Each and every winter the breaking news tag flashes across our screens to decry a “WINTER CRISIS” and yet all of them pale in comparison to “CHRONIC CRISIS” currently pulsing through the NHS. Average waiting times for an ambulance in England and Wales sit at over an hour, over seven million people are on elective waiting lists and within hospitals themselves there aren’t enough beds, enough staff nor the ability to discharge. Those staff retained are taking strike action to plead for reform of the system as well as a decent wage to cope with a brutal cost of living crisis.
As several commentators say, the front door of the NHS is broken, and the exit is clogged. In the middle of this crisis, media attention has drifted from fixing the crisis itself, by negotiating with the nurses and finding solutions to bed shortage and discharge, to questions around the pre-existing ‘model’.
The idea established by Nye Bevan in 1946 with the National Health Service Act and delivered under Clement Attlee’s Labour government in 1948 was that healthcare should be “free at the point of use”. This principle has until now been adhered to, paid for by general taxation. Yet, with recent interventions by Sajid Javid that we should pay for individual visits to a GP (£20) and A&E (£66) and the wider desire to shift toward an insurance model, we have to ask ourselves, is the model we currently operate the right one? The answer is, like most things, Yes and No.
The NHS is such a complicated machine that to be able to explain and understand its issues would not be possible within one article and so I will here only be dealing with the current way the NHS is funded and how it deals with physical health, particularly its emergency response. However, these alone cannot explain the current state of the NHS, as 33% of its capacity is absorbed by those requiring social care and another 23% is occupied with mental health-related issues as logged in 2018. Not to mention the importance of the forgotten art of community and preventative medicine. Therefore we are judging a system operating, truthfully, at 44% capacity. Is that fair? Yes and No.
NHS funding
Firstly, we must discuss the funding. As it stands the NHS budget for 2022/23 will be £180.2bn and although that number appears large, the current pressures cannot be explained by it, rather we must look back over the last 13 years to understand how chronic underfunding and poor prioritisation allowed the flashpoint of a pandemic followed by a heavy flu season to bring down the entire system.
Prior to 2010, the NHS had received on average a 4.1% yearly increase in its funding since its inception, between the years 2010 and 2016 this nosedived to 1.3% as a result of the austerity programme. The programme removed some £284bn from the system between 2010 and 2019 according to the BMA. This is equal to more than the government spent on health in its 2021 pandemic budget. To put that in perspective, in pure equitable terms that £284bn is enough for eight and a half million new nurses. Of course, that comparison is facetious but the point still stands. That’s a lot of funding the NHS could have used to modernise, invest and ultimately cope with a once in a generation pandemic.
NHS investment
However, funding alone isn’t the solution to the NHS’s issues if the funding is not being invested properly. Here we come to perhaps the greatest issue with the way the current model works.
Regarding physical health, funding is allocated between operational work and capital investment. Between 2010 and 2019 £71.1bn was assigned to capital investment, which includes maintenance of all NHS buildings, equipment and the building of expansions/new hospitals and infrastructure. The overall Department of Health budget for this period was £1.36tn. Capital investment therefore accounted for just 5.2% of funding. This is key when discussing the front door of the NHS, specifically in regards to A&E waiting times, as well as ambulance delays.
Why? Because, whilst doctors have risen in number from 97,048 in 2011 to 124,078 in 2021 and nurses from 300,466 to 333,660 over the same period, equating to 46.6% of the budget, there has been no increase in productivity. Since 2019 the number of NHS treatments has gone down. 44% of ambulance handover times were longer than 30 minutes in the week of 1 January 2023 and A&E waiting times for some exceeded 15 hours. This is in large part because these increased levels of staffing are stuck dealing with symptoms rather than finding the root causes of why patients are there.
It is no coincidence that within the OECD the UK has a very low number of MRI scanners (8.6 per million compared to say 25.6 in Switzerland) and one of the lowest number of CT scanners (10 per million versus 28 in Sweden). One may ask: “where the delays are if staff have increased?”. Firstly the inability to diagnose, limits the ability to treat. Combine this with the third fewest patient beds in the OECD (2.3 per thousand against France’s 5.7), falling by half in 30 years, and the arteries of any hospital, even one with high levels of staff as well as high morale, would start to clog and churn to a halt. Especially if it were only able to treat physical emergencies at 44% capacity.
Government control
Perhaps the greatest limitation with the current model, especially regarding emergency care, is not the funding formula, in which any extra funding according to the multiplier effect would pay back half of the cost due to circulation in the economy and welfare bonuses more widely and could easily be covered by the approximately £46bn annual cost of tax avoidance (£32bn for non-compliance and £14bn for fraud). No, it is in the government’s direct control over capital investment, which is not adjusting to meet the needs of the population by improving infrastructure and diagnostic capacity within trusts. It is not seen as headline-catching or a vote winner.
What we need are independent NHS ‘capital investment tsars’ with a remit to report, free of the Department for Health and Social Care or the Treasury, on the needs of NHS capacity and diagnostic ability. Without such independent assessment, I fear that the core problem of crumbling infrastructure will not be addressed and that privatisation will be seen as a cure-all. The private health care of the USA costs a lot more than our NHS. Private medical care appeals precisely because of its extraordinary investment, but that is recouped from those who can pay. The NHS needs to adopt a similar approach but investing for all and not just those who can pay.
The NHS’s limited capacity when dealing with emergency care can be fixed, if we invest in modernising the system through greater embracing of the technologies so prevalent in similar developed nations. Only through this investment can we ensure the horrifying scenes so common in today’s hospitals won’t persist long into the future.
So, is the NHS model broken? The approach to capital investment certainly is, but the principles and the source of funding remain strong and affordable for a government with the right priorities. However, that is only 44% of the story. What of the other 56% covering social care and mental health provision? That’s for another time.
