The NHS as we know it is dying. It’s no longer a matter of if it will collapse, but when. Those of us who work on the front line have known this for some time, and it’s heartbreaking. Last week’s ransomware cyber-attack served to highlight how frail and vulnerable the health service is. While many tried to blame Health Secretary Jeremy Hunt for failing to prevent such a disaster, the archaic IT system is actually emblematic of how the NHS as a whole has struggled to keep up to date and adapt to the modern world with the necessary speed.
I trained as a doctor specifically because I was so proud of the NHS and the ideologies underpinning it. It is one of this country’s greatest achievements: a fair, equitable and cheap way of delivering healthcare. It worked pretty well for about 60 years, but its sickness has become terminal. The root problem is political: a systematic refusal by all parties to acknowledge the problem.
Max Pemberton and Lord Saatchi advocate for a Royal Commission on the NHS in the Spectator Podcast:
This election campaign has so far been marked out by the almost complete absence of any substantial discussions. Yes, Brexit matters — but so does the coming collapse of our health service. For years, money has been thrown into an antiquated, creaking system that can’t adapt quickly enough to keep up with the demands being placed on it. As a result, the NHS is a confused hotchpotch of short-term solutions imposed in a haphazard and uncoordinated way on an anachronistic model. And, if it falls apart in the next few years, it is the NHS, rather than anything to do with Europe, which will define Theresa May’s premiership.
Does this sound alarmist? I’ve worked in the health service for more than 20 years and I can honestly say I’ve never known things quite like they’ve been over the past few years. People talk about cuts, but they have no idea what it’s really like at the coalface and what the reality of this means. I work in mental health, and routinely encounter suicidal people who have been turned away; the threshold for treatment is now so high they won’t actually be seen until they try to kill themselves. In eating disorders — the speciality where I work — I regularly hear of anorexic patients being turned away because they aren’t skinny enough.
A few weeks ago, I was in a meeting discussing the most high-risk patients in my service and prioritising who should be admitted. As we sat there a manager came in and casually mentioned that she had just been telephoned by NHS England; it had informed her there was not a single bed available in any eating disorder unit in the entire country. Not one. Every bed was occupied, meaning we could not admit any patients anywhere. We all looked at each other, then at the list of sick patients we were discussing, and gulped.
I’ve never known things to be this bad and mine is just one tiny area of medicine. Colleagues in other parts of mental health have told me similar horror stories, of patients having to be admitted hundreds of miles from where they live. This is not unique to mental health; most hospitals operate a one-in, one-out policy.
Theresa May is avoiding set-piece debates in this general election, indeed any environment where voters might gang up on her. I can see why: it might not be too long before she’d run into a patient, or even a doctor, who’d share with her the kind of stories that we come across all the time.
Blind old ladies being denied cataract operations, for example. One of my closest friends, an orthopaedic surgeon, has horror stories of having to deny knee and hip operations to patients who cannot walk because the budget is simply not there. There has always been rationing in the NHS, but this has now reached epic proportions. A&Es are overwhelmed. GPs are buckling under the pressure and quitting in their droves because they simply can’t handle the workload. Morale is flatlining. When I started out, the talk among junior doctors was about what speciality they wanted to go into; now, it’s about what career they want to use their medical degree to enter. Nurse recruitment and retention is at an all-time low and is only likely to get worse.
When the NHS was created in 1948, life expectancy was 13 years shorter than it is today. Longevity has been a great triumph of public health policy but it has come at a cost: the longer people live, the more likely they are to develop a chronic disease such as diabetes. The average 65-year-old now has one chronic condition; the average 75-year-old has two. Two thirds of hospital beds are taken up by over-65s, and an average 65-year-old costs the NHS 2.5 times more than the average 30-year-old; an 85-year-old costs more than five times as much.
So where to draw the line? The health service is currently considering capping the amount it will pay for each new drug at £20 million a year, even though a fifth of new treatments cost more than this. The calls on the NHS are growing exponentially. Last year £140 billion was spent on health across the UK; that’s ten times the figure ploughed in when the service was founded in 1948, even allowing for inflation. It is almost two years since the target of seeing 95 per cent of A&E patients within four hours was met in England. And it’s only going to get worse, with the numbers admitted to casualty rising by a third in the past 12 years.
