NHS at 70: the health service is at a critical point in its lifetime

David Brindle
The Guardian
<span class="element-image__caption">The NHS is a system envied by other countries for its universal coverage, humanity and value for money.</span> <span class="element-image__credit">Photograph: Fotosearch/Getty Images/Fotosearch RF</span>
The NHS is a system envied by other countries for its universal coverage, humanity and value for money. Photograph: Fotosearch/Getty Images/Fotosearch RF

The Bible tells us our life span is “three score years and 10”. As the National Health Service prepares to pass that milestone, it seems paradoxically both held in higher regard and to be in greater danger than at any time since its founding on 5 July 1948.

Seventy years always looked a little on the optimistic side for the time of Moses in Psalm 90. Even in 1948, life expectancy for men was only 66 and for women 71. Today, though, it is 79 and almost 83 respectively, which tells you a lot about the problems the NHS faces in sustaining its founding principle of cradle-to-grave healthcare, free at the point of use.

We are set for a summer of celebration of the NHS’s 70th. There are crude party political reasons for this, on both left and right, but there is undoubtedly deep-rooted support – indeed, love – for the institution among the British people. Six years on, the NHS section of the opening ceremony of the London Olympics is still widely and fondly remembered.

Those dancing nurses and doctors struck a chord across the world, too. For the NHS is a system deeply envied by other countries for its universal coverage, its humanity and its value for money – and judged the best in the developed world by the Commonwealth Fund, a respected international thinktank.

That surprises many people in the UK fed a relentless media diet of “NHS crisis”, fuelled by political point-scoring and pressure groups’ hyperbole. Last winter proved no exception, but the show was kept on the road thanks to often heroic efforts by health workers and by pushing hospital bed occupancy levels far in excess of recommended limits. English hospitals met the target of maximum 85% bed occupancy for just three days over a month-long period, yet no emergency departments ever closed.

With some parts of the system warning that winter crises are becoming a year-round phenomenon, prime minister Theresa May has suggested she wants to mark the NHS’s 70th by awarding it a long-term funding settlement so it can better plan to meet the spiralling healthcare needs of the ageing population.

No figures have been mentioned, but the Nuffield Trust has projected that funding for the NHS in England alone needs to rise from its current level of £125bn to about £150bn by 2022-23 – £20bn more than currently planned.

Historically, the NHS budget enjoyed average 4% annual rises above inflation from 1948 until 2010. Since then, according to the King’s Fund thinktank, increases under austerity constraints have averaged 1.2%.

A £20bn boost would, of course, be affordable if the “£350m extra a week for the NHS” promised by some Brexiteers in the referendum turned out to be a real dividend of leaving the EU next year. Few in the health world are banking on it.

Reviews and injections of funding seem to come round regularly. Most recently, in 2014, NHS England chief executive Simon Stevens agreed a five-year programme to make savings rising to £22bn a year by developing new models of care in return for a pledge by ministers to make good an £8bn annual funding shortfall.

Those new models, based in part on a US approach called “accountable care” whereby health agencies take overall responsibility for the wellbeing of a local population for a fixed per-person fee, have prompted fears of privatisation and triggered legal challenges which may yet force a halt pending new legislation.

While some see such a drift towards a more US-style health system as a real and present threat to the NHS, others see the bigger threat in the growing difficulty of satisfying rising demand for care within a wholly state-funded system, however much the government contributes. As the British Medical Journal has put it: “In the NHS’s 70th year, the debate is at a critical point about the service’s very essence and its sustainability.”

Can we continue to expect the NHS to meet all our needs? Are we prepared to accept the kind of radical changes that Stevens says are needed to modernise the system, including closure of some local hospitals? Are we willing to pay more so that the system can go on dealing with more than 1.4 million patients every 24 hours in England alone?

At least on the latter, apparently we are. New data from the authoritative British Social Attitudes survey show that 61% of us are ready to pay more tax for the NHS, up strikingly from 49% in 2016 and 41% in 2014. For the first time, more than half of Conservative voters say they would dig deeper.

These remarkable findings tell us two things: first, for all its flaws, the health service at 70 continues to be held in deep affection by the British people; and second, May has a following wind for whatever she has in mind by way of a birthday gift.

But history offers us a third and salutary lesson: politicans tinker with the NHS at their peril.

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