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One of the reasons the population is proud to be British is possession of the NHS. The way in which it was set up to provide health care without any restrictions on the ability to pay remains a concept that is worth protecting. It is why I do not go along with proposals to change the arrangement for funding to an insurance-based system.[i] Nor do I believe that privatisation, whatever that might mean, is acceptable. We would jettison the basic tenet of ‘free at the point of service’ at our peril. Since the NHS reached its 75th birthday in July 2023, and despite the many examples of excellent care, there have been calls for a complete reform of the way it is managed and funded.
One hears suggestions that the NHS is completely broken and that we should break it up entirely and start again with something new. I am not in that camp either. It’s too trite and not thought through.
But that the NHS is in trouble is clear, and it is increasingly seen as symptomatic of Britain’s general decline. It is ‘the central symbol of what is wrong with Britain today.’[ii]
As a nation, we seem to stumble from one crisis to another as we face the impact of Brexit, the Covid epidemic, and the invasion of Ukraine by Russia (with the subsequent inflation and energy problems that are increasing the cost of living). All of these distract governments and constrain their capacity to deal with the myriad difficulties facing the NHS. But we should not be deluded into believing that these recent pressures are the sole or even the main source of our difficulties. They had been building well before these recent problems.
Social and community care and the NHS have been in a slow, steady decline for many years. What is new is that the volume of complaints has been ratcheted up, and the recent strikes by health care professionals have simply served to emphasise the problems.
The size of the NHS is daunting, and the workload is huge. A million people attend general practice every day; that is almost 30 million attendees a month.[iii] Hospitals deal with about 250,000 out-patients every day and carry out ten million operations a year. Almost 45,000 attend major Emergency Departments each day.[iv] These are startling figures for a megalith service run as a single entity from central government. No surprise then that such large enterprises have proved extraordinarily difficult to manage or that they are failing.
What is remarkable is that despite these concerns, many in the population feel they are well cared for. But not everyone. The British Social Attitudes Survey found that only 29% of the population were completely satisfied with the service in 2022, a dramatic fall since 2010.[v], [vi]
Reports of the problems faced by the population may be accurate but fail to describe the innumerable ways in which patients benefit every day from high-quality expert care for much of the time. Individually, many people feel enormous gratitude to their doctors, nurses, and carers. It is the overall picture of services under extreme stress where the population at large, and individuals within it, are under pressure. It is hardly doubted that services are failing and in more significant ways than ever before.
The challenges for any government to rescue the NHS are huge. Pledges by the Labour Party are well meant, and the Conservative Government’s proposals are wordy, but both face huge barriers that will not be readily overcome. Both are constrained by limited resources and the difficulty of resolving the conflict inherent in devolving delivery of care while retaining responsibility on behalf of the taxpayer.
We have a long way to go as, for the first time in a century, since 2011, life expectancy has stopped rising.[vii], [viii] Not all due to a failing NHS, but it is clearly a contributing factor.
Too many patients are left drifting in a system ill-designed to meet their needs, and staff feel increasingly stressed as they recognise that – despite all their efforts – their NHS is failing to meet expectations.
The service has been designed around the needs of acutely ill patients who should be treated in hospital. That need should certainly be met, but it has been increasingly clear over several years that the much larger long-term needs of patients in the community have been sorely neglected. Patients with multiple morbidities, largely elderly, too often end up in hospital when their needs would be more suitably met within the community. It is primary care and, most obviously, social care that have been neglected in a damaging way. This is hardly a novel description of the current state of affairs. It has been the subject of repeated comments for years.[ix], [x], [xi], [xii]
Numerous questions arise as to how and why the NHS and social care are failing so badly in so many ways. It is not as if we are short of reports, books, papers or Acts of Parliament to tell us that all is not well.
Health Ministers and Prime Ministers from the past have queued up with their ideas about how to rescue it, happily seeming to forget their own roles while in office and that they bore some responsibility for the current parlous position.
It has been a persistent struggle to provide a National Health Service within limited resources. But each of the reorganisations and re-reorganisations have focussed on the management and structure of the service. We now, in 2024, have returned from a multi-year unsuccessful flirtation with several models of an ‘internal market’ with a ‘purchaser-provider split’, to an ‘integrated model’ last fashionable in the 1970s and 1980s. This La Ronde has been an inordinately expensive and distracting exercise that has ultimately seen the service on its knees.
Certainly, more could be done with more money, and the need is starkly felt – especially in social care. But money is far from the only reason for our failing services. The Government must bear some of the blame because it cannot resist the pressure to change the administrative structure every few years. The caring professions, particularly the doctors, are in part responsible, too, because of their seemingly passive acceptance of government edicts and their apparent resistance to change. Both have caused difficulties, but governments must bear much of the responsibility.
