The UK National Health Service: a MONSTER out of control

Roger Watson

The UK NHS was formed in 1948 to address a problem that largely did not exist. Medical care was far from perfect prior to the formation of the NHS and largely provided by a combination of private and charity hospitals. Gaps in care certainly existed and some GPs made vast amounts of private income. But others served the poor for very small financial contributions made possible by the fact that they could charge richer patients more for their services. This enabled them to provide care, often for free, to their poorer patients.

Whilst anecdotes abound, there was no systematic evidence of the inadequacy of health provision prior to 1948. Instead, the novel The Citadel by A.J. Cronin was used as an example of healthcare disparities in the UK. Based on Cronin’s experience of general practice both in a Welsh mining community and also in prestigious Harley Street, The Citadel describes the disparities and the low levels of health and healthcare amongst poor working class communities. But the book is a work of fiction, not a research study. Plus ça change, we have still have significant health disparities in the UK, described as a ‘postcode lottery’. Where I work in the Northeast of England, if you turn left from my house towards one of the more affluent areas of the city compared with turning right towards one of the largest municipal sink estates in Europe it is reckoned that there is a ten to twenty year disparity in life expectancy in favour of the affluent area. As explained, the NHS was not formed to solve a genuine problem. If it was, it has manifestly failed.

THE NHS IS POLITICAL

The NHS was formed to fulfil a political agenda. It was expected that the incumbent Prime Minister Winston Churchill who had led the UK through the Second World War and was much loved by the British people would win the general election after the war. Instead, he was defeated, and a socialist Labour Party gained power. This paradoxical result was achieved to some extent through the activities of the Royal Army Educational Corps which had become infiltrated by communists. In its role of helping to return thousands of men and women—many still young—to civilian life and employment it radicalised the demobilised troops. The NHS thus became the ultimate brick in the wall of the Welfare State, a Liberal initiative that had begun between the two wars. And it remained largely unchanged for its first quarter of a century.

ENDLESSLY REARRANGING THE DECKCHAIRS

Fast forward past countless subsequent reforms, reorganisations and initiatives to the present day. The only certainty about the NHS is that, annually, it receives an increasingly larger slice of taxpayers’ money.  This also represents, since inception, an increase in percentage of GDP that has more than doubled. The NHS largely provides a good service thanks to the hard work of its staff but nothing regarding the organisation and management of the NHS makes a positive contribution to the care patients receive. There is not a shred of systematic evidence to demonstrate that reorganisations have proved beneficial. In any case, before the implementation of one change has been completed, another is being planned. The Nuffield Trust provides a very useful timeline of reforms and the fact that it is all but impossible to count the reforms which range from major to minor, local to national and which sit alongside a plethora of funding scenarios and clinical staff training models says it all. One striking illustration of the extent to which reorganisations have influenced the NHS is the fact that, according to THE lowdown webpage, in the past quarter of a century the “Numbers of relatively local bodies running the NHS have up to now varied from over 700 to as few as 80”.

…BUT STILL SINKING

Everyone knows what it wrong with the NHS, it is overfunded and underperforming, but nobody dares to suggest the radical reform that it requires. It is now largely a cliché but the NHS is often referred to as the ‘jewel in the crown’ of the UK welfare state. That said it is yet to be copied in its entirety by any other country and, while it has been ranked even lower in the past, it currently only stands at tenth in the global rankings of health services. Moreover, as the NHS continues to attract increasing annual funding with political parties of neither shade having the courage to put a stop to this, satisfaction with the NHS continues to decline amongst British people. The NHS is like a ship that is holed below the waterline and sinking fast. Instead of investigating and plugging the leak, the captain orders more cabins to be built above deck. Thus, the structure grows and an increasing number of senior managers accumulate salaries that are way above the national average. Indeed, many earn more that our Prime Minister.

THE POST-COVID ERA

In the age of Covid, still with us as I write, the NHS has been exploited but, in its turn, has exploited the British public towards its own ends. The NHS was exploited—or, rather, its front line staff were—in the sense that they were expected to manage a pandemic without the proper equipment due to a lack of planning and funding and the lack of political will to put existing pandemic plans into operation. Luckily, the pandemic in the UK turned out to be a lot less severe than the modellers had predicted. The NHS was briefly ‘overwhelmed’ in the early days of the pandemic but has largely coped. This is well illustrated by the fact that the much heralded Nightingale hospitals, built to alleviate the major hospitals, stood empty for months, were probably a waste of resources and eventually closed. But this did not prevent the NHS ‘upping the ante’ regarding the likely effect of the pandemic. The ‘overwhelmed’ narrative continued—and continues—well beyond the point at which the NHS was overwhelmed and well beyond the bounds of credibility. The NHS in turn has milked the attention it received in the media and by the public in futile gestures such a Clap for our Carers. 

But a worse and probably longer lasting effect of the pandemic has been the instillation in the minds of the British people that we are here to serve and, indeed, to save the NHS. In fact, Stay Home, Save Lives, Protect the NHS was one of the more insidious slogans of the Covid era. It ranked with the emotional blackmail in the exhortation not to kill Granny by ignoring Covid restrictions. The NHS and its spokespeople took to the airwaves to lecture the public on how to behave, who to see and what to wear. We were prevented from seeking treatment in almost all circumstances except emergencies and even then, a very poor service was provided. Ambulance response times have doubled. Screening programmes were put on hold, operations were cancelled leading to deaths and a huge NHS backlog was created that may take years to clear. 

It is beyond my capabilities to say exactly how the NHS could or should change to make it more efficient and to restore the rightful balance between it and the public who—without choice—fund it. We could begin by stripping out several tiers of management but that is merely another reform. Probably the whole funding model needs to change and possibly the very existence of an NHS needs to be questioned. But any suggestion that, for example, people could make a nominal financial contribution for visits to the GP in an effort to discourage trivial appointments is met with howls of protest. The myth of free healthcare, at least at the point of delivery, has been perpetuated since the NHS was formed. But the word ‘free’ should never be used in relation to the NHS as it is not free at any point. We pay for it and increasingly it seems to treat us with contempt. Lord Sumption has pointed out that “The NHS is a facility not a regulator”. The problem is that nobody seems to have told the NHS.