March 28, 2024 - 7:00am
For all that politicians and commentators find endless things to talk about in the stretches between elections, there are only a few issues which really matter to most voters. Crime and the economy are two stand-out candidates for this select list. A third is the NHS.
So it is not good news for the Conservatives that, according to new polling, public satisfaction with the Health Service has fallen to its lowest ever level.
Labour nearly always has the edge in public perception when it comes to the NHS, of course; it probably matters more for the Tories’ prospects at the election that the Opposition now leads on almost everything else too.
But the struggling Health Service will, for many people who are themselves affected or know people who are, be one of the most palpable signs of a country that feels as though it’s fraying at the edges. And, having been office since 2010, the Government cannot evade the blame.
Not all of that blame is fair. For starters, and contrary to public perceptions, the Conservatives have hardly starved the NHS of cash. According to the King’s Fund, real terms spending is up 25% since 2010, from £130 billion to £180 billion. During the pandemic, it was even higher.
Yes, the rate of growth was faster under New Labour. But Tony Blair had a specific commitment to raise NHS spending to a target point. Its real terms budget doubled between 1997 and 2009; there is obviously not enough cash to have doubled it again. The excuses only go so far, however. Much of the current crisis can be laid at ministers’ feet.
For example, it was the Government’s decision to lock down as long and as strictly as we did. That caused huge disruption to the Health Service (alongside everything else), with millions of people having appointments and operations pushed back. There are now millions of people on waiting lists, many of whom (such as cancer patients) will have seen their condition worsen due to the delay.
Those in power at the time can defend that decision — we will never know how costly, in financial and human terms, the alternative would have been. But they must still own the consequences.
Less forgivable is the state of NHS hospitals. While the Conservatives have increased the budget in cash terms, George Osborne squandered the opportunity presented by a long period of near-zero interest rates to borrow for capital investment.
In fact, the Coalition went so far as to allow the NHS to start drawing on its capital budgets to meet day-to-day running costs — just as ministers are doing now in local government, with councils being authorised to sell assets to stave off bankruptcy. This is the definition of an insolvency spiral.
Finally, it’s worth remembering Andrew Lansley’s botched reforms from 2010, which saw the Tories burn all their political capital for NHS reform to merely saddle the Health Service with more complexity, for little gain. (Contra to mythology, they did not lead to significant privatisation.)
As a result, the final sin is one of omission. After 14 years in office, the Conservatives have done nothing substantial to reform the NHS and put it on a more sustainable footing.
Now neither party has an easy way out. That Labour isn’t proposing to turn the taps back on, and has Wes Streeting talking about reform instead, gives lie to the idea that it would all work if it wasn’t for those nasty Tories. Still, there is truth enough in the charge that voters will give the Tories a kicking all the same.
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SubscribeThere’s no doubt lockdowns caused backlogs at the time, the author does not back this up however with the suggestion it’s the reason for current increasing problems.
I have a rule of thumb that after 70 years or so many organisations tend to be taken over by self promoting careerist managers and workers ‘defending Spanish Practices’ with the original aims of the organisation trailing far behind.
I suspect the NHS is too corrupted to be saved. No mere reorganisation will achieve anything beyond window dressing. It would probably take two Parliaments of concerted effort to rebuild our health service along more successful continental lines. I cannot see the political will to do so.
My guess is that those that can will gradually switch to private health care (rather like people paying for their own glasses and using private dentists now). They will resent paying for services they don’t use. Which also means that those who cannot afford private care will be saddled with the remains of inadequate health care.
You’re roughly describing Jerry Pournelle’s Iron Law of Bureaucracy.
Indeed. There’s also the Iron Law of Oligarchy, plus findings from C. Northcote Parkinson that the motivating force of a bureaucracy is simply the survival of that bureaucracy.
With all this recognition it’s surprising that people are not more aware of the risks. Or not attentive enough to see them developing.
Here in the US, most people used private insurance to pay for major health events, like surgery, and just paid our family doctors directly for basic checkups and common things like ear infections. Advantage: personal relationships and reasonable fees that often included payment plans. No middle man necessary.