Staffing Issues
It is the staff on the frontline – the doctors, nurses, physiotherapists and other ancillary staff, plus community care workers – that patients rely on, and who face many difficulties. Their lot is a demonstrably unhappy one.
The strikes of 2023/24 were just the tip of an iceberg of despair. They were not only about pay but an accumulating disenchantment with working conditions and an awareness that the services they provide are inadequate. The overarching problem for patients is that there are too few active staff, and those who are left feel disaffected and sometimes unsafe. Demoralised staff can lose their humanity, and there are reports of the disturbing brutalising of care.[xiii]
Government-inspired recruitment drives make too little impact, while efforts to retain staff remain poorly effective. There is a hole in the bucket as disaffected staff continue to leave. And it is by no means due to poor pay alone.
NHS and Social Care Divide
Providing care in the community, funded separately, is even less able than the NHS to keep up with demand and is extremely confusing for those in need who try to navigate it. The aging population is putting greater pressure on the services offered at the same time as these services are shrinking. This says nothing of the even larger but uncertain numbers of unpaid carers looking after disabled or family members at home.
There is also a serious discrepancy between the ways in which the NHS and social care are each funded and organised (Chapter 2). The NHS is provided by the state, free at the point of service and available for all. Social care is mostly funded through local authorities but provided by privately owned establishments. And it is means-tested. While private funding of health care in the UK accounts for only about 14% of the total, almost half the funding for community care is derived from individuals paying privately; the remainder comes from local authorities. We thus have two distinct systems: a free health service and an almost entirely privately owned social care arrangement, means-tested, and subject to market forces with no national plan for the distribution and availability of its services. Little wonder then that, despite much brow-beating, a way in which these two disparate services may be integrated has proved so elusive.
Governments of different persuasions have, over the years, made much of the need for ‘patient choice’ and making the NHS more open to patients’ wishes.[xiv] However, it has become clear that there are few if any options open for patients from which they can choose. Unless, of course, they choose to opt for private care. It is of interest that a survey of patients seeking private care revealed that many of them had tried to gain NHS treatment before doing so.[xv] You might suspect that the NHS was failing in its efforts to offer choice despite the NHS Constitution enshrining patients’ rights in law.
International comparisons
The UK lags behind most other OECD countries across many measures. We have higher mortality rates for cancer and other major diseases, fewer doctors, nurses, hospital beds and scanners, and the proportion of our GDP spent on health care per head of population is less than many.[xvi] The usual sense is that the health and social care services are underfunded for what is expected of them.[xvii], [xviii]
The NHS cost 7.3% of GDP in 2019-20; that is about 19% of total public expenditure, representing £164.1 billion. It had been about 7.0% to 7.4% of GDP for at least ten years before that.[xix] Seventy per cent of this expenditure is accounted for by salaries for the almost 1.4 million staff in the NHS.
In the EU, our neighbours spent rather more. The average day-to-day health spending in the UK between 2010 and 2019 was £3,005, which is 18% less than the EU14 average of £3,655.[xx] If UK spending had matched the EU14 average, it would have been £227 billion per annum from 2010 to 2019, which is £40 billion more than the actual spend.[xxi]
Matching actual spend to that of France reveals a shortfall of about £40 billion, and compared with Germany a huge £73 billion shortfall, (a 21% and 39% difference in funding). In 2019-20, Germany spent 11.7% of GDP, France, 11.1%, Italy, 8.7%, Netherlands, 11.1%, Norway, 10.5%, Sweden, 10.8%, Canada, 11.0%, while the USA was off the scale at 16.7%.
Even though comparisons are not exact, as there are differences in how GDP is calculated, we have spent a smaller proportion of our wealth on health care than many similar democracies. And our total wealth is smaller. The event that markedly distorted these figures was the outbreak of Covid between 2019 and 2022. An explosion of untrammelled funding to control the epidemic in the UK resulted in a dramatic rise in NHS funding to £218.6 billion in 2020-21 and £216.8 in 2021-22 to be spent on emergency measures against Covid.[xxii] That is, 10.2% and 9.1% of GDP and about 20% of total public expenditure. Similar, if smaller, responses were seen in EU states. These remarkable increases were never likely to be sustained, and in 2022-23, spending was back down to £160.4 billion.
The situation in capital funding for buildings and estates is no better. If the UK had matched EU14 average capital investment, it would have funded 55% more cash than the £5.8 billion a year that the UK spent from 2010 to 2019.[xxiii]
It is little comfort to know that most countries across Europe are now struggling with similar, if not as severe, problems. The adverse demography of ageing populations coupled with overworked medical and nursing staff are causing pressures in Germany, France, Italy and Spain.[xxiv] Israel, long seen as an exemplar of health care, is suffering from shortages of medical and nursing staff and community carers.[xxv] Many medical staff in these countries are leaving their service, and fears are rising about the increasing costs of health care. Knowing that we are not alone does not help, but suggests that solutions will not be easy, will require very hard decisions, and will need to be shared by others. They will undoubtedly have to be based on a greater acceptance of the likely costs and sacrifices, and a determination to meet the challenges head-on.
