It dominates everything. It’s so far ahead in the rankings of public concerns as to be laughable. There can be a surge in crime, immigration may be soaring, schools are in crisis — none of it matters. The state of the National Health Service is what counts.
It’s falling apart. For reasons of history and demographics. The service was conceived at a time when the country’s population was a lot smaller than today, life expectancy was shorter and medical treatment and equipment less sophisticated and cheaper. It’s in desperate need of reform and not just tinkering, but a wholesale rethink. Yet nobody dare go there.
It’s the elephant in the room, the love that dare not speak its name. Britain goes into bat, trying to compete against other economies, with one arm behind its back, with a £180 billion bill for free health care that must be met — we’re a health service with an economy attached.
During Covid, what was the slogan that the government implored us to follow? “Stay Home, Protect the NHS, Save Lives”.
Not, please notice, “Save Yourself, Your Family & Friends”. It was nothing like that. We were being asked to lockdown and follow the rules, to “Protect the NHS”.
We were in a bind before the pandemic struck with the NHS. Now, thanks to the impact it’s had on our hospitals, it’s even worse. If Rishi Sunak is to have any chance of winning the next election, he must reduce the backlog of patients waiting for treatment. Until major inroads have been made and the list falls substantially, there is no prospect of an early ballot. He will not go to the country against the backdrop of a reeling health system.
The problem that Sunak and anyone in his position faces, is that the financial numbers continue to head in one direction. Upwards.
In 1966-1967, the Bank of England and Office for Budget Responsibility reported, the bill for supporting the NHS amounted to 3.4 per cent of GDP; in 2024-2025, it’s projected to be 8.4 per cent.
No other item comes close to matching that scale or the rate of increase. Defence has fallen, down from 5.4 per cent during the Cold War to 2.1 per cent. Education has risen slightly, from 4.3 per cent to 5 per cent. The non-pensioner welfare budget is up from 2.9 per cent to 4.8 per cent; the funding of pensioners from 3.4 per cent to 5.8 per cent.
On the NHS goes, seemingly set on an inexorable ascent. If any politician, would-be politician, wants to add to their popularity all they have to do is demand greater funding for the NHS. Better still, if they can construct a model that appears to illustrate how that can be achieved. Although such is the drain on resources, so tight are the public finances, that you have to say good luck with that. Not unless they are proposing tax rises aimed specifically at boosting the NHS; such is our sacred veneration of the service that even they could be palatable.
A 'billion-pound hole'
Woe betides them if they speak sense and call for increased efficiencies from the NHS. Then they can expect to plummet in popularity.
This applies across the spectrum and is not confined to the centre or left. Tories, even right-wing ones, are afraid to voice what they know to be true, that the NHS is no longer fit for purpose and some form of health insurance and charging must be introduced.
Which is why the news from Scotland that leaders of the devolved NHS there have discussed abandoning the founding principles of the service and making the wealthy pay for treatment is so fascinating.
A two-tier health service is mentioned, reports the BBC, in draft minutes of a meeting of NHS Scotland health board chief executives in September.
Scotland’s Health Secretary, Humza Yousaf, was quick to pounce on the leak, disavowing it and insisting the NHS would stay publicly owned and publicly operated. He added that health services “must always” be based on individual patient needs and “any suggestion” that it should be about the ability to pay was “abhorrent”.
However, the minutes are marked “in confidence, not for onward sharing” and while they highlight the sensitivity, they also illustrate the parlous nature of the NHS’s funding in Scotland. The meeting began with an update from NHS Scotland chief executive, Caroline Lamb.
The service cannot continue to run in its present form; there is warning of a “billion-pound hole” in the budget; they can’t carry on offering the range of programmes currently offered while remaining safe. Tellingly, the minutes describe the “disconnect that the boards are feeling and the message from SG [Scottish Government] that everything is still a priority and to be done within budget”.
The document does not pull its punches — indeed it’s possible to sense the frustration of those charged with providing care while sticking to the financial limits. It suggests that “fundamental reform” of the existing service “must be on the table” and that the success of the NHS has been built on a model “that no longer works today”.
For Scotland and despite the lack of acknowledgement from the Scottish health secretary, read the rest of the UK. The Scottish paper merely reflects what is being contemplated and explored elsewhere. The only surprise is that it was written down — such conversations are far too delicate to be had in public.
There are solutions to the funding gap: rationing a greater variety of drugs, especially those that don’t cure but make the patient more comfortable; and yet again, examining if efficiency savings can be made.
These, though, only tinker at the edges. The one that would make a real difference is charging. It’s not as radical as all that — after all, dentistry, prescriptions and glasses are subject to fees for those who can afford to pay them. Prescriptions are free in Northern Ireland, Wales and Scotland, and one of the proposals aired at the meeting was whether that measure should not be reversed in Scotland.
In his Tory leadership campaign, Sunak proposed charging £10 to patients who miss GP or hospital appointments. No sooner did he come into office, however, than he backtracked, his spokesman saying “now is not the right time to take this policy forward”.
Charging for bed-and-board while in hospital — as opposed to charging for actual treatment, for consultation and surgery say — has also been mooted by NHS managers in private.
It’s clear that something must give and pressure is building relentlessly. Wanted: a brave politician who forces the nation to confront a problem that is staring everyone in the face, who is prepared to make that first step.