In September this year two reports appeared on the state of the NHS. The Institute for Public Policy Research (IPPR) had been researching this topic for three years and was able to publish a report that not only scrutinised clinically the service, but was able to produce a whole series of suggestions as to how matters could be improved.
Taking the latter point, the IPPR report was able to give the hope of a better future – indeed its report was entitled ‘Our greatest asset’. The thrust of the report was the suggestion that investing more in health would make a significant contribution to economic regeneration.
The second report to emerge was commissioned in July this year, following Labour’s general election victory. The new health secretary, Wes Streeting, asked the eminent surgeon Lord Ara Darzi, to carry out an urgent review, which was presented in mid-September. (Since Darzi had also been closely involved in the IPPR report, unsurprisingly there is a deal of commonality in their conclusions of the state of the NHS). Clearly this second report had a political purpose and Darzi was able to provide a store of evidence that things were very bad and that the Conservative government had mismanaged and underfunded the NHS over a 14 year period.
Just how bad are things at the NHS?
The IPPR report states:
“The number of people with long-term conditions is rising and people are spending longer proportions of their lives in poor health… the nation’s health challenges have reached historic proportions.”
Since the Covid pandemic 900,000 potential workers have gone missing from the UK workforce. If those 900,00 had been in work, then tax receipts would have been £5bn higher.
A strength of the IPPR report is the use made of international comparisons. It takes the seven G7 countries and compares the UK with France, Italy, Germany, Canada, Japan and the USA. Six criteria are used, and the UK ranks sixth out of seven on five of those criteria: we are second bottom of the league table on life expectancy, health spending, avoidable mortality, obesity and the Gini coefficient (the latter is a measure of income inequality). As regards proportion of children in relative poverty, the UK ranks fifth.
Further impacts
“Britain is also getting sicker in absolute as well as relative terms. The UK is experiencing a sharp rise in the prevalence of many long-term conditions. This is not solely about the population ageing: indeed children, teenagers and working age people are also getting sicker, as well as people in retirement.”
Queues for treatment have lengthened dramatically. Taking 2011 as our base, compared with that year the number of people today waiting more than 18 weeks for treatment has risen thirteenfold.
What has caused this crisis of the NHS?
There are several factors that have driven the NHS into a downward spiral; four key ones are long-term underfunding, the Lansley Reforms, Brexit and Covid.
Since 1980 government spending on health as a proportion of GDP has risen in most countries. This has been due to demographic changes (ageing populations) and developments in medical technology. These are not cheap. In 1980 UK spending on the NHS was 5% of GDP and by 2010 this had risen to 10%. By 2019 (pre-pandemic) this was required to rise to 12% of GDP to maintain standards but in the event remained flat.
Spending and budgets
As his contribution to the austerity policy Jeremy Hunt chose to ‘run the NHS hot’ – meaning ‘close to capacity’ and on a tight shoestring. Another aspect of budget cuts was the nearly 50% reduction of central government funding to local government. Since local government was responsible for public health, a significant prop for the NHS was weakened as public health spending was reduced.
Mark Dayan, policy analyst at The Nuffield Trust, has written: “The service remains strapped for cash, and through much of this period invested a strikingly low amount in equipment and buildings compared to other systems globally.”
A disastrous Act
Lansley as the coalition’s health secretary drove through parliament an act to greatly change the organisational structure of the NHS, a main theme being to make greater use of competition within the model, together with scope for wider use of the private sector in health provision. The Darzi Report for Streeting concluded that “the Health and Social Care Act of 2012 was a calamity without international precedent – it proved disastrous”.
Darzi goes on: “The result of the disruption was a permanent loss of capability from the NHS.” The act was “an important part of the explanation for the deterioration in performance of the NHS as a whole … Rather than liberating the NHS, as it had promised, the Health and Social Care Act 2012 imprisoned more than a million NHS staff in a broken system for the best part of a decade”.
Broken Brexit benefits!
Famously the Vote Leave campaign asserted that leaving the EU would allow the NHS to benefit by £350mn per week from money saved by not being in the EU. Mark Dyan takes that as his starting point and goes on to show that not only did the money not arrive, but almost every other impact of Brexit was adverse.
For a start Brexit led to a number of EU citizens employed in the NHS leaving to return to the continent. Writing in February 2023 Dyan reports “a virtual stalling of the flow of new nurses arriving from the EU and EFTA countries”. The NHS had got caught up in the vice of governmental “domestic short-termism… many key staff groups were in serious shortage seven years ago, and many still are”. Particular specialisms identified by Dyan as hit by staff shortages include heart and lung surgeons and also psychiatrists.
A second adverse effect was that of loss of access via the single market to supplies of medicines. “We nonetheless found clear signs that the UK has faced elevated shortages to some extent since 2016”, Dyan reports. Overall he concludes:
“Leaving the European Union dealt unfortunate blows to structural weak points which already existed in staffing and financing, and created a new weakness which would later be exacerbated by global shortages in medicine supplies.”
By the time Covid struck in the UK the NHS was already in an overstretched state. Underfunded for ten years, too little investment in equipment or estate and with a chronic staffing crisis it was already close to being on its knees. The current Covid enquiry is uncovering a series of policy disasters that led to the NHS lacking the resilience exhibited by other nations’ health systems. In June 2020 BBC news reported:
“The UK currently has the third highest number of recorded coronavirus deaths in the world. Only the United States and Brazil have had more, and both countries have far bigger populations.” Having to respond to the pandemic has proved a drag anchor on any attempt to move the NHS forward.
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