Figures released recently show that up to 100,000 patients have been left waiting in ambulances outside hospitals for at least half an hour so far this winter in Britain, due to overcrowding in A&E departments, with many among them waiting over an hour. Following the cancellation of thousands of non-urgent operations earlier this month, these figures highlight the extent of the problems faced by the National Health Service. Though winter is typically the most testing time of year for the NHS, the scale of this years’ issues has been largely unprecedented.
The NHS enters its 70th year in the midst of one of the most severe crises in its history. It could be argued that the NHS has been in a constant state of crisis for as much as two years, but with so much else to occupy journalists and hold the public’s attention, its perils are only covered during comparatively slow news cycles.
The NHS faces a number of problems, and the severity of this year’s winter crisis is attributable to a long list of factors, with staffing levels and funding at the top of that list. Questions of funding, at least, are nothing new. Since its inception, Britain’s National Health Service has been an incredibly costly venture — at the time of undertaking it was the most significant amount of government spending ever allocated: £437million in its first year.
Many of the arguments put forward by those who opposed the NHS 70 years ago are still being used by its opponents today, but the NHS remains perhaps Britain’s proudest achievement and is held up as a shining example by proponents of nationalised healthcare all over the world. Even now, its existence suggests that — at least in terms of healthcare — Britain is a country that cares for all, regardless of their financial situation. But the NHS faces a gravely uncertain future. To guarantee its survival, politicians may need to look beyond partisanship and short-term political point scoring, to work on real solutions.
After World War II, something of an awakening went on across Europe, and Britain was no different. Thousands returned from war with a fresh outlook and a determination to create a better world than the one that so much had been sacrificed to preserve. After such horrific loss came introspection; people came around to the view that good health should be a universal right, not just one for those who could afford it.
At the time, Britain’s hospitals were run either by charities or by local authorities; those in work could get treatment at a cost, but for many, that cost was too great. And for those below the poverty line, arguably the most in need due to their dreadful living conditions, healthcare simply was not an option.
It was Clement Atlee’s Labour party, elected in 1945 on a manifesto of sweeping social reform, who introduced the National Health Service in 1948 based on four core principles — the same principles that underpin its function today. They are:
1. Free at the point of use
2. Available to all who need it
3. Paid for by general taxation
4. Used responsibly
Though it was Atlee’s government, it is Aneurin “Nye” Bevan who is rightly credited with its creation. A much-loved socialist and head of the Labour party’s leftmost MPs, Bevan came from an impoverished Welsh family and had become involved in politics during the 1926 General Strike, as the de facto head of the influential South Wales miners.
These four principles were Bevan’s, and he fought fiercely to stick to them, winning out in many battles against his own party, the opposition and the medical profession to preserve them. He would later resign from government after the introduction of fees for dental and spectacle prescriptions, which he saw as a diversion from these principles, but would pave the way for the introduction of more fees (a fear hard to consider unrealised).
Though overwhelmingly popular now, at the time, the National Health Service faced much opposition. The line of thought among Tories and the conservatives was that the feckless poor would take advantage of the service and overburden it almost instantly. Doctors too had their serious reservations; the thought of working directly for the government worried many in the medical profession, and since the war, the pay of doctors and nurses had bottomed out. The feeling was that it would only continue to decrease post-NHS.
After an initial surge in use, which was likely attributable to a backlog of illnesses among the poorest, it began to look as if the NHS might fail, as predicted, due to the high cost. Whether it was the balancing out of a backlog, Atlee’s pleas not to overburden the service during a national address, or the introduction of dental and spectacle fees, costs did fall to forecasted levels within a few years, and the service has remained since.
Despite criticisms that the current government doesn’t spend enough on the NHS, it is also true that a lot of money is being spent. In 2017/2018, the figure will be around £143 billion, or 18% of all government spending, making it the second-largest single government expenditure, narrowly topped by pensions, at 20%. The amount of funding received by the NHS has increased year-by-year, though in recent years the amount by which it has increased has dropped.
Between 1955/1956 and 2015/2016, the average annual growth in per-person spending, accounting for inflation, was 3.7%, whereas the average from 2009/2010, when the Conservative government took over, is only 0.6%. So, while it’s true that the government technically spends more on the NHS every year, the question remains as to whether that increase — considering inflation, rising cost of treatment and an expanding population — is enough.
The opinion of many on the left, as well as a large section of the medical profession, is that it is not. The difficulty in this is that it is possible that the government is spending an awful lot of money on the NHS, and at the same time, still not be spending nearly enough.
Perhaps the most significant among the voices advocating for more money for the NHS is its director, Simon Stevens. In a role that is rightly intended to be completely apolitical, Stevens has, some would argue, been forced to abandon strict impartiality in order to make public requests to the government for more money for the NHS on numerous occasions. This breach of protocol is either viewed as unjust partisan grandstanding, or an indication of the severity of the NHS’s current situation, quite probably depending on the colour of your tie.
If the medical profession and the left are correct and the NHS has indeed been underfunded, then its performance could still be judged as exemplary despite that. The UK ranked 1st of 11 in the Commonwealth Fund’s international comparison, which judged countries’ healthcare systems on a wide number of variables, including quality of care, access and efficiency.