Then came the hideous HMOs many of us were forced into through our employers, who offered insurance packages tied to our jobs. It was at that point my husband and I opted out and started our own medical savings account. We paid for everything directly, including two C-sections, and because of that, the hospitals couldn’t gouge and had to itemize every single cost.
These government schemes are always disastrous for those forced to use them. Quality and timeliness of care is appalling, and the only ones who benefit are the faceless bureaucrats and worker bees.
“Change in methodology”, from 2019 onwards, for calculating satisfaction is also significantly responsible / to blame for the dissatisfaction.
Forget the election. An irrelevance. What is clear is that this failed and now broken 2m strong institution is taking the UK deeper itself into that insolvency spiral. Lockdown has made recovery of its already unmerited reputation forever impossible. Worse, it broke the bond of trust – we were locked up and denied non covid treatment to protect IT and its reputation. A monstrous event. It is to the eternal shame of our miserable weak cowardly political class that they still (see the Fool Hunt) laud this 1940s Socialist relic as a source of national pride. That is a now total lie. The We forgot to build hospital beds NHS has been totally unmasked. Now its nasty narcissistic Red Guard Young Doctors & striking gold plated consultants have shown we can no longer even respect the workers within this mismanaged rotting monpolistic hulk ship. We can all see how a modern accessible fair health service can be funded and run in France and Germany and elsewhere. Shame forever on our political pygmies for denying us that rational path and so making inevitable more silent suffering and a terrible crash in a decade or so.
Assuming you are of the same ‘management not money is the problem’ school of thought as Peter B below, how do you dismiss the relevance of spending when those European Union countries you favourably reference spend far more per person than the UK on their health services?
https://www.health.org.uk/news-and-comment/news/uk-spent-around-a-fifth-less-than-european-neighbours-on-health-care-in-last-decade
Some of them spend more because many EU countries health services are only partially funded from taxation. The rest is topped up by medical insurance.
Quick Google search would show that while NHS funding is around middle of league table of developed countries, medical outcomes, especially in cancer care, are at the very bottom, with only Greece being worse.
Problem with UK health care starts with lack of basic diagnostic capacity and profiteering.
How come that in Poland you can buy extensive battery of tests including cholesterol, prostate, liver function etc for £50 with results available next day.
My prostate test was £8.
The same test in London was more than 80 pounds.
Yes Poland seems a commendable case study for social health insurance, already scoring better outcomes than the UK as far back as 2015, from what I can find.
This is also an admission that the NHS does need more money, and that this money will have to come from us, either through taxation for a universal system where quality of treatment does not reflect the wealth of the patient or through a partially privatised one where treatment quality will reflect the wealth of patient.
Yours is a fair question, and some of the answers to it below make interesting reading.
A supplementary question to yours might be along the following lines: How much of the NHS spend relates to its overweight, self-feeding bureaucracy the managerialism machine that pays vast salaries to bureaucrats, not health professionals) and staffing hierarchies that are wholly irrelevant to actual healthcare (e.g. DEI managers, etc.)?
The NHS, like all public sector organisations, the corporate sector and mainstream charities have been corrupted by their reorientation to deliver political ‘social justice’ agendas, and not exclusively focusing on their core purpose. Indeed, some might argue that their leading priority, collectively, is now to deliver social justice and to ‘decolonise’ the UK.
Ok interesting – could you advance the case that worse NHS outcomes are a result of money wasted on ‘decolonising’ the UK? I struggle to even imagine what you mean by that. Are you supposing that money is being hemorrhaged on ‘woke’ PR campaigns or something? Can you find me an amount that even comes close to the £29bn the Conservatives handed over to private providers like Serco and G4S for the dysfunctional test and trace system they gave us in 2019?
I do agree with you by the way that social justice agendas have been coopted by corporations that have no real interest in improving living conditions for the vast majority of people. Take Amazon’s donation to Black Lives Matter – a nauseating piece of virtue signalling. If Bezos really cared about Black Lives he’d pay his workers properly instead of hiding behind one-off social justice gestures.
I think our perspectives are not that far apart.
