The Slow, Lingering Death of the English NHS

Abstract

The death of the English National Health Service (NHS) may be slow in coming but that does not mean that it is not the Conservative-led UK government’s desired end state. The government is displaying tactical cunning in achieving its long-term purpose to remould the British state. Powell seeks greater clarity amidst the confusion but the lack of clarity is a principal weapon in the government’s assault on the public realm, including the NHS. Moreover, there is ample supporting evidence to caution against Powell’s tendency to complacency concerning the ultimate fate of the NHS.

Martin Powell makes a persuasive case in support of his thesis that ‘accounts of the death of the NHS have been exaggerated.’¹ While conceding that its death may yet be imminent with the ‘wolf… now at the door,’ he objects to repeated siren calls over the years which have heralded the National Health Service’s (NHS’s) demise only to see it not only survive but prosper. As he puts it: ‘just because something can happen does not ensure that it does happen.’ At the same time, Powell is worried about the converse scenario, namely, that with the wolf now at the door ‘alarmed cries may no longer be heeded.’

While not disputing Powell’s desire for greater clarity in the discourse surrounding the NHS and its repeated ‘redisorganisation’ over the past few decades, at the same time he overlooks or understates the mounting body of evidence to suggest that the NHS is under assault from various quarters and that what has been called ‘the plot against the NHS’ does indeed have substance.² Arguably, those seeking to dismantle the NHS have been tactically clever. Rather than storm the ramparts, and by so doing risk incurring the wrath of the public and those employed by the NHS, they have adopted more cunning, low intensity tactics. To achieve their goal, they have operated below the radar of public scrutiny allowing them to transform the NHS largely by stealth. It is a reform journey that has been described as ‘ad hoc, fragmented, gradual and covert.’³ The government is in it for the long haul and it is all part and parcel of a bigger project to shrink the state and reduce the size of the public sector.⁴

While it may be true that governments generally proceed more by cock-up than conspiracy,⁵ this is not to deny that powerful ideological stimuli guide and drive their actions. There is sufficient evidence that has been accumulating since the 1990s to suggest that UK governments of various political hues have all espoused a shared set of beliefs and assumptions about health system reform and the role of competition, markets and choice in this endeavour. The steps may have been faltering and the direction itself may have deviated slightly, or appeared to, at various stages but even if governments lose the odd skirmish or tactical battle, the end game is not in doubt.

That quiet persistence arguably culminated in the arrival of the Coalition government in 2010 and its attempt to go further and faster than the preceding Labour administration in opening the NHS up to new providers through outsourcing and other similar mechanisms. The neoliberal ideology that has guided the actions of numerous governments across the world has certainly become embedded in the thinking and in the policies and practices of the UK government, though not the devolved administrations in Wales and Scotland.⁶

A major contributory factor in the journey embarked upon by successive governments is the existence of what has been termed ‘institutional corruption.’⁷ Governments increasingly no longer represent their publics as distinct from corporate vested interests which lobby heavily and effectively to have their interests not only protected, but actively advanced. The ‘revolving door’ between politicians and civil servants and the board rooms of the City and big business ensure that governments do not stray far from the path which those powerful interests wish them to pursue. Little wonder that the public has become disenchanted with politicians and no longer believes they are in tune with their concerns.

A conspiracy theorist might argue that the problems currently facing the NHS, including financial and staffing pressures that are compounded by growing health inequalities and a rise in lifestyle related diseases that threaten to bankrupt the healthcare system, constitute a deliberate ploy on the part of government to soften up the public and prepare it for a system of healthcare that relies much more on a mixed economy of care and may even entail the introduction of charges or co-payments for care and more aggressive rationing of treatments. After all, since the May 2015 general election, the Conservative government has made no secret of its mission to shrink the state, reduce the size of the public sector, and reshape it in ways which will render it unrecognisable by the next election in 2020. Major respected public institutions like the NHS and BBC stand out as curiosities in this scenario, fond relics from the post-Second World War welfare state era that is quickly disappearing in a new emerging era of market triumphalism.

Apart from those who sincerely believe there is an ideologically driven determination to undermine and dismantle the NHS,⁸ many other observers of health policy, and of the changes that have been unleashed in recent times, consider that the NHS is probably unsustainable in its current form without an injection of significant new funds and that these can only come from a rise in taxation if a tax-based system of healthcare is to survive.⁹ But the government shows no signs of acceding to such demands – its whole policy thrust is in the opposite direction, namely, to cut taxes and reduce public spending.

It is exactly the same dilemma which confronted the Labour government in 1997 and which led to the Wanless review of the challenges facing the NHS over a 20 year period up to 2022.¹⁰ His recommendations resulted in the government sanctioning significant new catch up funding between 2002 and 2008. Increased funding continued, though at a lower level, until 2010 when the government changed and there was the global financial collapse to contend with. Since then, governments have shown no desire to increase NHS spending significantly although they have sought to protect it from the savage spending cuts affecting other public services. But without new money in the form of raised taxes, which goes against everything the Conservative government elected in May 2015 says it stands for, it is inconceivable that the NHS can survive in its current state. Efficiency savings are not the answer and while there is a case to be made and scope for innovation and transformational change which might render the NHS fit for the new challenges facing it, this too requires additional investment.

