The social contract has been ripped up (Lynsey Addario/Getty Images)


January 10, 2023   4 mins

Every day, we’re told that the NHS is collapsing. It’s failing the sick and wounded at their hour of greatest need, leaving frail old people lying for hours without an ambulance, farming out patients to care homes, and forcing the chronically sick to wait years for treatment that would enable them to get on with their lives. But is this true?

Yes, I am afraid it is. I wish I could give you a more optimistic take, and embrace the prospect that swift action can turn around the dire state of the UK’s National Health Service, but the data doesn’t lie.

“This is obviously a crisis, but we have been in crisis for a very long time,” a doctor friend told me yesterday, when it was announced that strikes by NHS staff will go ahead this month. As became clear during the pandemic, the NHS has not been able to cope with normal levels of demand for years. Even before Covid struck, one in five A&E patients were not seen within four hours, while the waiting list for non-urgent treatment had grown by 50% in the previous five years.

Today’s stories of patients waiting in ambulances for hours to be admitted should sound familiar. We heard them in 2018, with the same warnings of inevitable harm to patients, both those in the ambulances, and those waiting in vain for an ambulance to come to them. Patients were already dying in ambulances, waiting for transfer into hospital, in 2021.

The British Medical Association, attacking the Prime Minister’s “baffling lack of urgency” in addressing the crisis, says that “retaining and regrowing the workforce… is our way out of this mess”. Nurses’ leaders have also pointed to understaffing as one of the reasons for their industrial action, with pay levels falling behind inflation for the past decade as one cause of that understaffing. But while it’s true that NHS spending has increased year on year since 1997, it has done so more slowly than in comparable countries.

As early as 2013, the UK was already spending less than any other G7 country except Italy on healthcare. In 2017, when France spent £3,737 per head, and Germany £4,432, we spent £2,989. In the same year the BMJ compared the NHS to healthcare in nine other high-income countries, and found the lowest per capita spending, lowest ratio of doctors and nurses to population, and below average patient outcomes in cancer survival, life expectancy, and some types of stroke and heart attack. But throwing government money at the problem now will not turn around a collapsing system overnight. Long-term refusal to deal with problems cannot be wiped out with short-term, high-profile initiatives.

During the Covid pandemic, the Government swiftly created a string of Nightingale Hospitals to receive pandemic patients. It was an impressive crisis response — but there were no extra staff to care for patients, so they stood unused. Encouraged by tech-loving former Health Secretary Matt Hancock, several health trusts signed up in 2019 to a privately-run digital system designed to reduce pressure on Emergency Departments. For instance, a chatbot in the Babylon Health App would tell people in Birmingham whether or not they needed to go to hospital, in a service described as “AI Triage”. The trust hoped to shift large numbers of cases to online assessments, and to avoid the “avoidable attendances” which it estimated at 30% of A&E arrivals.

At the time, doctors expressed concern that the symptom checker app made potentially dangerous mistakes. Unlike medical treatments, the software underwent no peer-reviewed, randomised controlled trials. After a string of complaints from clinicians and the health regulator, the NHS hospital contracts with Babylon Health have now been terminated, some of them years early.

Babylon’s rise and fall revealed a larger truth about the UK’s healthcare system: a quick fix, whether it’s a hi-tech app or an injection of cash, makes good news headlines, but long-term problems need long-term solutions. The NHS has reached the point where chronic problems have turned into an emergency.

Take the crisis in social care, which successive Prime Ministers have promised to remedy — something that would make a huge difference both in preventing medical emergencies and in enabling patients to leave hospital faster — but still remains unsolved. In 2017, NHS leaders were already calling for better work with care homes to keep people out of hospital, and to get them out quicker after hospital care to free up beds for people awaiting admission. Today, more than 10% of patients are medically fit to be discharged but have nowhere to go. Everyone seems to acknowledge that the NHS cannot be fixed without fixing social care, but nobody seems able to fix social care.

As populations age across the developed world, and more advanced medical treatments cost more while keeping us alive longer (to need more care), healthcare costs will continue to rise, unless we decide that we want a worse standard of care. This doesn’t mean we just need to spend more. Americans spend twice as much per head — on average — and still have worse average outcomes. But that’s not the only alternative model. Most other G7 countries spend more than Britain on healthcare, and have better outcomes.

But to raise our standards to those of France, Germany or Australia requires structural change. Those countries deliver universal healthcare with better outcomes than ours, but as well as higher budgets they have different systems of provision and payment.

If we try to cling on to healthcare that looks like our existing system but with bigger budgets, we risk a two-tier system by stealth, in which those who can afford to pay get private treatment, and others take their chances in a lottery of inadequate NHS provision. That is what gives the edge to repeated questions about which politicians use private healthcare provision: it may no longer be a matter of convenience in timing and location, but of life or death.

The generation now lying on floors with broken hips for 12 hours, or in hospital corridors with dementia for days, in a limbo of triage with no end in sight, are the generation who trusted in the post-war social contract. They paid their taxes and National Insurance with the expectation that the state would be there for them in their hour of need. That contract has been ripped up and thrown back at them in pieces. There’s a bitter irony in the fact that the NHS is trying to move away from treating acute conditions, and towards prevention by promoting long-term health: somebody needs to do that for the NHS itself.


Timandra Harkness presents the BBC Radio 4 series, FutureProofing and How To Disagree. Her book, Big Data: Does Size Matter? is published by Bloomsbury Sigma.

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