The collapse of the NHS is on the horizon
To blame COVID-19 for the waiting times is to ignore how capitalism has led us here.
Since the post-war period of the late 1940s, the UK has had the National Health Service. It was originally created to tackle the issue of health outlined in the Beveridge Report. A population struggling since the beginning of the century, was now facing the effects of total war. It was necessary to modernise healthcare which would determine the future of the UK.
The NHS would make accessing care free at the point of access - instead funding from tax contributions was used to ‘pay for it’. This idea was incredibly popular at the time as the precedent had been set long ago that the government was responsible for providing aid to those who needed it. However even in the early days of the institution cuts were made. The Bevanite Revolt saw Bevan (the brain behind the NHS) rescind his place in government over the costs introduced to dental care and prescriptions. Despite the looming ‘threat’ of Communism, people were angry that a basic right was becoming a chance for profit.
The NHS being funded by tax means it is the responsibility of the UK government. The government collects the tax, and alongside any other income it receives (perhaps through the sale of bonds) makes up the amount of money they have allocated for public spending. This has to cover the wages of all government employees, funding for different sectors, and any debt it has incurred. And despite all the evidence in the contrary, the latter is considered most important. The level of national debt is usually considered the biggest indicator of a country’s economy, despite it being almost impossible for a balanced budget to be achieved by a wealthier nation. This focus on appearing to control national debt has meant wages and funding have fallen to the wayside. And even within these two categories there is discrepancy with which sectors get more of the budget.
The government is expected to collect around £1,058 billion from taxes (roughly £37000 per household) but is forecast to run a defecit of £131.6 billion. This shows that more money is being spent than coming into the hands of the government, and therefore the UK has ‘national debt’. In attempts to make this look better for the government, many cabinets over the past few years (especially following the 2008 Financial Crash) have attempted to cut how much is being spent by the government to make the input and output match.
In a practical sense, austerity cuts have been seen majorly since the Coalition Government of 2010, which notably passed the 2012 Health and Social Care Act. The aim of the budget was for the NHS to be managed more like a business, focusing on cutting costs and increasing efficiency, rather than increasing the quality and reach of care. The NHS was advised, and legislated, into spending the money they were allocated in a worse way.
When considering the NHS, many people think only of hospitals or GPs, but health and social care is much more than that. Cutting spending and loosening policies in this area leads to the closure of childcare and educational centres, decreasing education funding, more dangerous work hours, unstable housing, and generally an inability for the majority of people to live a healthy life. All of this means that the amount of people in need for healthcare is increasing, whilst the ability the health care system has to treat them decreases.
An obvious example can be seen with smoking. A decrease in funding for schools means less education on the dangers of smoking, as well as lower paying jobs. This makes the children more susceptible (as they grow older) to begin smoking. Smoking increases health issues for people smoking and those around them - but despite the increased demand, there is less money going to hospitals to run checks but also to treat those with smoking related ailements. This further compounds and the healthcare system becomes overwhelmed.
There are 2 main ways a health concern can begin to be treated, with the most common being through a GP practice. GPs essentially triage situations, and decided who is best suited to treating an issue (if at all). GPs are notoriously stressed due to the sheer amount of people and their variety in concerns on a daily basis, with 35% suffering from anxiety, depression or burnout. This level of stress has led the number of full-time GPs falling by 5% between 2016 and 2019 and very few newly-trained doctors are willing to take this momentous task on. The continuity provided by GPs is important for many long-term or complex cases, and this means there aren’t enough GPs to keep up with the new patients or the pre-existing ones. It is well established that the over 4 month wait period which can be seen from the first GP appointment to getting a referral means that many people were going to A&E despite not needing inpatient hospital treatment and causing over-crowding. On the other hand, many people with serious conditions were never made aware of this as they were unable to access care from their GP. With the issues facing the first step of the chain, the effect only snowballs.
Once the referral process from the GP begins, depending on the nature of the condition, the legal right is to begin non-urgent consultant-led treatment within maximum waiting times. On the NHS website the maximum waiting times for non-urgent treatment is 18 weeks from the moment the service receives the referral letter whilst for suspected cancers it stands at 2 weeks. This issue has been the target of many plans for decades, with Rishi Sunak most recently announcing that reducing waiting lists was a priority for 2023. But year after year the NHS has continued to struggle to increase the proportion of people on their waiting lists that are actively getting treatment. The rise in waits shows that there is a mismatch between the treatment people need to access and the resources healthcare services have. For waiting lists to start falling a meaningful amount, there would have to be a complete restructuring of how funding is allocated, which is quite the opposite from the austerity measures which have been seen.
