The cabinet meeting this week turned into a surprisingly frank conversation about the National Health Service. Rishi Sunak was asked to give his thoughts on the future of health and social care. He gave a candid assessment of the dangers of being blind to the NHS’s many shortcomings. It’s political blasphemy to criticise the NHS. But once Sunak started, others joined in. Jacob Rees-Mogg added his concerns. Steve Barclay, the new Cabinet Office minister, and Kwasi Kwarteng, the Business Secretary, also contributed.
By the end of the meeting, the ministers had heard each other say out loud what they have long been thinking: that the NHS, as it stands, is failing. The government will soon be pouring almost half of day-to-day public service spending into a system which is falling short of what patients (and tax-payers) deserve. The money is there: since extra spending on the NHS became a Brexit mission statement, Boris Johnson has seen to that. The UK now spends almost 13 per cent of its economic output on healthcare — the highest in Europe. But the results are not coming through, and people are starting to notice.
The arrival of the Omicron variant has, yet again, raised the prospect of people being asked to stay at home — not so much to protect each other but, to use the language of lockdowns, to ‘protect the NHS’. Covid-19 is no longer dominating the health service: vaccines work, and patients with the virus currently occupy only 5 per cent of hospital beds, a far cry from 31 per cent in January. Things are relatively under control — for now.
Still, something is going wrong. In many ways, NHS emergency services are harder to access now than they were last year. The average ambulance wait time (for a non-life-threatening call) is now nearly an hour — twice what it was in the depths of the pandemic. The standard answering time of a 111 call should be 20 seconds. For those in the north-east of England, it’s taking closer to 20 minutes.
Amanda Pritchard, the new chief executive of NHS England, admitted at the start of last month that the NHS was ‘running hot’. So it would seem. Too many GPs are still refusing to see patients in person. In desperation, these patients go to A&E. The emergency wards have become so full that in October, just over 7,000 patients waited more than 12 hours to be admitted. This is more than five times the number in the previous October, when no vaccines were in sight. Ms Pritchard is right to sound the alarm, but she can’t really blame Covid.
So what’s going wrong? In a way, nothing: the NHS is designed to ration health-care, using waiting lists and running hospitals at nearly full capacity. This is why almost every winter the ‘NHS in crisis’ headlines appear. These stories are not really exaggerated: doctors and nurses work ridiculous hours, often in overflowing wards. This is, for political reasons, the way Britain chooses to run its health service: as a top-down bureaucracy, funnelling resources to management and keeping competition at bay. It wastes money and, worse, it costs lives. We’re long overdue a conversation about how to do better for everyone.
Most international studies tend to rank NHS performance as mediocre. A 2019 study of developed countries, published in the Lancet Oncology, showed that the UK has the worst survival rates for five out of seven cancers. The study that tends to be kindest to the NHS, produced by the Commonwealth Fund, recently demoted the UK from first to fourth place. But even in years when the NHS has ranked first overall — out of 11 systems in developed countries — it has consistently ranked near the bottom in the category for patient outcomes. As the Guardian once put it: ‘The only serious black mark against the NHS was its poor record on keeping people alive.’
How many people? Five years ago, the Institute of Economic Affairs ran the figures. Were UK patients with lung, breast, prostate and bowel cancers treated under the German system instead, 12,000 lives would be saved every year. Under Belgium’s system, 14,000 lives. For stroke patients, roughly 3,000 more would survive if they lived in Switzerland. Decades of experience across the world suggest that patients tend to fare better under hybrid systems: where universal access is guaranteed for everyone, but private and charity sector provision work in tandem with the state to ensure the best outcomes for patients.
Two decades ago, it was easier to claim that the NHS’s problem was simply not enough money. When Tony Blair famously sat down on the late David Frost’s television sofa and promised to match Europe’s average for health spending, he made Labour the party of giving more cash to the NHS. The Tories have taken this idea and run wild with it: between 2010 and 2025, the health budget will have increased by 42 per cent — squeezing cash spent elsewhere in government. Schools, by contrast, will be up just 3 per cent. ‘We’re treating NHS investment like it’s paper money,’ says one government source. ‘We put over £5 billion extra into the NHS to give it a six-month boost and no one noticed. Some cabinet ministers don’t even remember it.’