Like you, I abhor the money wasted by the Conservatives, and by previous Labour governments before them. You’ve focused on my reference to ‘decolonising’, when my substantive point was about the huge waste of money and resources that feeds a self-aggrandising NHS bureaucracy, not least the proliferation non-medical jobs that contribute nothing of substance to actual healthcare.
Both our children were once NHS healthcare professionals (emergency medicine consultant / oral surgeon) and they became utterly disenchanted with the burgeoning bureaucracy, endless social justice initiatives (including programmes to address white supremacy, toxic masculinity, homophobia, islamophobia, misogyny, etc., etc.), rampant managerialism and the mindless bureaucratic tasks and ideological commitments they had to implement to remain in their jobs. They both complained about the numbers of non-medical managers/administrators, the paucity of healthcare workers (e.g. nurses) and the frequently sub-standard equipment they had to use. Both left the NHS. So while I don’t have specific facts and figures, the insights I gained from both our children plus my own direct experience of the poor levels of services I have experienced directly (e.g. being told I may have to wait for 7 years for a hip replacement) is sufficient for me to make an informed, if subjective contribution to a discussion.
Thank you for your clear and honest response and like you I would indeed also like to know how much of the health budget goes on NHS staff who make no contribution to positive health outcomes.
However, I find that your preoccupation with NHS bureaucracy (to the neglect of say shareholders of outsourced companies with connections in the Conservative party reaping in taxpayer money for doing nothing) is an example of a wider problem among commenters on this site i.e. misidentifying the greatest sources of power in society and of rent-seeking in the economy. So often are ‘NHS Consultants, top civil servants, GPs, council leaders etc’ to quote WM above, singled out, entirely incorrectly, as ‘our super rich,’ the 1%, when the highest salaries of these people barely scrape the lowest threshhold required to be a member of that group.
At the same time, groups whose salaries do comfortably qualify them for the 1% (bankers, media moguls, hedge fund managers (like the £630m Paul Marshall who owns this outlet as well as GB News) company CEOs and (the least deserving of them all if you take work as a measurement of desert) old landowners like the Grosvenor family (value: £9.5bn, land owned: 50% of Mayfair)) get a free pass. After all, they’re only people who make money by owning things, or by liberating capital from labour (read: raising rents, firing people). Nothing to see here.
Now your point about a bloated bureaucracy is still fair and the experiences of your children interesting (albeit in conflict with those of my friends working as NHS registrars who cite underfunding as the principal problem). Although I think statistics have more weight than personal experiences, if enough personal experiences seem to challenge the statistics than that is of course cause for a reconsideration of the stats. But to continue with statistics a moment longer in relation to the assumption – prevenlent on here – that more spending will do nothing for the NHS: we have (apart from the examples of our higher spending European counterparts, the ironic admiration of our anti-spending fellow commenters on here) the example of our own history to look to; under Blair, NHS spending went up, and, low and behold, so did healthcare outcomes.
To accomodate your point, the IFS report, reviewing spending under the Blair years, does say that ‘this increase in measured public service outputs [was] less than the increase in inputs over the same period.’ In other words, ‘productivity [had] fallen.’ (spending was increased by 56% over a period which saw a ‘one-third increase in the quantity and quality of public services’). So not perfect, BUT outcomes did improve considerably. Yet this outlet is loud with complaint about the ‘poor’ (imperfect) record of New Labour and dead quiet on the demonstrable failure of the Conservatives over their last 14 years. Again, what have they done for the NHS? I would like to hear the case, but it’s never made. Can it be made?
And what government can with any legitimacy begin a transition to say, social health insurance (admittedly a succes in many other countries from the Netherlands to Poland, but still requiring more of our money to work as well as it does in the cases given), when 82% of people want an NHS primarily funded by taxation?
PS Happy Easter and all the best with the hip.
Thanks for your good wishes, Desmond! Please accept mine in return.
