Is Britain loving the NHS to death?
I remember blessedly little of the night the National Health Service saved my life.
Waking in the throes of an overwhelming asthma attack, I had just enough breath, and presence of mind, to stumble into my parents’ bedroom. The last thing I recall is gasping out a desperate plea — “Do something, anything” — before collapsing into an oblivion that lifted only many hours later in hospital. A nurse, in a tone of chatty unconcern, began asking me questions about myself, which I answered politely if a little bemusedly. Only afterwards did it occur to me she had been checking for signs of brain damage.
In my family’s eyes, the paramedics and doctors who had treated me were far more than individuals to whom we owed a debt for their skill and professionalism. They stood as symbols of a system of universal free healthcare that has served Britons without caveat or credit card for 70 years. It is hard, in similar circumstances, to imagine an American feeling gratitude not only to his physician, but to his health insurer.
The story is a skein in the tapestry of my life but scarcely a household in the land would lack a similar anecdote: the inevitable consequence of a system that, in the words of its 1940s progenitor, the social reformer William Beveridge, covers everyone “from the cradle to the grave”.
This intertwining of the service with its users’ best and worst times has created a relationship that is as much emotional as transactional. Consider the 2012 London Olympics opening ceremony, for example: how many nations would assert their essence to the wider world with a stylised parade of nurses and hospital patients?
But the fealty increasingly persists in defiance of the facts. While, at its best, the care the NHS provides is world-class, in some areas it falls shockingly short. The service’s proudest claim has always been access for everyone, yet attaining a timely appointment with a general practitioner — the gatekeeper to the wider health system — has acquired the aspect of a mythic quest. Those least able to do so, the elderly and sick, often find themselves having to battle for attention. Queues for hospital treatment, which fell sharply following an infusion of cash in the early 2000s, are now rising again.
Yet a majority of Britons declare themselves “very” or “quite” satisfied with the NHS, while support for its founding principles is ironclad. It is hard to escape a sense that reverence for the model is leading the British to overlook or rationalise its failings, while the passion with which they resist any serious changes — even, on occasion, closing down a demonstrably unsafe hospital — speaks of an institution that encapsulates the nation’s sense of itself.
As the NHS enters its eighth decade, is there a collision between what we want it to be — a health service fit for a demanding, developed nation — and what we need it to mean?
A child of the NHS, reluctant beneficiary of its vaccination programmes and standard-issue spectacles, enthusiastic consumer of its free orange juice, I suspect I have been as guilty as most Britons over the years of subscribing to a rather smug kind of exceptionalism when it comes to our health service.
Much of this is due to a tendency to compare it only with the US, a system Britons are inclined to see as the service’s evil twin, as heartless as the NHS is munificent. (Stereotypes cut both ways. In debates over reform Americans are as likely as the British to deride the other’s, supposedly reprehensible, system in defence of the status quo.)
The spare, strangely powerful prose of the pamphlet in 1948 that introduced the new service to a country still suffering the privations of wartime rationing exhilarates a little even today: “Everyone — rich or poor, man, woman or child — can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a charity. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”
Yet Paul Johnson, a leading British economist who recently co-led an inquiry into its future funding needs, argues the US is an international outlier, and thus the wrong point of comparison for a service that has never been as unique as Britons like to believe.
“No other large advanced economy has anything like the US. [The western Europeans] basically all have something that looks a bit like the NHS. Some call it a social insurance system, some call it a tax-financed system. But it’s basically free at the point of use, near enough,” says Johnson, who runs the Institute for Fiscal Studies.
“We spend an average amount of national income on the NHS. About the average for the rest of Europe. Our outcomes are average at best. You can make an argument they’re below average for what we spend,” he adds.
Take cancer, where British survival rates lag some other European countries, including several that spend an equivalent proportion of national income. The UK is consistently among the four countries with the highest mortality rate for breast cancer, for example: Spain, which spends about the same, has among the lowest.