Considering this, and the fact that only one country (New Zealand) on the list spends less per capita on healthcare than the UK, one could conclude that the NHS operates not only extremely effectively, but also remarkably efficiently. Whether you see this as a valid defence of Conservative spending on healthcare, or just an even more impressive feat in spite of it, again, may depend on the colour of your tie.
Privatisation, PFI and the Future of the NHS
Those who doubt the Conservatives’ devotion to the cause of socialised medicine in Britain point, among other things, to the set of reforms carried out by Conservative Health Minister Andrew Lansley in 2013, namely the much-maligned Health and Social Care Act. These reforms were far-reaching, enacting an almost-complete overhaul of the NHS’s bureaucratic and management structures, as well as reshaping the service in a way that placed a much greater focus on competition and markets.
One study by the British Medical Journal found that since the passing of the Health Act, a third of all NHS contracts had been awarded to private companies — though these contracts only accounted for 5% of the total value of contracts awarded. An increase in private provision under consecutive Conservative governments is undeniable, though so too is the reality that it was not Lansley’s reforms that introduced greater privatisation to the NHS, but the previous Labour governments of both Tony Blair and Gordon Brown.
In 2006, 2.8% of NHS spending went to private companies, and at 7.6% in 2016, the rate of growth has been more or less consistent over both Labour and Conservative governments.
Another problem for the NHS, which can be attributed largely, but not entirely, to Brown and Blair, is the use of Private Finance Initiatives. Though introduced by John Major, it was New Labour that hugely increased the use of PFI across all sectors — mainly the NHS. PFI is a kind of procurement in which large public infrastructure projects like hospitals are funded, designed, constructed and run by the private sector, who then lease them back to the government to cover the initial costs, plus interest.
Their use has continued, though at a slightly reduced rate, under consecutive Conservative governments. Though significant, the repayment costs of these PFI projects are often overstated. In 2015/2016, they only accounted for around 2% of the NHS’s budget. This cost is spread over 105 NHS projects, past and present, with the most recent projects not forecast to be paid off until 2050. Perhaps in acknowledgment of what many see as a problem caused by Labour, Shadow Chancellor John McDonnell used his conference speech to announce that all PFI contracts would be reviewed under a Labour government, and where necessary, some would be taken back into public ownership.
This move by McDonnell is only one aspect of what is a completely different — and some would argue, more traditional — approach to NHS policy by the current Labour party than the previous Labour governments of Blair and Brown. Corbyn’s Labour would also see various measures introduced to bring more healthcare provisions back under state control, as well as stricter criteria for private companies wishing to carry out work for the NHS. Labour would also see funding for the NHS increase significantly through higher taxation on top earners and by clamping down on tax avoidance.
What Comes Next
The NHS will emerge from this crisis, as it has others in the past. But the severity of the problems faced by the Service this winter, despite relatively mild conditions, should serve as an alarm bell for those who wish to see the NHS continue to exist and function well.
This increase in funding proposed by Labour would undoubtedly have a positive effect on the NHS,nbut given that both the demand for healthcare and the cost of healthcare seem to be ever-escalating, the problems faced by the NHS seem to require more solutions than just throwing more money at it.
Since the inception of the NHS, its role and capabilities have changed undeniably, due to both technological advances and other factors, like the increase in end-of-life and palliative care. The NHS was formed on principles that were set for the situation in 1948, not 2018. Its founders could have in no way envisioned that one day the Service would be providing the level of care that it now does.
This is a great thing, but if we are to acknowledge that the scale and the scope of the NHS has far exceeded those initial expectations, then perhaps we must also expect some of its principles to be flexible. Though Labour wishes to stick as closely to those principles as possible, for the NHS to continue to function at all, it must adapt. This means being open to lots of ideas, some of which may be in slight contradiction to the tenets laid down 70 years ago by a Labour government.
This truth does not absolve the current administration of its failings on the NHS, however. Its poor funding seems to have been less motivated by the need for the NHS to adapt, but more an ideological preference for austerity and increased private provision across the board. As the NHS continues to grow, extra funding cannot be the only solution, but it surely must be part of a larger approach.
The NHS saves millions of lives every year and increases the quality of life for countless more. It deserves and requires a better, more nuanced debate about its future and the problems it faces. This debate cannot be hindered either by political indifference or ideological purity. For this, it is far too important.
The effect that Brexit will have on the NHS remains to be seen, though at this stage, with the details of Brexit yet to be decided, it is impossible to predict how a post-Brexit NHS will fare. The NHS undoubtedly relies on foreign workers, particularly from EU countries, and with understaffing already a major issue, fears that Brexit will continue to negatively affect recruitment from the EU are more than justified.
Trade agreements and terms will not substantially affect the NHS directly, but the ramifications on government spending if the British economy suffers post-Brexit will add to an already critical level of strain on the NHS, which even an institution as well-established as the NHS may not survive.
All but the most ardent of Brexiteers have long-since abandoned the now-infamous claim that Brexit could mean £350 million per week extra for the NHS, with most acknowledging it for what it was: an at-best ambitious and questionable claim. It would be a terribly cruel irony though, if something that had been voted for by some largely on the basis of helping the NHS, ended up contributing to its downfall.