It’s good to encounter folks like yourself who focus on the discussion, not ad hominem attacks and ill-tempered reactions. I definitely ‘listen’ to your arguments and responses and these help me to develop my perspectives and move towards a deeper understanding of these complex issues. You are right to state that statistics are more reliable than personal experience. The trouble with statistics is, and we all know this, is that they can be manipulated and presented to fit any argument or viewpoint. Since the arrival of the Blair administration in 1997, his and successive governments have thrown gigantic extra funding in billions into the NHS, and yet it has declined. So why is the NHS facing such huge problems and delivering rapidly deteriorating services across its remit? It is a multi-facted problem which embraces, inter alia, massive immigration without corresponding investment in capital projects and lack of revenue investment in expanding the clinical staff (and correlated increases in administrative capacity) to meet these enormous new demands (ditto public services generally – grotesquely slashed by Cameron’s administration with the enthusiastic support of Nick Clegg and his lot). In this respect, inadequate funding, over and above the vast increases given to the NHS over the past 20+ years) is a core problem – but the problem is driven by external factors that have not been controlled by successive UK governments, especially the Tory administrations of the past 14 years. Striking doctors demanding 35% pay increases merely add to the impression that the NHS is bloated and filled with self-serving elites.
Oh dear, I am baffing on … reigned in!! 🙂
You and many others can see that European health care model works much better than NHS.
However, till covid it was very small minority view.
Any attempt to reform NHS was met with cries of “privatisation” from both NHS unions and Labour Party.
With Labour soon in power no serious reforms are possible.
So we can’t trust Labour with the NHS, but we can trust the Conservatives? The Conservatives have certailnly made use of private providers in our healthcare provision. Which was your favourite example? The £122m given to PPE Medpro for sterile surgical gowns that turned out not to be sterile or the £29bn spent on a dysfunctional test and trace system? In Germany test and trace was only 600 times cheaper, at £48m. Most of the £29bn (a 6th of the £180bn spent on the NHS annually) went to private contractors like Serco and G4S. This is my understanding of Conservative reform, but if you have a more positive tale to tell I would genuinely be glad to hear it.
And could you also tell me in what ways health outcomes deteriorated under New Labour? Also very curious to know!
Waiting times were longest in 20 yrs before Pandemic. Lockdown 1 certainly exacerbated that but even without a legislative lockdown planned care would have largely ceased. Recovery then heavily impacted by insufficient capacity, much the same capacity shortfall that led to Lockdowns.
Author rightly draws attention to poor state of NHS capital infrastructure and the opportunity missed. But he also misses the biggest strategic decision that has stymied healthcare in UK for too long – lack of a joined up long term workforce plan that ensures we properly model our needs and plan for the required training places. For too long blocked by the right wing bias in the Treasury and in Right wing ThinkTanks imagining a ‘market’ approach will miraculously provide. Thus for too long NHS has to ‘shop abroad’ for staff – exacerbated and made more costly by Brexit twaddle. Although Sunak/Hunt have recently finally allowed the formation of a long term plan it’s taken Tories, and the Right more broadly as you won’t have heard likes of Farage/Reform say much on this either, far too long. It will take a decade to correct.
And all this without a mention of the meltdown in Social care inevitably ‘backwashing’ into NHS capacity.
Dreadful wasted 14yrs. The choices we face are not easy but the Rights denial for so long that these might even exist has made recovery now a Herculean task.
Not sure why this attracted a downvote, absolutely nailed it imho.
Because (as usual) it’s not a simple Left/Right political issue. This bureaucratic monster has been failing for 30 years and no government of either hue has had the courage to seize the bull by the horns and put it out of its misery. Throwing more money at it and expecting it to change is the equivalent of Einstein’s definition of insanity.
I remember a TV series where successful businessman Gerry Robinson tried to turn around a small unit of the NHS. Managers were totally resistant to change and (God forbid) any ideas coming from the ‘shop floor’. Even he had to throw up his hands and say it can’t be done.
You might add to that the Left’s denial that any change or reform is necessary – or indeed possible. That’s the same as I remember it in the 1980s when they simply had nothing better than “business as usual”. But if “business as usual” isn’t working, you need to change something.
Yes, we should absolutely train our own medical staff and stop asset stripping poorer countries (while boasting about this shameful practice).
The main problem isn’t money. It’s management.
There is much talk of reform from both Left and Right but v little detail. That probably reflective of two things – firstly public wouldn’t support radical change and v nervous about any move away from ‘free at the point of use’, and secondly the awareness all developed nations have major dilemmas in health policy with few simple solutions.