Late diagnosis can itself be a British disease. My father, who had viewed the NHS as an expression of our national humanity, was diagnosed with cancer six and a half weeks before it killed him. Days earlier a GP had described him as neurotic. As that same doctor left the house after signing my father’s death certificate — the cancer so pervasive it had proved impossible to determine in which organ it had originated — he stuck out his hand and reflexively I shook it. I have always regretted that.
The service’s untouchability, at least in the minds of politicians, has ironically added to its problems since austerity began reshaping Britain’s welfare state in 2010. While the past eight years have been the most consistently lean since the service began, health was one of the few areas of public expenditure to be allotted the scant protection of minuscule real-terms rises.
At the same time other areas, which Beveridge would have seen as making their own vital contribution to public health, have suffered deep cuts. This has applied most devastatingly to social care for elderly and disabled people, many of whom have ended up in hospital beds for lack of any alternative.
The NHS, in other words, has become the safety net of the safety net.
Seventy years ago Britons still lived in dread of infectious diseases such as tuberculosis or polio; the latter could strike down a child within days of a jolly outing to the local swimming pool. Now the biggest demand on the NHS comes from the multiplying chronic conditions of an ageing population, which can require treatment for decades — a tribute, in its way, to the success of the NHS in keeping us all alive for longer.
Yet despite this transformation in the pattern of disease, the structure of the health service remains very similar to that of the 1940s, with all-too-often impermeable divisions between hospitals, GP practices and social and community care.
The service’s untouchability has ironically added to its problems since austerity began reshaping Britain’s welfare state in 2010
None of this is lost on healthcare leaders. A national plan for England published almost four years ago vowed to “take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care”.
However, the vision has been marred by subsequent cuts not only to social care but to the budget for preventive health. Incentives also remain misaligned. Hospitals are mostly paid on the volume of patients they treat, giving them little reason, financially at least, to try to stem the flow through their own doors, at a time when even the nation’s most distinguished institutions are struggling with deep deficits.
How, then, to break our national addiction to hospitals? In search of a different approach, I travelled to Tower Hamlets, a borough in London’s East End that has one of the most deprived populations in the country, to visit Sam Everington, a local GP who runs the Bromley-by-Bow health centre. I first met Sam 30 years ago, when he was a firebrand junior doctors’ leader and I was a neophyte health reporter.
Grey-haired now, and knighted three years ago by the very establishment he once harried, he has channelled his instinct for subversion into running a very different kind of health centre. Alongside medical care, those who attend are offered advice on employment, housing — even relationships. Everington rarely gives out sick notes: “If you get a job, you will be healthier. Full stop,” he says.
As we chat to the accompaniment of birdsong in the beautifully tended garden that surrounds the centre — bare of any NHS logo or branding — Everington argues that the fundamental mis-step of the past 70 years has been the emphasis on “biomedical medicine” in contrast to the far broader definition of good health that Beveridge had embraced, which included work and decent housing. “What we know is that at least one in seven of the procedures in the NHS probably shouldn’t be done. There’s not good evidence for them,” he says.
As proof that this is a broken model he produces some grim statistics about his own patients. “The tragedy is, for a lot of my children locally, they are actually in worse health than [their counterparts in] 1948,” he says. Half of all five-year-olds in Tower Hamlets are Vitamin D deficient and suffer from severe tooth decay; 11 per cent are obese, rising to 23 per cent by the age of 11.
“The final shocking thing”, he says, “and why this has to be a wake-up call for schools and the Beveridge wider project”, is that the cognitive development of his five-year-olds is 10 per cent lower than average. “So where does that leave you in your life chances? . . . And to me that’s an absolute tragedy,” he adds.
Most doctors are trained to find out what is the matter with patients, an approach that positions medics as all-powerful diagnosticians. For Everington, the question needs to be turned around: “what matters to you?”
All terminally ill patients are given his mobile phone number, ensuring they can summon help to their own timetable, not that of the medical professionals. In some areas, such measures have reduced the number dying in hospitals rather than at home by two-thirds.
