The NHS in crisis

Before the end of the Warsaw Pact, when Eastern Europe had Communist regimes, I visited countries in that part of the world several times (USSR, Poland, East Germany). The British Embassies in their capitals always inspired me with pride. They advertised two of our greatest 20th century social innovations: government-funded university education – tuition fees and support grants – for everyone who qualified for university entry; and the National Health Service (NHS), which was dedicated to providing health care to all UK residents “free at the point of delivery”. In those two regards, Britain led the world.

Not much remains of that pride. Free university education is now a thing of the past and the debt burden on modern-day graduates is a matter of growing concern. As for the NHS, it is still providing health care free at the point of delivery, but it won’t do so for much longer. The reasons are well known: a growing population; demographic change (we have a lot more people over pension age); medical advances that enable us to cure or ameliorate conditions that defeated us a mere decade or two ago, but at great financial cost; etc. Everyone working in health care in Britain tells the same story: they’re under-resourced. Not enough money, not enough staff. The NHS is creaking and crumbling.

The staffing issue has been exacerbated by the failure of the relevant systems to provide properly-trained home-grown practitioners (doctors, nurses, and specialists such as midwives and physiotherapists) in adequate numbers, and by the low pay and long hours that have compelled many nurses (and others) to seek different employment. More recently, it has also be aggravated by the departure of many excellent doctors and nurses from other European countries, who are unsettled by the potential implications of Brexit. As for “not enough money”, Britain now spends relatively less on public health care than do other wealthy nations. A government devoted to a policy of “austerity” has ensured that.

There’s also the problem of social care. Some patients, particularly the elderly, need help and support when they leave hospital – or to prevent them from needing hospital residence in the first place. For the most part, such social care is provided by local councils. Local councils have been starved of money because of central government’s “austerity” policy. Ipso facto, social care has been cut. As a result, we see “bed-blocking”. Patients who are in principle fit to be discharged from hospital can’t leave because there’s no care for them in the community apart from what family can provide, and in many cases professional care is needed. Also, many carers, like nurses, are leaving for other careers because they’re overworked, underpaid and undervalued.

It is high time that the NHS was rethought. No one loves and respects the principle of the NHS more than I do. I worked for it and I value it highly. As I said at the start of this blog, it was always a source of pride for me when I visited other countries. During the 1960s and ’70s it worked superbly well. By the ’80s it was starting to struggle, partly because of the increasing demands for the reasons aforementioned and partly because of constrained government support. It’s been mostly downhill since then, notwithstanding the best intentions of at least some of those in authority.

Some of the things that need to be done are well established and widely discussed: we need to integrate all aspects of health and social care far more smoothly and efficiently than we’re doing at present (though some health authorities have made commendable efforts in that direction); we need to increase resources; and we need to focus those resources better, for instance by reducing the number of administrative rather than medical staff. Changes in these directions will assuredly help. But the problems of the NHS are, sad to say, more profound.

When the NHS was established in 1948 it rested on three particular assumptions, which seemed valid at the time and during the decades that followed but can now be seen as flawed; yet they’ve never been explicitly challenged. The first assumption was that as free health care at the point of delivery improved the health of the population, the demands on the system would diminish. In the event, expectations have increased, people live longer, and the demands have actually increased. The second was that the specific new tax introduced by the government, National Insurance, would pay for the public expenditure on health care. Of course, as the demands have increased, the costs have far outstripped what National Insurance could cover, so money to finance the NHS has in effect been taken from other government ministries – and it still isn’t enough. The third was that there would be no great change in the demographic structure of the population over the years to follow. In the event, changes in birth rate and life expectancy have refuted that assumption, and so, independently, has net immigration.

Pumping more money into the NHS will help the current crisis and almost everyone agrees it should be done. But it isn’t a long-term solution. For that, we need not only to consider smoother integration of the different aspects of health care, and to ensure a better focussing of resources, but also to review the founding assumptions of this wonderful and threatened organisation. We have to reconsider them critically. Future health care for our population depends on squaring a circle: maintaining the principle of the NHS while replacing the three basic assumptions with more realistic and up-to-date alternatives.