In the midst of all this uncertainty and assaults on the NHS’s long-term sustainability, those who can afford to opt out will take fright and do so leaving the public sector to cater for those on low incomes and the poor. In their marketing efforts, private health insurers have not been slow to capitalise on the NHS’s woes. Such a fate for the NHS would be a far cry from the enlightened vision of the NHS’s architect, Aneurin Bevan. Sure, the NHS might continue in some capacity but it would be a hollowed out shell and a pale imitation of what was created 66 years ago and which many still regard as the only viable model of healthcare in a civilised society.

The combination of the continuing squeeze on public funds and the ideological stance that favours greater private sector provision suggests that the slow death of the NHS will result from a pincer movement from within and without. Such a lingering death will not be the consequence of a specific policy to end the NHS but a consequence of numerous actions and nonactions that interact in both predictable and unpredictable ways. Over time they will create a tipping point. When that tipping point has been reached is unknowable although Owen believes it will be before 2020 unless major changes occur and that it will happen not with a bang but with a whimper.⁸ If he is correct, it may serve to dispel what some might regard as a whiff of complacency pervading Powell’s perspective.

Interpreting the signals is always a tricky business. On the one hand, the NHS chief executive, Simon Stevens, is the devil incarnate to those who insist there is a plot to end the NHS. His biography, they say, bears this out. He was the architect of New Labour’s incursion into the health marketplace in the late 1990s and early 2000s, working first as health adviser to the health secretary, Alan Milburn, and subsequently to the prime minister, Tony Blair, both of whom were NHS modernisers in extremis. He then went off to the United States to preside over United Health, bete noire of the US private health insurance industry. When the Coalition government’s plans were announced in 2010 to reform the NHS he was quick off the mark to applaud them and say they were intent on finishing the job Labour began but could not bring itself to complete.¹¹ He is also an advocate to extend personal health budgets in order to embed choice which some regard as a step towards an insurance-based system.

On the other hand, Stevens’ strategy, the highly acclaimed Five Year Forward View published in October 2014,¹² makes much of the NHS’s special place in the public’s affections and seeks to reassure those who suspect both Stevens’ and the government’s motives. None of the challenges facing the NHS, it is claimed, ‘suggests that continuing with a comprehensive tax-funded NHS is intrinsically un-doable.’

Can these different sides to the chief executive – his Jekyll and his Hyde if you will – be reconciled? Well, yes, perhaps they can. There are many who distinguish between a publicly funded health system and one that is also publicly provided. For them, it matters less who provides the NHS than who funds it.¹³ As long as there is robust regulation and scrutiny of quality then who provides healthcare should not be an issue of political debate between left and right. Nor should it spell the end of the NHS.

But increasingly there is a view that it does matter who provides healthcare and it is one that is not only shared by public sector unions. There is the public realm to be considered and the public interest which extends to those who provide care as well as fund it. Abandoning the public service ethos, or mission, to the vagaries of the market in the form of outsourcing public services to for-profit providers is to forget why public services came into being in the first place.¹⁴ The corrosive consequences for public life are ignored at our collective peril.¹⁵ Moreover, critics of such moves demand to see the evidence supporting such changes knowing full well that such evidence is lacking and that what is cited in support is weak and contested.¹⁶

Powell may well be correct when he fears that ‘the wolf is now at the door of the NHS.’ The wolf in question may not be wearing sheep’s clothing exactly but there has been a lamentable absence of public engagement with the issues. The fact that ‘alarmed cries may no longer be heeded,’ however, may not have anything to do with what he regards as ‘accounts of the death of the NHS [having been] exaggerated.’ More likely it is a reflection of a serious lack of political literacy in the population and little sense of recent history – what historian Tony Judt calls ‘the unbearable lightness of politics’ whereby political movements have been replaced by ‘fragmented individualism.’¹⁷ Public concerns over climate change or bringing bankers to heel or opposing war ‘are united by nothing more than the expression of emotion.’ Governments proceed to do their bidding regardless.

The unstated, and arguably more important and troublesome, message in Powell’s plea for clarity is Judt’s depressing conclusion that ‘in our political as in our economic lives, we have become consumers’ and lack a connecting coherent narrative setting out the sort of society we want. Only when we have achieved that end will the NHS be safe. Until then it is vulnerable to the neoliberal embrace which is the only, and somewhat threadbare, narrative there is.¹⁸ Rather than being concerned with who killed the English NHS, our attention should focus on what killed it and why.

Ethical issues

Not applicable.

competing interests

Author declares that he has no competing interests.

author’s contribution

DJH is the single author of the manuscript.

Citation: Hunter DJ. The slow, lingering death of the English NHS: Comment on "Who killed the English National Health Service?" Int J Health Policy Manag. 2016;5(1):55–57. doi:10.15171/ijhpm.2015.165