The NHS at 75: A Celebration Gate-Crashed by Market Enthusiasts Wanting the Cake Sliced-Up

Right-wing politicians, opinion columnists and small-state think tanks are lining up to hammer the nails in the coffin of the first system in the world to offer universal, free at the point of use health services, based on need and not the ability to pay – the founding principles reiterated in the 2012 NHS Constitution.

They have been itching for some time to push the case for insurance-based funding to replace general taxation, for up-front patient payments and more competitive care delivery, with for-profit companies taking a greater share of care and for less central oversight and accountability. 

Its 75th birthday coincides with the NHS being in the worst existential crisis and performance failure since the end of John Major’s Government in 1997. But many good people, with great values, work in it and however appreciated they may be by the public, there is no doubt that the service is currently failing and on the edge. 

Things will only get worse without urgent, medium and longer-term action. But the ‘reforms’ called for by those unsupportive of the NHS’ model and founding principles assume that there is a magic bullet in insurance, markets and direct payments and that this is the only way to go. They would say that, wouldn’t they?

Two high-profile calls hit the press this week which typify the wider vibe.

First, journalist Andrew Neil in The Mail told us that “choirs are singing for the NHS 75th birthday… but if it continues to resist reform, when it turns 100, it will need a funeral cortege”.

Then former Chancellor and Health and Social Care Secretary Sajid Javid wrote in The Times that “we need to agree a new NHS future or else the 1948 dream dies”. He called for a royal commission and cross-party consensus on the NHS. 

Below the headlines, Javid referred to the “adulation” of the NHS and “religious fervour” about it as a “barrier to reform”. Neil described the celebrations themselves as “left-wing wackery” and “fashionable wokery”. 

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Javid claimed that NHS spending was no barrier to good service delivery and argued for means-tested co-payments – the “contributory principle” and “co-payments” to be combined with greater use of competitive market provision of care. He seems to have decided in advance what the independent, cross-party commission should conclude. 

Neil pointed out, correctly, that some other developed nations with good universal systems do use these mechanisms and have better outcomes. He argued for “choice, competition, decentralising” and, correctly, that just labelling these as heretical “privatisation” was a barrier to sensible discussion. 

Conservative MP Steve Barclay compounded all this by repeating  populist soundbites targeting “pen-pushers” and “bureaucracy” with managers, administrative, technical and support staff a key target. This is despite the fact that these roles are necessary for any service to function, and our management spend and numbers are lower than most systems. 

It won’t take long for others to start blaming the systems’ problems on the existence of equality, diversity and inclusion managers – who make up a tiny percentage of the NHS’ headcount.  

A Poorly Performing System Under Huge Strain

Both Javid and Neil argued that the current system is seriously broken, in terms of access to care, system performance, facilities, staffing, inequalities and outcomes. Even the most ardent defender of the NHS model would have to agree. 

The evidence is in plain sight. It is laid out in several recent reports – including January’s Institute for Government study on ‘The NHS Crisis’; the recent National Audit Office report on the current failings in urgent and emergency care; and the King’s Fund report published last week on how the NHS compares to the healthcare systems of 18 other countries.

Indeed, the Government’s own 15-year plan this week for the NHS workforce is clear about the extent of the big and growing staffing gaps and the impact on services. 

The service and the staff have yet to recover from the pandemic. Staff morale on the annual satisfaction survey is at its lowest point since data collection started. We have unrest, industrial action and growing numbers of doctors, nurses and paramedics, young and old, leaving the NHS payroll, or the country.

Both the annual British Social Attitudes Survey and the rolling Health Foundation/Ipsos poll show that the public are now seriously dissatisfied with NHS provision. The most unhappy they have been since 1997. Access, waits and staffing are their biggest concerns. 

So there is no pretending that the system is not in serious difficulty. But the pro-market, pro insurance and pro-co-payment advocates leave some important details out of their (partial) arguments. 

What Health Insurance and Co-Payment Pushers Ignore

The NHS was performing well in 2010 at the end of 13 years of generally good stewardship by the Labour Government, which put in the highest level of real-terms funding increase over a decade that the service has ever seen.

The investment and staffing uplift, and the performance improvements driven by the NHS Plan, had paid dividends. We performed well on several international metrics, and both the public and staff reported high levels of satisfaction. 

What happened subsequently was not some inherent feature of a broken NHS model, providing ‘proof’ that the system is unfit for purpose – as the Institute for Government report, and the King’s Fund review of the NHS from 2000-2020, made clear.  

The NHS under David Cameron and Theresa May received the lowest real-terms funding increase in its history. Both social care and public health were cut.

It was then sent into needless entropy by ill-advised ‘reforms’, before being further hammered by a pandemic we are still recovering from.

There has also been a serial failure to address the wider determinants of preventable ill-health and inequalities, as it does not appear to suit business interests or ‘personal responsibility’ dogma. Health outcomes are not all amenable to healthcare per se but to issues such as housing, education, employment, income inequality, obesity, food, drink and sugar policy, support for carers or for people with addiction problems. 

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As the King’s Fund report also made clear – reiterated by the Health Foundation’s policy lead Hugh Alderwick and the Nuffield Trust’s head Nigel Edwards – there is no consistent relationship between funding models and the quality of health services. Staffing and funding and capacity matter, as do wider public health policies. But both insurance-based and tax-based systems can function. An insurance-based system is not a panacea nor automatically better.

Yet commentators on the right consistently fail to mention that several decent systems in developed nations have a strong element of tax-based and state-delivered – cherry-picking examples that seem to suit their pro-market agenda. However, many of those systems are less centralised, less politicised and more regionally managed and this is worth exploring.   Even insurance-based systems increasingly rely on state support for the poor or elderly or other disadvantaged groups such as the homeless or refugees. It is not the false binary presented. 

On international comparisons, the NHS continues to score very highly on the issue of people not being denied or avoiding healthcare for fear of being financially harmed by the cost of care. Andrew Neil did at least partly acknowledge this. For all the talk of means-testing co-payments, they contain risks – as does not being insured at all. Javid openly talked in his article of using payment as a tool to deter people from using services or at least think twice about it. 

The immense disruption and transaction costs and legislative change involved in switching our established and understood funding and delivery model to something radically different should also not be underestimated when what the service urgently needs is stability and action on staffing gaps and capacity. 

No Public Appetite or Political Mandate for ‘Reforms’

Most importantly, while the public are rightly concerned about the current failings in the system and pessimistic about its future, there is no public appetite nor political mandate for the kind of reforms Neil, Javid and others would like to see.

In the British Social Attitudes Survey, more than 85% of voters continue to support the founding principles of an universal NHS, based on need and not ability to pay, and free at the point of use. They don’t want a different system. They want the current one to work like it used to not so long ago. 

The success of propagandists will lie in them persuading them that they don’t really believe this after all.

David Oliver has been an NHS acute hospital doctor for 34 years, looked after a Coronavirus ward throughout the pandemic waves, and has held a variety of medical leadership and policy roles. He is a regular columnist for the British Medical Journal