A&E has much clearer admission and discharge statistics as well as visually representing the majority of the interactions people have with the UK healthcare system. Even pre-pandemic the wait times at A&E departments were abysmal, and it has only been highlighted by the pandemic how critical the conditions are.
The underfunding in other areas of the healthcare system has led to A&E departments receiving the patients that would go into other areas as well as their own increasing caseload. More and more people are going to A&E rather than their GP, or due to their inability to access a GP are forced into critical conditions which require A&E treatment. These departments are stretched beyond capacity and the beds aren’t able to be cleared because the other services lack funding and resources. These A&E delays which have been increasing since 2011, are not responsible for around 500 deaths a week.
Many people have only picked up the crumbling remnants of the NHS in the aftermath of the pandemic. It was clear in 2020 that hospitals were unable to treat the capacities they were supposed to, and that underfunding meant the country was unprepared for such mass events. However, research and professionals have been warning us for decades - “if you’re at the front line, you know that this is a longstanding problem”. And when politics influences healthcare the consequences are real. Many are quick to assume that who they vote for and if they vote doesn’t actually matter. But the people in power are choosing how much funding goes where, and this can be seen clearly. Cuts to public services across Britain from 2010 contributed to 335,000 excess deaths and life expectancy has fallen by 1/5 for women and 1/10 for men by 2019. Austerity measures are more than just the ballot, they have real implications for people’s lives. As with many issues, those with lower incomes are affected disproportionately. The UK has the worst access to healthcare in the entirety of Europe, despite being considered one of the world’s wealthiest nations.
The changes to the NHS largely came after the death of Ian Weir, a reknowned photographer, who passed away on the waitlist for a triple heart bypass. The death of someone in the public eye shocked politicians into action to reduce waiting lists. The Labour government of the 2000s worked hard to ensure that healthcare was more accessible. But after the 2008 financial crash and the introduction of a new coalition government, policies towards the NHS changed massively.
The first austerity policies saw cuts to social care and public health budgets, which we have seen over 10 years later has made it near impossible to keep people healthy outside of hospitals and in the long term. Their aim was to cut the capital budget which pays for the buildings and machines - this meant a manufactured cap on modernisation and investment in the quality of healthcare. So although the percentage of GDP put towards public expenditure decreased by 10% in 10 years, the estimated costs of the backlogs it caused is well over £10 million. The government made short-sighted decisions to cut back critical investments in preventing poor health and services that evidence showed worked and prevented this were scaled back. Although not necessarily explicitly said, the aim was to run the NHS like a business which would be maintained through the market competition, and so in order to manage the norm was to keep staff salaries below inflation and to employ as few professionals as possible.
But austerity affected more than just the health sector, pensions and disability benefits were cut, which amongst others lead to 1/5 of the UK population living in poverty by 2019. It is a well-established fact that poverty is directly detrimental to physical and mental health. Austerity impoverished millions of families whilst simultaneously removing the safety net meant to aid them. More people in Britain died due to austerity in the five years before the pandemic than died from COVID-19 in the first three years of the pandemic. And the mortality rate of COVID-19 could have easily been reduced had funding and training been protected from austerity cuts. And whilst promises were made by politicians throughout the 2010s that the NHS would be protected from the cuts, they were only ever protected relative to other public services. There was still a net decrease in the spending going towards the NHS despite the demand increasing.
With this background, it is no surprise that the pandemic was so damaging not only to the NHS but to the British economy as a whole. The hospital system had been so depleted that it could only meet the needs of Covid-19 patients by abandoning almost all other kinds of care. And even so, the lack of funding meant once the cases reached the hundreds, the NHS relied on temporary hospitals, out-of-date PPE stocks and a limited ability to test. During the pandemic, more than 4/5 hospitals in England were operating with a dangerously low spare capacity that is far from inherent to pandemics. The low spare capacity was the direct product of underinvestment. This lack of funding led to poor staffing levels and training, as well as a lack of crucial equipment such as ventilators.
The government, faced with critiques across the media, realised that perhaps funding the NHS would increase the capacity and quality of care. But instead they placed their trust (ie: the taxpayers’ money) into private companies such as Serco and Capita. The UK government had been systemically underfunding the NHS, were shocked to learn that it was rendered essentially ineffective, and then chose to fund private firms because they were aware that subsidisation would increase their capacity.
