For those who believe that unconstrained freedom trumps all other values, that taxation is a form of forced labour, and that the words “common good” deserve to be wiped off a shoe, then nothing sticks in the ideological craw quite like the NHS. For a start, it’s obnoxiously big. It is the world’s sixth-largest employer, behind Amazon, Walmart and the People’s Liberation Army of China. But what incenses libertarians is the public’s affection for the NHS. For how do you dismantle an institution that’s so deeply valued and still get re-elected?
Sneering is one option. Right-wing commentators love to deride the NHS as a vast, monolithic “national delusion”. But the real answer, in the face of such public enthusiasm, has to be gradual destruction by stealth and subterfuge. You must whittle subtly, undermine with discretion, and cloak every cut in protestations of love. This has been the approach of successive Conservative governments since 2010. Like the gaslighting husband who croons terms of endearment to a wife he is harming, they’ve subjected the NHS to the most sustained and savage funding squeeze in its history, all the while indulging in performative displays of affection.
Today’s health service is a travesty of what it used to be. The sheer scale of the human misery inflicted on patients by a waiting list of 7.5 million, the collapse of emergency care, the delays in cancer care and the Dickensian overcrowding in our A&Es is shameful. Tufton Street types like to insist these conditions prove the NHS is inherently “unfit for purpose”, somehow doomed to fail. But if, instead of relentless austerity budgets, the UK had matched pre-2004 EU countries’ average spend on health from 2010-19, our health spending would be £40bn higher every year. Today’s failings stem at least in part from yesterday’s political priorities. They were not inevitable – they were politically orchestrated.
If we want to rebuild a functioning NHS over the next five years, we must resist the narrative that the NHS is doomed by its funding model and founding principles. Work by the Organisation for Economic Cooperation and Development (OECD) shows, for example, that there is no clear evidence that social insurance systems are more financially efficient than tax-funded systems. Nor is the NHS a “bottomless money pit” because a lack of point-of-service charges encourage their misuse (prostate surgeries are not like iPads: we don’t crave more of them if they’re free). International comparisons show that people in the UK generally use less, not more healthcare than those in other similarly wealthy countries. This is not to say there aren’t huge socio-demographic challenges facing every country with an ageing and increasingly multi-morbid population. By 2040, for example, more than 9 million people in England – around one in five of today’s adult population– are projected to be living with major illness. But the question of how to fund the additional healthcare costs imposed by these population changes is one faced by all societies, whatever the funding mechanism used.
If the NHS is to survive, let alone thrive, in the next five years, both increased funding and reform are needed. There is a reason we have fewer doctors, fewer beds, fewer CT and MRI scanners, longer waits and worse outcomes today than our OECD neighbours. Labour dares not say it out loud this close to polling day, but money is obviously part of the problem. If we want world-class health care, we have to pay for it.
In terms of reform, the NHS cannot flourish while social care remains in crisis. It is a national scandal that one in seven patients cannot be discharged from hospital due to lack of social care services. This blocks the flow of patients through hospital, meaning patients start dying at the front door – at least 250 avoidable deaths every week in England. Shame on every politician who has broken a promise to fix social care. Next, we must pivot attention to preventative health. The NHS alone cannot fix the health harms of soaring obesity, lack of exercise, polluted air, loss of green spaces, mouldy housing and in-work poverty. But a government that finally began to rein in the sugar, alcohol and gambling lobbies would help the population become healthier, reducing downstream pressures on the NHS.
Despite the allure of shiny new things, I’m sceptical of the cost-effectiveness of pumping funds into high-tech innovations such as AI, when even the most basic NHS IT is so maddeningly inadequate. The most valuable technological change by far would be investment in a single, unified platform for electronic patient records that is accessible across both primary and secondary care. Current IT is so disjointed and fragmented that continuity of care is all but impossible, a failing that sometimes costs patients their lives.
Finally, an incoming government must address the plummeting morale and unprecedented levels of burnout among NHS staff, so many of whom are quitting jobs they used to love in despair. The single best way to do this? Be honest. Don’t spin. Say something and do it. Give us reason to hope by your actions. And do it fast, please, while there’s still a shell of an NHS left.
This article is part of the series “How to fix a nation”
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