He adds: “The fundamental principle needs to be that everyone in the system needs to feel responsible for the population, and before they become ill . . . So hospitals should be thinking: What can we do in our local community to stop people even starting smoking?”
At times in its recent history the NHS has flirted with market mechanisms to drive up performance and increase capacity, but the momentum has slowed in recent years; now the watchword is collaboration, not competition.
While many western European countries live happily with a mixed health economy, it is a peculiar aspect of the British pathology that the greatest act of courage a minister could commit would be openly to advocate for a greater role for the private sector.
Perhaps the most transformative shift the NHS could make, however, would be to stop seeing itself as a beloved public service and start operating like a regular public-facing industry.
It is the world’s fifth-largest employer, and health and care services make up 10 per cent of the economy, yet the NHS still runs as a series of individual fiefdoms, commissioning and providing treatment. Many suffer from a bad case of “not-invented-here syndrome”, so that even demonstrably successful changes to management practices, or ways of delivering care, spread slowly if at all.
Stephen Dorrell, a former Conservative health secretary and now chairman of the NHS Confederation, suggests some of this stems from our view of the NHS as a vehicle for delivering social equity rather than a service in which change is as normal and necessary as in any other area of economic life, when demands alter or technology advances. “We think that the NHS isn’t subject to those principles but actually it does need to be, otherwise we’re actually undermining social justice and equity because we’re regarding the institution as more important than the objective,” he says.
Some in the NHS are fighting the good fight. Take Salford Royal Hospital in Greater Manchester, whose chief executive Sir David Dalton is one of the service’s real stars. Quietly spoken, a man who takes delight in evoking ideas from his frontline staff rather than trumpeting his own, he has succeeded in “systematising” change in a way that has eluded much of the health service.
At this big inner-city hospital, which has a palpable buzz of engagement I have not encountered at similar institutions, knowledge is a resource to be shared with patients and their families, a medium for accountability. Outside each ward a large whiteboard shows performance on a range of different measures, such as the proportion suffering from pressure sores and when a patient last fell.
In a rare development for the NHS, Sir David now also oversees four neighbouring hospitals, where he has succeeded in entrenching the approach honed at Salford. “You maintain services which are responsive to local needs but you do it within an operating framework where people do cede their sovereignty into the group to determine what’s in the best interests of all,” he says.
Standardisation of provenly effective operating procedures: outside the NHS that would scarcely rank as radical.
Amid a post-Brexit search for national identity, it is perhaps not idle to ask what part the NHS will play in how the UK sees itself after it leaves the European Union.
The health service remains a symbol of security, or the absence of it. That much was obvious from the result of the Brexit referendum, in which a rhetorical flourish by the Leave campaign — a pledge to deliver an extra £350m a week for the health service if Britain quit the EU — seems to have swayed votes, not least in areas where the service has endured some of the steepest cuts.
Yet there is something about the NHS’s very size and opacity that makes it hard to have a debate about how it should be run that does not descend into caricature, argues the IFS’s Johnson.
“We’ve never really worked out how to . . . balance [giving] appropriate autonomy, which you have to have in a system that big, [with] levers and controls and accountability. As soon as you start that you immediately get terribly simplistic: ‘You need a market’. Or ‘you can’t privatise it’ . . . It doesn’t work in political discourse.”
Nevertheless, a national reckoning is coming, with or without a national debate. Until now, the NHS’s outsize share of public spending has been made possible in significant measure by steep cuts in the defence budget. No longer, however: the peace dividend has expired. Now Britons may either have to accept even bigger cuts in the remainder of the welfare state — which spends far more proportionally on health and pensions than 30 years ago — or pay higher taxes.
Either route may lead them to turn a sharper, less misty-eyed gaze on the way it is run. This is no bad thing. For if we cannot overcome our national romance with the model we have always known, we may be in danger of loving the service to death.
Sarah Neville is the FT’s global pharmaceuticals editor
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