It is almost as shocking to hear that hospitals faced financial penalties from the government if they kept patients waiting for more than 18 weeks for surgical treatment, despite lacking the funding for spare operating theatres of surgical beds. Therefore, in order to preserve the little budget they were alloted, many NHS hospitals referred their patients to nearby private hospitals. However, those working in the private hospitals are the same consultants who work in the NHS, but have to take two jobs in order to keep themselves afloat amidst the pay freezes. In essence, the NHS was renting resources from nearby private hospitals. However all the procedures done were by NHS consultants in their non-NHS working hours, meaning the supply of doctors was less than the resources available. The private healthcare firms were delivering a quarter of all planned NHS hospital treatments across the country, due to the systemic underfunding of our supposedly free at the point of access healthcare.
And this is not some far away myth affecting the poorest parts of the UK. This is systemic issue affecting the entire country. I am privileged enough to live in one of the most affluent areas in the UK, and have (by sheer-luck) a mother who’s job provides health insurance. I am middle class and so have the privilege to avoid the health issues which come from living with low income. I am probably about as privileged as one can get in terms of health care access. And yet, from the ages of 11, the chronic underfunding of the NHS has affected my everyday life. Many of the earliest symptoms of severe mental illness I displayed were over-looked. Although I cannot say for certain, I am sure that this is due to the sheer workload my GP faces. After my inital admission the mental health services I was placed on waiting lists varying from 6 months to 18 months for different therapies. Throughout the time before my 18th birthday, I have experienced over 6 hour waits from ambulances after suicide attempts. I have been in A&E for almost 10 hours, before being told to talk to my pre-existing therapist. When I turned 18, I was promptly discharged from CAMHs and was told that I was likely unable to get treatment from adult services. When I finally reached adult services after many more serious incidents, I was given my diagnosis and told the waiting list for my type of therapy was around 4 years. Throughout this journey I faced so much anger. Over and over, we are taught the rhetoric that reaching out is the hardest part. That once you are able to talk to a professional that things only get easier. But this was far from the case. Over and over I was forced to tell my story again to varying professionals, none of which were able to promise me consistent care. And the resources available within my community were far from helpful. Again, due to chronic underfunding and high demand, they were failing systems also. My school was only able to afford my school counsellor two days a week, despite having waiting lists of over 100 pupils. The charities in my area lacked the adequate training. And none of this considers the likely human error which comes from the nature of our society. I fear to think about the experiences of people who aren’t as privileged as I am. I am lucky in this scenario, and that is a frightening thought.
Despite what we are told, there is a fix to this problem. The NHS Providers’ chief executive urged the government to introduce a fully funded workforce plan in order to reverse staff shortages. Setting rigid waiting time targets is unlikely to help at all as the issue lies with accessing treatment quickly and consistently. This will need to happen alongside investment in buildings and premises, ensuring resources reach those general practices where need is greatest.
Fundamentally, the government is the people we elect to run the country the way we want them to. The people in parliament are there for our bidding, not for their own. They are supposedly the people who represent what we want. Therefore, if we want to see changes in the public health care system, we need to vote for the people that will provide that. We need to vote for people who will fund not only the NHS but all public services. Healthcare is not just intervention, it is also prevention and therefore funding is needed across the public sector.
We need to vote to fund our NHS.
Sources:
https://www.nhs.uk/nhs-services/hospitals/guide-to-nhs-waiting-times-in-england/
https://ifs.org.uk/news/nhs-waiting-lists-unlikely-fall-significantly-2023
https://www.ft.com/content/168e1278-2b24-11df-93d8-00144feabdc0
https://www.theguardian.com/society/2023/feb/08/nhs-waiting-lists-in-england-unlikely-to-fall-in-2023-research-suggests
https://www.healthwatch.co.uk/news/2023-04-13/nhs-waiting-lists-reach-record-levels-what-about-hidden-waiting-list
https://www.kingsfund.org.uk/blog/2022/11/critical-for-health-government-learns-lessons-austerity
https://www.opendemocracy.net/en/nhs-a-and-e-delays-austerity-emergency-care-hospitals-hunt-hancock-lansley/
https://morningstaronline.co.uk/article/b/ae-delays-causing-500-deaths-a-week
https://theconversation.com/austerity-led-to-twice-as-many-excess-uk-deaths-as-previously-thought-heres-what-that-means-for-future-cuts-192033
https://www.bma.org.uk/news-and-opinion/austerity-covid-s-little-helper
https://tribunemag.co.uk/2020/07/how-a-decade-of-austerity-brought-the-nhs-to-its-knees
https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis
https://obr.uk/forecasts-in-depth/brief-guides-and-explainers/public-finances/