Both the NHS and social care are huge enterprises, and that they are failing to keep up with demand is increasingly borne by everyone.
A discussion of the reasons why they are failing and the impact they are having on the population is an uncomfortable exercise. In the following chapters, I explore the issues we face and offer some suggestions as to how they might be tackled.
Summary
The founding principle of the NHS – that it is free, regardless of ability to pay – is well worth preserving. But despite many examples of excellent care, patient care is failing to meet the demands placed on it across the broad field of social and community care, primary care, and secondary care. The causes of failure are multiple and not all due to lack of funds, although that is certainly significant. Poorly motivated staff are too frequently unable to meet their patients’ needs. Local authorities can barely afford to support care in the community, and the split between the NHS and social care damages efforts to encourage collaboration.
These are some of the issues that face patients today. They are the subject of more detailed examination in the following chapters.
I begin with how we provide care for the elderly and the needy in the community because it is here where – if we get it right – so many of the problems we face in the NHS are likely to be eased.
[i] Britnall, M., In Search of the Perfect System, Palgrave MacMillan, London, 2016.
[ii] Marr, A., The New Statesman, 26 May 2023.
[iii] Trends in Patient-to-Staff Numbers at GP Practices in England: 2022, Office of National Statistics, 9 December 2022.
[iv] A&E Attendances and Emergency Admissions 2022-23, NHS England, March 2023.
[v] British Social Attitudes, NHS and Social Care, National Centre for Social Research, 2022.
[vi] Morris, J., Schlepper, L., Dayan, M., Jeffries, D., Maguire, D., & Merry, L., Public Satisfaction with The NHS and Social Care in 2022, King’s Fund Report, 29 March 2023.
[vii] National Life Table – Life Expectancy in the UK, Office for National Statistics, 2020-2022.
[viii] Raleigh, V., What is Happening to Life Expectancy in England? King’s Fund Report, 9 August 2022.
[ix] House of Lords Debate on The Future of Adult Social Care, Hansard, Column 358, 30 March 2023.
[x] A “Gloriously Ordinary Life”; Spotlight on Adult Social Care, House of Lords, Adult Social Care Committee, Report of Session 2022-23, 8 December 2022.
[xi] An Ageing Society Cannot Turn its Back on Social Care Any Longer, Financial Times, 10 June 2023.
[xii] The State of the Adult Social Care Sector and Workforce in England, Key Findings 2022/23, Skills for Care, October 2023.
[xiii] Mind Reveals True Extent of Crisis in Mental Healthcare with More than 17,000 Reports of Serious Incidents in Past Year Alone, Mind, 10 October 2023, https://www.mind.org.uk/news-campaigns/news/mind-reveals-true-extent-of-crisis-in-mental-healthcare-with-more-than-17-000-reports-of-serious-incidents-in-past-year-alone/
[xiv] Your Choices in the NHS, NHS, 10 May 2023.
[xv] One in Eight Britons Pay for Private Health Services, Survey Shows, The Guardian, 17 April 2023.
[xvi] Anandaciva, S., How Does the NHS Compare to The Health Care Systems of Other Countries? King’s Fund Report, 26 June 2023.
[xvii] Rebolledo, I., & Charlesworth, A., How Does UK Health Spending Compare Across Europe Over the Last Decade? The Health Foundation Report, 16 November 2022.
[xviii] Health Services in Western Europe, Office of Health Economics, London, 1963.
[xix] Rebolledo, I., & Charlesworth, A., How Does UK Health Spending Compare Across Europe Over the Last Decade? The Health Foundation Report, 16 November 2022.
[xx] Rebolledo, I., & Charlesworth, A., How Does UK Health Spending Compare Across Europe Over the Last Decade? The Health Foundation Report, 16 November 2022.
[xxi] Anandaciva, S., How Does the NHS Compare to The Health Care Systems of Other Countries? King’s Fund Report, 26 June 2023.
[xxii] Europe Struggles to Revive Health Services after Pandemic, Financial Times, 10 May 2023.
[xxiii] Rebolledo, I., & Charlesworth, A., How Does UK Health Spending Compare Across Europe Over the Last Decade? The Health Foundation Report, 16 November 2022.
[xxiv] Europe Struggles to Revive Health Services after Pandemic, Financial Times, 10 May 2023.
[xxv] Israel Facing Acute Shortage of Physicians, Jerusalem Post, 2 June 2023.