British Prime Minister Keir Starmer could work on his bedside manner. “Reform or die” was the headline message from the UK’s prime minister on the National Health Service, in keeping with the dour tone that has characterized his first two months in the job. Patients facing a difficult prognosis sometimes appreciate straight-talking, but there is no harm in sugaring the pill. After all, you would have to have been living in a cave for the past five years not to know that the UK’s National Health Service (NHS) is in close to the worst shape of its 76-year life.
Starmer was presenting the conclusions of an investigation into the state of the NHS conducted by Ara Darzi, who is a surgeon, former parliamentary under-secretary of state for health and independent member of the House of Lords.
There is little to surprise in Darzi’s 163-page report, which collates and updates the multiple interconnected challenges confronting the health service — from bulging waiting lists and crumbling, vermin-infested buildings to surging rates of youth mental health distress, and high levels of staff burnout and absenteeism. What stands out, though, is the assertion that the NHS’ “vital signs” are strong, along with the opportunities for improvement from technological innovation, particularly in artificial intelligence, and a return to adequate capital funding.
Illustration: Yusha
The reality is that the NHS is not going to die. At worst, the service would wither, struggling to fulfill its universal mandate in a process that encourages those with the means to seek alternatives. This two-tier system has already developed to some extent, as people frustrated with months-long (sometimes years-long) waiting times for routine operations, such as hip and knee replacements, turn to the private sector instead. However, it is hard to envisage any circumstances in which the NHS ceases to exist. For one thing, popular support remains strong for the concept of a taxpayer-funded universal healthcare service that is free at the point of delivery. (The NHS is frequently referred to as the UK’s “national religion.”) Moreover, countries rarely change the fundamental character of their health systems; gradual evolution is the more common path.
The political spin of “reform or die” does not appear in Darzi’s report. The line taps into the anxiety running through public debate on the NHS as the service has spiraled into crisis.
The message is that the Conservatives brought the very existence of the health service into question with 14 years of mismanagement. Only Labour — the party that founded the NHS in 1948 and has been its staunchest advocate since — could fix the system, and it would take at least 10 years, Starmer said on Thursday.
To be clear, the blame is deserved. The NHS was persistently underfunded under the austerity policy of the post-2010 Conservative-led government. Spending grew about 1 percent annually in real terms in that decade through 2018, against a long-term average of 3.4 percent. Capital budgets were repeatedly raided to plug holes in day-to-day spending. The result was decaying buildings, outdated scanners and a lack of automation, which all hurt productivity. The shortfall of capital investment amounts to ￡37 billion (US$48.55 billion) — the amount that would have been spent if the NHS had matched peer-country budgets in the 2010s. On top of this, there was a disastrous 2012 reorganization under then-British secretary of state of for health Andrew Lansley.
The consequence was that the NHS entered the COVID-19 pandemic in a weakened state, with higher bed occupancy rates, less equipment, and fewer doctors and nurses than most comparable health systems. That reduced resilience can be seen in the data.
Hip replacements between 2019 and 2020 fell by 46 percent in the UK, compared with an average of 13 percent for countries in the Organisation for Economic Co-operation and Development (OECD). Knee replacements dropped 68 percent compared with an OECD average of 20 percent — a decline that Darzi said was “staggering.”
However, overemphasizing this admittedly difficult legacy risks obscuring the NHS’ enduring strengths. These are considerable. The vital signs include an “extraordinary depth of clinical talent,” a shared passion and determination among staff to improve the service, and its level of resources, the study said. Contrary to the persistent fear that the NHS would be dismantled and replaced with private healthcare, the funding model itself might be counted as an advantage.
“With the prominent exception of the US, every advanced country has universal health coverage — and the rest of the world are striving toward it. But other health system models — those where user charges, social or private insurance play a bigger role — are more expensive, even if their funding tends to be more stable. It is not a question, therefore, of whether we can afford the NHS. Rather, we cannot afford not to have the NHS, so it is imperative that we turn the situation around,” Darzi wrote.
The upside of self-defeating policies is that you could expect things to improve simply by stopping them — by, for example, avoiding ill-conceived top-down restructurings that alienate NHS employees. Some of the changes that could help look like relatively easy wins, even if they might take time to pay off. Buying the equipment that would enable staff to do their jobs more productively should be near the top of the list, although Starmer pledged “no money without reform.”
Brightening the discourse might also help. Dwelling on the negatives can only exacerbate the gloom (in fairness, Starmer did inject a brief note of hope at the end of his address). A country that has been told things would get worse before they get better is short of reasons to feel good about itself. For all its problems, the NHS might still be one. A dose of optimism would not go amiss.
Matthew Brooker is a Bloomberg Opinion columnist covering business and infrastructure. Formerly, he was an editor for Bloomberg News and the South China Morning Post.
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