What is clear is over last 14yrs we have gone dramatically backwards on all ‘access to care’ metrics. With an aging population, and an aging workforce (esp in key areas such as Primary care) sustaining the position the Tories inherited was always going to be challenging, but I flagged two things they could have done that would have made a considerable difference – capital investment and workforce planning. They did neither.
Personally I would support some move towards social insurance model, some up front payments but with ability to reclaim, heavier charges on private healthcare for the training of professions they benefit from – with that reinvested, and fundamentally a new universal contribution for social care. Plus the crucial longer term workforce planning. Outside immediate healthcare I’d strongly support much more intervention in initiatives that aid good health – sugar tax, more support for exercise and mobility, more awareness of what you need to do to help yourself etc
‘imagining a ‘market’ approach will miraculously provide’
Firstly it is hard to find any other places that have taken the NHS as a model. Leaving that aside though, the NHS was one of the protected few.
A much, much under-remarked upon aspect of the Coalition was how it massively changed the shape of government spending and how it massively picked winners and losers, an issue we see to this day. What the Coalition did was a fiscal consolidation that protected the NHS, pensioners and (at the time) foreign aid. The necessary implication of all this was deeper cuts elsewhere to maintain the protections. So property millionaires got their triple locks, the NHS got to carry on and everyone else got clobbered to the point where students enter their 20s £50k in debt and it takes 2+ years for cases to get to court and we fret about how we can make ammunition shells.
And, of course, local authorities got a 40% front-loaded cut which in turn opened social care to a 40% cut.
The Coalition and subsequent Conservative governments most certainly did not imagine a market approach, the shaped the state in no small part around the NHS.
To this day I am amazed at how little comment the Coalition’s protections of sacred cows got, because it was a very, very influential thing. And, it has to be said here that Labour were not exactly screaming about the effect of protections for certain areas in a fiscal consolidation either.
We will, of course, never know how things would have worked out without the pandemic.
You forget the Coalition undertook a major NHS reorganisation in it’s early years. Turned into a disaster and cost a fortune. That almost certainly coloured their subsequent ‘leave alone’ strategy.
I was under the impression it was the BMA that set the labour supply targets and their objective is not aligned to patient care but maximising their clients returns.Happy to be enlightened as to precisely why right wing bias in the Treasury and in Right wing ThinkTanks have caused the problem.
Mixing up BMA there with Royal Colleges PtE. The Colleges have a role but fundamentally it’s about places Govt funds.
The failure to implement the Dilnott plan was catastrophic.
And Labour could have done it in the 2000s.
I agree with that
You got downvotes, because of your complete denial that failures of NHS have anything to do with its socialist, monopoly model, which ignores patients and benefits employees.
Classic example:
Before my recent consultation, which was cancelled before, I phoned to confirm that it was not cancelled again.
I asked whether consultant has my MRI scan on file.
They don’t have it, was the answer. Can they find out what happened? It is not their job.
So, I went in person (no one answered my repeat calls) to MRI center. They forgot to send it.
Consultant admitted that without MRI my consultation was pointless.
Do you seriously believe that pumping more money into dysfunctional organisation with so many lazy, unmotivated staff is going to solve NHS problems?
Given Thames water, privately owned, now wants to hike everyone’s bills after years of stripping out dividends, I’m not sure your anecdote a strong proposition for more private sector management?
But certainly nobody would defend the shambles you convey. The reasons why and how this can happen may be numerous. Your consultant shouldn’t need to be ‘sent’ it. They should be able to just pull it up on the Hospitals EPR (electronic patient record). Many NHS hospitals are currently implementing EPRs, many of which are US developed, and struggling. Things should get ironed out but your example will be far from unique I’m sure.
Comparing a “natural” monopoly with healthcare provision from potentially thousands of suppliers is ridiculous. Clearly, economics ain’t your forte.
Not following your point entirely JH. Elaborate and I can respond more.
