The Decline and Uneasy Future of the National Health Service

Published: Jan 13, 2023  |  

Mental Health Nurse & author

Has the English National Health Service (the NHS) had its day? If we conducted a benefit-cost analysis, it’s unlikely that the benefit of “health” would be best achieved for the cost of an NHS that is broken with no workforce plan and chronic morale problems. Further, a third-rate trajectory begs the question: is this path by governmental design, or is it the result of gross ineptitude?  

It began well enough. Postwar, 1942 William Beveridge identified five giants on the road to post-war reconstruction,” including want, disease, ignorance, squalor, and idleness. Tackling these giants was a primary focus of the 1945 government’s social program and remained important throughout the second half of the 20th century. Beveridge suggested various legislations and improvements in the welfare state to alleviate some of the aforementioned evils.

The NHS has an iconic status. British, along with the queen. It marks out for inspection by the world the enviable British value of fairness, and it is held on to with unreasoning pride. Yet recently, it has changed, notably morphing into a relic, a withering pastiche of its former self, a burden on the economy. The question must be: while we lost the queen, will we also lose the NHS?

 Healthcare is typically evolutionary, dynamic, fast, and frequently changing, and of course, people always want more when it’s free. Today’s healthcare is unrecognizable from that of the 1940s. Yet Great Britain, the base of the NHS, is no longer great, but a shrinking pimple on the backside of a developing world. An inertia has infected this national treasure that seems to mirror societal low expectations and demise. We no longer rule half the world but employ staff that finishes shifts to go to the food bank, that can’t heat their homes, and must engage in rhetoric justifying the withdrawal of labor. Quick loans, credit cards, and the volume of work have junior doctors leaving almost as fast as general practitioners. 

Yet the public seems oblivious and even alarmed by the suggestion of a different path of evolution to match the changing times. Beveridge and Bevan would surely have adopted a slightly different system in 2022 that reacts assertively to food banks as a norm, to begging and homeliness as standard, to mitigating squalor, and to energy as a service for the wealthy. However, when Beveridge and Bevan were about, Great Britain was a metaphor for a huge Empire, a definite force in the world. Is it by design that doctors and nurses are dissatisfied and walking away, that the ambulances are striking, that waiting lists are growing, and the situation regarding patient safety is worsening? Is the government readying everyone for a change in healthcare policy? And if so, would that be such a bad thing? The NHS is a cathedral, a leftover of the British Empire that, for fiscal reasons, would never have been attempted today. 

The Current State of the NHS in the UK

The population of the UK in 2021 was 66.33 million. According to national news feeds, we have trouble recruiting (12,000 doctors short and 50,000 nurses short) while the NHS costs just under 200 billion a year and the situation is projected to worsen simply because we are not currently training enough people to replace those who have left or retired. 

At the foot of a recession with rising inflation, both post-COVID and, of course, post-Brexit, working conditions and salaries are being contended by the central government while employees and patients get desperate. The NHS is being deconstructed by stealth with the emergence of private providers, out-of-pocket spending increasing, low staffing, and low pay, leaving the NHS decaying in its own popularity. On top of that, waiting lists for treatment have become intolerable and getting to see a GP is almost impossible—according to the the Kings Fund, “By March 2022, there were more than 300,000 people waiting more than a year for routine planned care.” So, is the government’s plan really no change, it will get better?” It is glaringly clear to those that experience it, that there are no answers, with every projection pointing to a deepening crisis.

Further, an increasingly common tactic of politicians is to remove themselves from the debate. It is unwinnable. Everyone will be familiar with the oft-heard quote, “it’s got nothing to do with me gov, it is the pay review bodies’,” neatly swerving that is they who set the terms of reference of those very review bodies, denying any influence on pay and the like, excepting to say that we can’t afford it.  

Even the opposition seems to be rabbits in full beam, unable to sort this Rubik-cube. Another ridiculous comment is that we should remove the politics from the NHS. Anything that costs in the region of £200 billion annually will of course, be political. 

Expressed as GDP, in 2022, the UK spent 12% on health: the highest is the USA at 18.8%, the lowest is India at a mere 3%. We are at about average spending, so couldn’t we reorganize to more efficient models of funding?

Possible Next Steps for the NHS

One possible option for reorganizing the NHS might be implementing a “pay as you go” model. This model is often referred to as out-of-pocket (OOP). From the literature, equity and fairness seem to be an issue, as is universal coverage. Under this model, the elderly and out-of-work do not appear to get similar coverage to the general population. This system is generally reserved for poorer countries, and provision is rationed.

Alternatively, we could adopt the Bismarck model. This model is funded by insurance payments made jointly by employers and employees. Patients who pay into these schemes have access to sickness funds,” which are used to pay for health services. Countries using this approach include France, Germany, Japan, and Switzerland. So all is fine, assuming employment. A considerable advantage of this model is that it reinforces competition, reduces waiting times, and improves quality.

Why not create our version of ObamaCare? This initiative was meant to address those in the USA who have no medical insurance, offering a type of safety net. The legislation aims to deliver more Americans with access to affordable health insurance, thus furthering universality. It also aims to improve the quality of healthcare and health insurance and make healthcare affordable to the taxpayer. Or: we pay national insurance, so why not use the NI model? This model takes in elements of the Beveridge and Bismarck models. The term is misleading, as most healthcare models have some form of central funding.

The NHS is not affordable in its current form, and has been deteriorating for well over a decade now. If we are to have reform, let’s have proper restructuring. But to make that happen will require someone to have the bottle to say something.

Finally, there is the welfare state—so poor it has been referred to as “the ill-fare state”—which requires massive reform. It would be good to refocus on Beveridge’s five giants on the road to reconstruction—stop sleepwalking into a queue and change.

Whatever we do, we must all take shared responsibility. A lowering tide will keep all ships aground.

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