These problems have been allowed to persist because tackling the health service is considered an enormous political risk — and one that no recent prime minister has felt strong enough to confront. But if Theresa May ends up with a landslide majority next month, it puts her in a fantastic, perhaps unrepeatable, position to do something. It gives her a mandate and political licence such as few other premiers have enjoyed.
So we need to decide what our NHS is for. We need to decide how it’s going to be funded and what we can expect it to provide. Getting a consensus on such things won’t be easy, but a prime minister with a huge landslide doesn’t need to worry about a consensus — and, anyway, inaction is no longer an option. Writing in the British Medical Journal, Lord Saatchi has proposed an answer: a Royal Commission. Now, I’m sure I don’t agree with him on many areas of politics, but we both agree we need to sort out the problems facing the NHS and that if we don’t do it now it’s going to be catastrophic.
A Royal Commission is an incredibly wide-ranging and very powerful inquiry, which is why governments tend not to like them. Once started, they can’t be easily shut down. They are independent of government and are so in-depth, hearing from such a wide range of experts and interested parties, that they can run on for several years. And this is precisely what we need: a debate, once and for all, about what the NHS is for.
Should it offer cradle-to-grave care? Or is it there to provide the essentials: life-saving or significantly life-improving care, but anything else has to be paid for separately? The doctors blaming the Tory government for things show a laughably short memory. Many of the problems that have brought the NHS to its knees — such as private finance initiatives which have left hospitals saddled with extraordinary levels of debt — were introduced by Labour. The introduction of the internal market and foundation trusts paved the way for hospitals being businesses in themselves, but with no clear plan for what would happen if they failed.
A Royal Commission is also a good idea from a political perspective, because it will raise the kind of questions that terrify politicians: do we, as a society, want to pay for obesity surgery, or IVF, for example? What about sex-change operations and breast enlargements? As our society gets richer, the definition of ‘essential’ care widens. So where should the NHS draw the line? The health service remains remarkably popular, but several generations have been born and brought up under its care, and no longer know anything different. They take it for granted. The cost of healthcare and the taxes we pay have become uncoupled in the collective consciousness.
We need to think creatively about how we could fund the NHS. For example: if people are willing to pay for their healthcare, should they be allowed to do so? Should prescriptions be subsidised for those who can afford them, and should we charge for GP appointments like the Scandinavians do? Might the NHS offer a basic service, with health insurance required for the extras? For my part, I’m attracted to the idea of a specific payment for the health service and social care — an ‘NHS tax’ — in a similar way to how National Insurance was introduced in 1911 to provide a safety net for workers when they fell on hard times. It would have to come with a cast-iron guarantee that the money was used only for the NHS and social care, and would only work if there were a corresponding drop in general taxation. There is a need to reassess the social contract between patients, taxpayers, health professionals and politicians.
The biggest problem holding back the NHS is political denial. Some, particularly on the left, seem not to accept that there is even a problem, despite the howls of despair from those of us working in it. As a result, we might get through this election without any serious discussion of health, even when there are swaths of the country where GPs are downing tools and walking out. As one colleague said, when it comes to the NHS, politicians aren’t putting out deck chairs on the Titanic — they’re still debating what colour deck chairs they should be putting out.
If Theresa May does get her landslide victory, she will be better placed than any of her predecessors to apply the fundamental reform everyone knows the NHS needs but has been too scared to say. And if we don’t act now, then when will we? We have to do something, because it is only a matter of time before the NHS collapses. Perhaps the ransom-ware attack will show people quite how close things are to catastrophe.
A series of freak political events have conspired to give Mrs May the opportunity of a lifetime. Those of us who work for the health service — to say nothing of the millions who depend on its care — can only hope that she takes it.
Max Pemberton, a Daily Mail columnist, and Lord Saatchi on the NHS’s future