Opinion | Britain’s National Health Service Is Exhausted

On Dec. 15, nurses walked out and began the largest nurses’ strike in the history of Britain’s National Health Service. They were protesting working conditions that have left them burned out and stretched thin — and compromised patient safety — and wages that fell in the last decade in real terms. Ambulance workers joined them. This week, thousands of junior doctors went on strike for three consecutive days.

“I come to work and can see that there’s a patient waiting eight hours to see a doctor. There are some days where I finish my shift, come back the next day and then I see the same patient still sat waiting in A&E” — the emergency room — “the next day,” Dr. Kiara Vincent, one of the doctors striking, told the BBC on Monday.

But you don’t have to work in a hospital to know that Britain’s N.H.S. is in the most serious crisis of its history; you just have to be injured, or ill. Thousands of people are estimated to have died in the last year because of overwhelmed ambulance and emergency services. There are 7.2 million people in England, more than 10 percent of the population, on waiting lists for treatments like hip or knee replacements, back surgery or cataract operations. And hundreds of thousands of people have had a doctor’s referral for outpatient care at a hospital rejected because there are no available appointments — they are simply bounced back to the doctor to begin the process again.

That the flagship health care service of one of the wealthiest countries in the world is in such a state is shocking, but not without explanation. Decades of marketization, 10 years of Conservative austerity and a pandemic have hollowed out the N.H.S. so much that people who can afford to, and increasingly those who can’t, are having to pay for health care.

A two-tier system with more and more in common with American health care is taking shape. It’s not working, and we’ll soon be at the point where it’s too late to do anything about it.

Wait times for treatment are increasing

Number of patients waiting for N.H.S. care in England

Source: N.H.S. England

By The New York Times

The damage to the N.H.S. was inflicted in three main waves.

In the late 1980s and early ’90s, a Conservative government introduced the internal market and closed long-stay hospitals — where care was free — under the euphemistic banner of “care in the community.” Private nursing homes backed by equity investors took over provision for older people, and care became chargeable and means-tested, mirroring Medicaid “spend down” rules.

In the late 1990s and early 2000s, Labour, under Tony Blair, built dozens of new hospitals with money from partnerships with private investors. The new hospitals were saddled with enormous loan and interest repayments — around $60 billion is still owed.

In 2010, the Conservatives, back in power — alongside the Liberal Democrats until 2015 — embarked on a decade of austerity. A government-commissioned report released last year called the years between 2010 and 2020 the N.H.S.’s “decade of neglect.”

The cumulative effect was devastating: In the three decades that preceded the pandemic the number of NHS beds in England was more than halved. Shortages — of beds, ventilators or intensive care specialists — in early 2020 were not unique to Britain, but Britain had fewer per capita beds than comparable countries. There was a palpable sense of panic about how Britain and its health service were going to manage.

Finding hospital beds in the U.K. is getting harder

Hospital bed per 1,000 people

Source: World Bank

By The New York Times

Britain did manage. And it was because of the dedication of the people who work for the N.H.S., and the retired staff who came out of retirement to help. Britons know this: Research from the spring of 2022 suggests that the British public still overwhelmingly support the founding principles of the N.H.S., even as their satisfaction with it sinks to the lowest level in decades. (Nurses and ambulance workers have the most public support of all of the workers who have been staging strikes in Britain this winter.)

Satisfaction with the N.H.S. has plummeted

Satisfaction with N.H.S. services

Note: Survey question was not asked in 1985, 1988 and 1992.

Source: The King’s Fund and Nuffield Trust analysis of NatCen Social Research’s B.S.A. survey data

By The New York Times

But people are also tired of waiting — or not able to wait — and more and more are paying for private treatment.

There was a 35 percent increase in people choosing to self-fund care between 2019 and 2021, with “market-beating growth” reported in the self-pay market since the Covid pandemic. The number of people self-funding operations like hip and knee replacements more than doubled.

And there are indications that some of the people paying for private treatment are doing so not because they can afford to, but because they can’t afford to wait: Between 2019 and 2021, as self-funding increased, the number of people paying with private insurance decreased; people are reportedly taking out loans to pay for operations and, in a development that will be familiar to Americans but is something quite new in Britain, more and more people are turning to GoFundMe to raise money for medical treatment.

The government has done plenty to encourage this shift: In 2012, the Conservatives increased the cap on what percentage of an N.H.S. hospital’s income could come from treating private patients to 49 percent.

An investigation by The Guardian newspaper in January found that some N.H.S. hospitals with private divisions were promoting self-pay for people who “don’t want to wait for an N.H.S. referral,” while warning N.H.S. patients that services were “extremely busy.” And it’s well established that doctors who work for the public and the private sector have a conflict of interest and can game the system, telling patients that they’ll have to wait months for N.H.S. treatment one week and then treating them privately the next.

More private patients is supposed to mean more money for the service. But since the profit margins on the income from private patients are treated as confidential, researchers have not been able to verify whether private patient units have created more money for N.H.S. patients, whether they make any profit or even lose money.

What we do know is Britons who want to use the N.H.S. are finding it increasingly hard to do so. It doesn’t have to be this way, but change won’t be easy.

In the short term the N.H.S. should stop treating private patients and use public funds to increase the numbers of beds and staff. And sooner rather than later, doctors should be required to choose between working for the public system or the private sector.

There have been four attempts to introduce a bill — that we co-authored — that would reinstate the N.H.S. as a planned system of universal public health care in England in the House of Commons since 2015 — and all four have failed, the last one in 2018. The prospects of any future attempt would depend on the next government.

On Thursday, after months of rolling strikes, the government increased its pay offer to nurses and ambulance workers. Three of the largest health unions agreed to recommend the offer to their members. Junior doctors went back to work, but their dispute is far from over.

The N.H.S. as Britons have known it — accessible, free at the point of use, cherished — is becoming something else. But as long as there are still people willing to fight for it, it’s not too late to save it.

Allyson Pollock is a clinical professor of public health at Newcastle University. Peter Roderick is a principal research associate at Newcastle University and a lawyer.

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