Interesting though you see healthcare provision as natural monopoly. Clearly information/understanding is asymmetric between doctor/patient and thus state intervention to provide protections been v important. That asymmetry though can vary depending on condition/disease/choices/patient education etc, hence why for 35yrs the NHS has endeavoured to run some degree of internal market – but with limited success and in part because outright Hospital/Provider failure often untenable in an area with limited alternatives.
Account for improvements in NHS outcomes under New Labour when spending was significantly increased.
No. The NHS itself is to blame. Lockdown just accelerated the symptoms becoming visible. And reinforced the public delusions about the NHS.
When the names of the top managers of the NHS are well known by the general public and failing leaders (rather than politicians) start carrying the can for their failings, we might start to see some progress. But there is no sign of that ever happening.
“Great companies don’t throw money at problems, they thrown ideas at problems”.
“Great companies don’t throw money at problems, they thrown ideas at problems”.
To this I would add ‘Great governments don’t throw money at NHS workers, they throw it at private companies like Serco and G4S. £29bn of it if they can.’ As a Conservative voter I’d have to believe this mantra to feel better about voting for them in 2019.
What a pointless shallow article. And the comments I have read so far are not much better.
Forget the NHS. Forged in the hot air of socialist fervour and almost a copycat of communist models, it was never going to be able to meet the needs of the population forever. Sooner or later, delivery was going to get bogged down in bureaucracy, while demand increases relentlessly. As in the communist system, resources are rationed through a waiting list, and the waits get longer and longer. Is it any wonder that no other advanced democracy has adopted a system like the NHS? And they all have much better health outcomes than the UK. Yet, everyone over here thinks the answer is just to throw more money at the service.
This is not to denigrate the medics that work in the NHS. I am sure most of us can attest to receiving excellent treatment. But the system itself denies most people timely treatment and timeliness in treating health problems is the key to successful outcomes.
While both major parties talk about increasing NHS funding, neither has the sense to understand (or the balls to tell the truth) that no amount of funding will deliver the outcomes that most people want – an efficient health service delivering timely care. The more you pour into the NHS funnel, the greater the bureaucratic wastage. Why cannot we have a party of sense that promises a Royal Commission (with a short-dated delivery deadline – a year is sufficient) to examine different healthcare delivery models in different countries, their costs, their outcomes, and their effectiveness and efficiency, and to recommend an alternative model for the UK?
Too bloody sensible for the cowards at Westminster.
I’ve marked that down – not because the main thrust of your argument is incorrect, but for this: “the comments I have read are not much better”.
You’ve not actually added anything of note that hasn’t already been posted in Comments.
Well, I did wonder about that, There were not many comments when I was stung to write what I did, and certainly no one spelling out we needed a totally different model. I started it just before lunch and finished it afterwards so things might have been added in that time. I should have rechecked or deleted the offending phrase. My frustration with the wishy-washy analysis of NHS ills does make me rather offensive sometimes. Apologies.
Great post.
I always get shouted at by lefties in London when I say:
Yes NHS is envy of the world, third world.
Let’s follow the money though.
Why would consultants in NHS wanted to solve the waiting times?
What would happen then to their private practice?
Till retirement I had private health insurance for 20 years and I received excellent care.
I did not realise how bureaucratic and unmotivated NHS is.
Simple answer to the question: no! People are fed up with an NHS that too often appears to exist for the benefit of employees rather than patients, spends a lot of dosh on unnecessary treatments for individuals with wants when the needs of the majority are underfunded, and cares more about identity than health.
Three points (I worked in both the NHS and social care for several years):
1. New Labour’s reforms failed. Dismally. Indeed were it not for the extra money, the NHS would have got even worse and more quickly.
2. The “Lansley Reforms” were basically a continuation of Labour’s plans. They would have been the “Burnham Reforms” but for the 2010 election result.
3. The fundamental problems are the failure to address the delivery of decent social care in the context of modern medicine and excessive demand due to unsustainable population growth.
Dissatisfaction is much more personal. I rang the surgery this morning at exactly 8.00 when lines opened, I was 12th in the queue and when I got through I was told that no more doctors’ appointments were available but I should see a nurse practitioner.I began to remonstrate in order to see an actual doctor and the woman told me that I needed to take the appointment quickly as the nurse slots were being filled we spoke. What a system!