Yet political and public discussion about healthcare refuses to move on from ‘more money’. To propose modernising the NHS is to be accused of selling it off. But if more cash really were the answer to the NHS’s woes, Britain would surely have the best healthcare system in the continent, if not the world.
The problems are most acute now because of the way the NHS shoved non-Covid treatments to one side when the pandemic began. When Sajid Javid became Health Secretary, he revealed that some seven million people had not come forward for health appointments. This is starting to generate more headlines: it was estimated this week that there are between 240,000 and 740,000 missing suspected cancer patients who would have needed an urgent referral.
These are the serious health problems that have been building up. NHS England’s waiting list stands at 5.8 million people — and it will only grow. An investigation by the Spectator’s data team reveals that cardiology appointments fell by nearly a fifth last year, eye treatments by 28 per cent and physiotherapy by almost 40 per cent. General surgeries were down by a quarter; urgent adult mental healthcare down by nearly a sixth. These issues didn’t just magically disappear.
How much of this disruption was inevitable? Lockdowns were a worldwide trend, and virtually every developed country took a major healthcare hit. But the picture now emerging shows that Britain has been hit worse than many others. During the first weeks of lockdown, a survey of oncologists showed cancer appointments in Germany fell by 33 per cent; in Britain, it was 61 per cent. (Germany returned to normal cancer service levels within three months, though they have since slipped again.) Swedish breast cancer referrals were down by about 10 per cent in the first ten months of last year. In Britain, that figure was closer to 30 per cent. Hip replacements were down 10 per cent in Norway last year, 19 per cent in Ireland, 27 per cent in Italy. In England, that figure was 48 per cent. It’s a similar story for knee replacements.
Other nations have also shown signs of faster recovery. Denmark’s system — free at the point of use — managed to actually increase hip and knee operations last year. Had the NHS achieved something similar, our system might today be ‘the envy of the world’. But it hasn’t.
Whenever NHS reform is brought up, a false choice is offered: it’s either the NHS or the USA. This is disingenuous, since virtually every developed country apart from America offers universal access to healthcare. But talk of ‘selling the NHS’ is a quick way to silence any talk of reform, to cover up the fact that in other parts of the world it is market-plus-charity oriented systems that have adapted better (and faster) to crisis mode.
Meanwhile, Johnson has taken political adulation of the NHS to new levels. It was invoked on his Brexit bus, then invoked to ensure compliance with lockdown. The slogan ‘Protect the NHS’ appalled senior figures at the health service — but focus groups showed that people who distrusted the Tories did trust the NHS. ‘Test and trace had nothing to do with us,’ says one senior NHS figure. ‘They used our name to get people to fall in line.’
It’s a tempting crutch for ministers to use. Even Javid, who intentionally forgoes the NHS badge so as to not idolise the service, got swept up in NHS-mania a few weeks ago, tweeting at someone complaining about their vaccine experience: ‘How about you show some respect for the NHS?’
Of course we should thank the doctors. But how much respect does the system deserve, given that it is currently preventing the treatment of the sick, yet still keeps nurses’ pay below their Chilean, not to mention their European, equivalents?
This explains the growing panic inside government: ministers can see the current model is failing, but no one is allowed to publicly point it out. The Health and Social Care Bill passing through the Commons will address few of these issues, as it seeks to further centralise care.
Should it be so dangerous, politically, to say that doctors and patients deserve better?
‘It should not be sacrilegious to say that the NHS is failing,’ said Johnson in 2002, when he was The Spectator’s editor. ‘It is all very well to treat the NHS as a religion, but it is legitimate for some of us to point out that, insofar as it is a religion, it is letting down its adherents very badly.’ Nearly 20 years later, the journalist-turned-prime-minister was nicking a journalist’s phone and jumping inside a fridge on the campaign trail to dodge questions about overflowing wards and poor NHS service.
The old Boris Johnson was right. In trying to protect the sanctity of the NHS’s reputation, by refusing to acknowledge its shortcomings, politicians are putting the principle of universal access in jeopardy. If you can’t see your doctor, the ‘free at the point of use’ principle becomes less relevant.
As we emerge from the pandemic crisis, there couldn’t be a better time to resume the conversation Johnson tried to start 20 years ago. Too many good people are trapped in a bad system. It ought not to be heresy to talk about how we might set them free.
Data reporting by Simon Cook. Kate Andrews discusses NHS reform on this week’s Spectator TV and The Edition podcast.