Why the NHS is ‘in crisis’: an answer at three levels

18 March 2024

Benjamin Stokes - Former Bank of England official and civil servant

If we can only face looking back so far as the Covid pandemic and the political dynamics set in motion from 2010 - highly significant as they are - we’ll be missing the full story. 

In a Sunday morning interview on 8 January 2023 the BBC’s Laura Kuenssberg asked Rishi Sunak why the NHS was in crisis. He blamed the postponement of much non-Covid healthcare after March 2020. When the same question arose this winter, as usually it does, Sunak added health sector strikes to his reasons. Unfortunately, these responses get us nowhere in grasping what’s really going on. Meanwhile, the British Medical Journal has called for the declaration of a ‘health and care emergency’ as the NHS experiences the gravest crisis in its history

But what would amount to a genuine answer? This piece proposes a more holistic, historically-minded political economy of today’s NHS crisis – one largely lacking in the media debate but that’s relatively simple in its principal features. To see those features more clearly involves looking back across three temporal horizons, each of which I argue opens the way to distinct considerations for public policy. 

1. ‘Going back to March 2020’: Covid-19, UK preparedness and response 

There is evidently truth in Sunak’s answer from January 2023 that the ‘backlog’ of treatment – not undertaken during Covid – is resulting in poorer service now. The need for care today is greater than it would have been absent Covid, while the capacity to deliver it is no greater. But Sunak’s implicit logic in the 2023 interview was that Covid be treated as a purely an external factor, a natural disaster, that simply knocked us all – including the UK government – off course in a singular, discrete way that could not have been other than it was. 

This is an entirely inappropriate logic: government policy determines the UK’s preparedness and response to pandemic disease and this was no different for Covid, with very significant bearing on the ‘backlog’ of healthcare not undertaken at the time. So the relevance of the pandemic to  today’s healthcare predicament should be understood on this broad basis, inclusive of public policy preparedness and response, and with the focus on how to do better next time. 

2. ‘Going back to 2010’: political dynamics of the Coalition government and its aftermath

David Cameron and George Osborne’s government that took office in 2010 with the support the Liberal Democrats increased NHS spending at low annual rates. This was an ‘underfunding’ relative to increasing demand on the service, and compared to prior trends. Between 1997 and 2010 real terms NHS England spending increased 5.5% per year; under the 2010 Coalition this was just 1.1%. But on its own this point about aggregate funding – itself relatively commonplace in public debate – misses the active steps taken after 2010 that increased demand on the NHS.

Namely, the severe weakening of the safety net that otherwise supports citizens’ health. These years witnessed drastically lower public spending on services delivered by local government, including youth support clubs and especially adult social care. Central government grants to councils were cut by 40% in real terms from 2010 to 2020, cuts that inevitably fell hardest on the places that rely most on these services. During these years life expectancy in the UK stopped rising and in the least well off areas of the country, it fell. 

But the relevance of post-2010 politics does not end there. The capacity of the NHS to deliver care by retaining and hiring vital staff, especially nursing staff, was also eroded during these years. David Cameron’s failure, measured against his own aims to resolve the twin issues of immigration and UK-EU relations, was central to this and culminated in new legal barriers to EU citizens working in the UK. NHS capacity to deliver care via its staff took a hit from those new barriers: the number of nurses who joined the NHS from the European Economic Area fell from over 6000 per year to just 900 during these years (it took around two years for the reliance on Europe to be replaced by the current reliance on other international staff). 

3. ‘Looking further back’: an underlying sickness in society

It is not simply that governments since 2010 caused an otherwise healthy population to demand vastly more of the NHS. Nor is it that government policies and the effects of the pandemic crippled a service that would otherwise remain immune from systemic issues. Were that so, there would be a good case for understanding today’s predicament squarely in terms of just the two factors above. But the truth is that societal structures in the UK, rooted well prior to 2010, continue to make an unnecessarily high number of people unnecessarily ill. This continuing, albeit worsening, aspect underlies a base level of very high healthcare demand and has deep roots. 

The UK’s oft referred-to ageing population is part of this, but so is the significant and increasingly unhealthy aspect of ageing in the UK, with more life-long and complex conditions. These are not merely inherent to ageing itself, but a product also of how we live. The effects of child poverty for example, as one of many socio-economics drivers of widespread ill-health in the UK, were softened by New Labour after 1997. But social impediments to good health for many never went away, even in the early 2000s - before striking back with a vengeance, as the Joseph Rowntree Foundation’s work on poverty has recently shown

Today in the UK, still relatively few of us are offered a steady route to a healthy life that asks much less of the NHS. This weakens the capability of the NHS to help when unavoidably we need it – as we all will in the end, and any of us may at any time. We need a wide lens to appreciate that working conditions, the price and quality of food and the cost and availability of dry, warm and safe homes are all relevant to our health. They are therefore also relevant to NHS capacity, as they are for the economy more widely. Only an agenda for health taking full account of this – the societal and economic drivers of much ill-health in the UK – has a hope of sustainably shifting the dial away from yearly NHS winter crises of varying, and generally ever increasing, severity.

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