Our health service is unwell. You’ve read the news stories – staff at breaking point, pitiless waiting times, patients languishing in corridors. The problems it faces are deep and knotty, though hope is not lost. Whether the solutions lie in smarter funding, technological innovation, or even our own actions, there are bright minds at work to find them. For this series, MH assembled a team of field-leading thinkers to share their strategies.
A little over three years ago, on 26 March 2020, we stood outside our front doors for the first time and started to bang our pots and pans and ‘clap for our carers’. For weeks, this continued every Thursday evening as we made a public display of affection for what is, in Nigel Lawson’s famous words, ‘the closest thing the English have to a religion’: the NHS. That all seems distant today. Yes, there rightly remains much recognition of the extraordinary efforts and sacrifices of NHS staff throughout the pandemic. But undiluted respect for the institution of the NHS itself? That seems to have vanished.
Consider the findings of the most recent British Social Attitudes Survey, the gold-standard measure of public opinion: satisfaction with the NHS has fallen to its lowest level since 1997, with just 36% of the population satisfied with how the service runs, an unprecedented drop of 17 percentage points from 2020. Record falls in satisfaction were seen across all individual NHS services, across all ages, income groups, sexes and political allegiances. This is the background against which Keir Starmer and his shadow health minister feel comfortable openly criticising the NHS. ‘If we don’t get real about reform, the NHS will die,’ Starmer has written. He’s called for an ‘unsentimental’ shake-up of a service that’s ‘undeniably failing. The idea that the service is still “the envy of the world” is plainly wrong’.
So what can be done, politically? The first and most important thing is to rule out any suggestion that we should have anything resembling a US style of healthcare. By nearly every measure, the American system fails: worse outcomes, extremely high costs, appalling inequity. We don’t want to go anywhere near there. But what we can do is to learn from the countries that do have better health outcomes than us, those that preserve the principle that everyone has access to first-class healthcare, irrespective of their ability to pay; where public, patient and staff satisfaction is high; and where the financial costs of healthcare are supportable.
Many other countries meet these criteria: France, the Netherlands, Germany, Italy all do better than the UK with a mix of state-funded care and social insurance. And so does Australia. There, the state funds healthcare through the Medicare system, with access to treatment being totally free for the less well off. But unlike the UK, where the NHS tries to both fund and run almost all healthcare, Medicare only funds healthcare. It doesn’t deliver any of it. Instead, patients choose their providers, with Medicare picking up the bill for those on a low income.
So there’s a huge range of healthcare providers, ranging from hospitals run by regional governments to charities and for-profit companies, all competing and innovating to attract patients with better services and outcomes. And if you are well-off, you’re expected to get private health insurance – if you don’t pay for private medical insurance, your tax rate goes up. The result: patient outcomes are better than ours on nearly every level, while staff are happy and less pressurised, working fewer hours for higher wages. All this while spending less on healthcare than we do: just 10.6% of GDP in Australia compared with 12.0% here, according to the Organisation for Economic Co-operation and Development.
The question then is how can we move from where we are now to where we’d like to be. This is a far bigger task than any of the dozen or so attempts at NHS reform since 1990. To have any chance of success, the ground rules of reform must be established. We must get broad acceptance of the need for deep-seated reform while recognising that doing nothing has a substantial cost (nearly 50,000 people a year die in the UK from medical shortcomings, the highest per capita rate of all advanced economies other than the USA). Any significant reform would be expensive in money, time and energy, and would therefore need cross-party support in Parliament, as well as wide support from the public, patients and every level of the NHS.
Which is where a Royal Commission might come in. Its authority and expertise could detoxify the best reform proposals, while its explicitly bipartisan nature could be preceded by concessions from all parties to accept its conclusions. Its huge investigatory powers – summoning witnesses under oath, offering indemnities, seizing evidence – might help it find the kind of solutions that will endure well beyond the first change in Downing Street. And with a tight remit and timetable, it could just find a way to reform a healthcare system in which so many of us have – sadly but rightly – lost faith.
