity. This has been a deliberate neglect, predicated on the belief – widespread among policymakers who have no understanding of the importance of expert medical generalists – that family doctors are an expensive luxury whose role can be carved up among cheaper allied health professionals.
We’re now down by some 8,000 GPs – around a quarter of the minimum required workforce. Healthcare needs don’t disappear because there are insufficient doctors: they flood into hospitals and emergency services, exacerbating stresses elsewhere in the system, at hugely inflated costs.
The current government has abandoned any hope of resolving the mess it’s created. The Chancellor, Jeremy Hunt, following his distinguished spell as chair of the Commons’ Health and Social Care Committee, has a better grasp of what needs doing than any politician currently in high office. Yet the sound of inaction is deafening.
What do we need from an incoming administration? The same BSA survey that enumerated today’s dissatisfaction showed that the NHS founding principles remain strongly supported. As Dan Wellings, a senior fellow at the health think tank the King’s Fund, put it: “The public do not want a different model of healthcare; they just want the current model to work.”
How do we make this happen? Bevan provides the steer, and history reinforces the lessons. First, provide the resources. Alongside its reform programme, New Labour raised healthcare spending to match the average of comparable developed countries. Notwithstanding the non-recurrent sums pumped in during the pandemic, our percentage of GDP spent on health has once more slumped near the bottom of the league.
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Reform is also sorely needed, but for too long patients and professionals have suffered the consequences of politicians with no background in healthcare determining the next direction the NHS should take. Roy Griffiths’ insight here is key: policy makers must engage meaningfully with experts in what is a fiendishly complex field.
I hesitate to fall back on that easy trope, the Royal Commission, but at the very least an incoming health secretary should sit down with bodies such as the Royal Colleges, the British Medical Association and the Royal College of Nursing, and, crucially, the Patients Association.
Yes, there will be competing perspectives and vested interests, but all want to see the NHS providing world-class care once again. Whatever reforms might be enacted, the micromanagerial targets and adversarial inspections of the past 20 years must be replaced by a culture of broad objectives and supportive oversight. It is time to liberate staff to deploy their creativity, training and experience – without political hindrance – to do the job they want to do.
[See also: Labour NHS mission: Will Keir Starmer’s plan work?]
This article appears in the 28 Jun 2023 issue of the New Statesman, The war comes to Russia