  • Hi Mark

    I think we all agree that the NHS is in crisis and that changes to integrate health and social care are long overdue. However, while you recognise the effect of ‘austerity’ policies and the need for more money you could have quantified the impact. Nor do you mention the privatisation of provision taking money out of the system to fund payouts to CEOs and shareholders. Then factor in the constant organisational change that is under-mining efficient provision and costing billions to implement.

    I believe it was Justice Oliver Wendell Holmes that said “Taxes are what we pay for civilized society …”. Too many people seem to want a civilised society without being prepared to pay for it and I include here many of the internet giants such as Amazon, Apple and that’s just the As. We spend relatively little on our NHS compared to similar countries. The average across the original 15 EU members was 10.1% of GDP in 2013 while in England it was 8.5%. It placed us 13th out of the 15 and raising us to the 10.1% average would have generated over £20 billion for the NHS. If France, Germany, Belgium, Denmark etc can find the money then why can’t the “fifth” largest economy in the world? Even the OECD average (excluding the USA) is 9.1% of GDP.

    What a government chooses to spend on healthcare is a political choice and this government is under-funding the NHS using the cover of “austerity”. Unfortunately, the people seem to have become conditioned to think that paying taxes are bad driven by a largely right-wing main stream media rather than the price we pay for being a part of a civilized society.

    • Fred, I couldn’t agree more strongly with you, but I was trying not to write too long a script. Nevertheless I take your point: I could have included numbers, and thanks for providing them in my stead.

      I believe the combination of austerity politics and Brexit is part of a plan to turn Britain into a low-tax, low-investment haven for capitalist exploitation, and I think we’re three quarters of the way there already. The exploiters aren’t interested in public health care because they can afford the private variety.

      Of course, Oliver Wendell Holmes was right. But as you say, the right-wing press would annihilate any British politician who suggested raising income tax. And multinationals can never be compelled to pay what they ought.

  • Health care is quite a topic across the pond.You have reason to be proud and I certainly hope the NHS is able to patch its crumbling walls whether by taxes or other means.

    If you have listened to much of the news from the USA, you’ve no doubt heard the term ‘Obama Care’. I don’t know much about the details (by choice – I would get irritated and want to slap someone and slapping people is frowned upon). What I do know is, I have friends who, under Obama Care, cannot afford insurance any longer, and because of this, they get fined at tax time. They choose to pay the fine because it is less than the insurance. Deductibles are in the thousands. When I taught Personal Insurance to future insurance agents I would tell them to counsel their customers against settling for state minimum limits. The minimum limits would, for the most part, cover an aspirin and an x-ray. If the NHS solidifies their walls again, they could teach us a thing or two.


    • Obama Care was well intentioned and I understand it’s benefited some people, but as you point out, it’s harmed others financially and – crucially – in regard to health.

      The NHS has been a source of national pride on this side of the pond since its foundation in 1948, but our government spends a lower percentage of our GDP on the NHS than the governments of France, Germany and other European nations spend on health care. (Fred Pickford’s comment on this blog provided up to date figures, which I hadn’t mentioned.) A little more money would at least help to shore up the walls!

      • I think Obama Care helps those in significant financial predicaments, as in the case of those on Public Assistance. That is noble, but there was already a system in place. Now I have reached the end of my understanding of the topic, but to say that the wealthy purchase healthcare without difficulty. It seems to be those in the middle that get stuck, and unfortunately we are a large group.

        It is a pitty that taxes have gotten such a poor reputation. They are a necessary part of society, and I believe you and your friend, Mr. Pickford, have valid points. It almost persuades me to be more in tune with politics and health care reform. Almost. Perhaps when the laundry is done.


        • There’s a lot of what is commonly known as ‘political spin’ (i.e. misrepresentation and lies) to get through before one can understand politics, and the politics of health care is particularly sensitive to such terminological inexactitudes. But on the matter of taxes: yes, we do need to pay more for our public services, notably health. It’s a nonsense to claim that low-tax regimes benefit the poor. They don’t; they benefit the rich. And since the rich hold power, democracy being what it is, taxes remain low!

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