How Market Ideology Destroyed Resilience in our NHS

Corporate management tactics – and the mantra to 'do more with less' – claimed to be cutting waste from the NHS, but what they actually cut was resilience and its ability to deal with crises like Covid-19.

The government recently announced ambitions to carry out an independent enquiry into the UK’s torrid experience of Covid-19. It couldn’t be more needed. Our outcomes have been amongst the worst in the world. Most recently, the ONS confirmed that England had the highest level of excess deaths of any country in Europe in the first half of 2020.

If the government are serious about understanding why the pandemic has wrecked so much damage in the UK, they need to look back further than you’d expect. They need to look back to the legacy of the Thatcher governments.

It might sound facetious to lay blame at the door of Margaret Thatcher. But there’s a serious point. It was the New Public Management (NPM) dogma, introduced by her government’s in the ’80s and ’90s that laid the groundwork for the UK’s poor Covid-19 outcomes.

NPM is a doctrine that recommends treating public sector bodies like businesses. It preaches the importance of ‘general management’; consumer choice; labelling of ‘service-users’ as ‘clients’; and extensive use of targets and performance management. Most importantly, it has a very specific central objective: greater efficiency – defined as ‘doing more with less’.

Austerity is just an extreme interpretation of this mantra. David Cameron often framed his austerity politics around driving efficiency. “What you call austerity, I call efficiency,” he told tractor factory workers in Basildon in 2012, flanked by coalition partner Nick Clegg. It is NPM taken to its logical end point.

It is easy to see why this might be appealing. Who could argue if the health service could find £20 billion in efficiency savings between 2012 and 2015 – and then billions more by 2019 – and really cut nothing but waste?

But that’s not reality. It wasn’t waste that was cut. It was resilience. Any last vestige of spare capacity was driven out of the NHS and, with it, its ability to cope with spikes in demand. 

The Night Before Covid

New analysis by the Institute for Public Policy Research (IPPR) shows how bad things had become on the eve of Covid-19. More than four in five hospitals had unsafe levels of occupancy in December 2019. 

This was not because 10,000 hospital beds were closed between 2010 and 2019  (after all, everyone agrees that shifting care from hospital and into communities is the right thing to do) but because they were closed without investment in corresponding capacity in community care, social care and public health.

Likewise, there is little point having beds open with no one to staff them. Yet, we now have one of the smallest workforces relative to our population, anywhere in the world. To match the kind of standards a G7 nation should be meeting, we’d need literally tens of thousands more nurses, doctors and social care workers.

The problems were not just reserved to the healthcare system itself. As the Prime Minister’s new obesity strategy realises – sadly, retrospectively – the overall health of the population was an important factor. Whether Covid-19 or a different disease, a healthier country would have been in a far better position to stave off a new health shock. 

So we must also question a decade of cuts to local government, public health and welfare services. For example, IPPR estimates put cuts to local public health services – which include addiction services, stop smoking clinics and childhood obesity programmes – at almost £1 billion since 2014. Of that, £1 in every £7 was cut from just the 10 most deprived neighbourhoods in the UK. 

The consequences on the nation’s health are clear. The number of years in our life that we can expect to live in poor health (that is with an ‘underlying health condition’) is growing. On average, it now totals almost two decades – and longer for the most marginalised people in our society.

Combined, it was these factors that forced the government into making some very  harmful policy choices when the pandemic hit. While the NHS was not overrun by Covid-19’s peak, that was only the case because government had withdrawn universal care at the start of the outbreak. 

First, they cancelled routine treatments and operations. Two million people went without care that was defined as ‘non-urgent’ – but which is often still very important. But this wasn’t enough. Care for almost every condition has been impacted. For example, Cancer Research UK estimates, 2.4 million people had seen their cancer screening, diagnosis or treatment disrupted by June.

High Price for Poor Outcomes

The salt in the wound is that prioritising efficiency didn’t even save money. This was meant to be the saving grace of an approach focused on ‘doing more with less.’ Proponents tell us that, even if our outcomes aren’t the best, they will at least be the best value.

This is a fantasy. During Covid-19, we had some of the worst outcomes and we’ve paid a high price for the privilege.

Proper health investment only came after the crisis had hit. For example, as part of desperate drive to free up beds, the government announced £1.3bn of to support discharge out of hospital. Naturally, it was too reactive to have a full impact. Many cases of discharge going wrong meant Covid-19 positive patients getting discharged to social care at a time government proclaimed to have drawn a ‘protective circle’ around care homes.

If we’d invested earlier, it would have led to better outcomes both before and during the outbreak. It is not that we didn’t know we had a problem. The National Audit Office alone published two reports on discharge during the 2010s. But the investment to fix it – investment that would, in the long-term, have paid for itself – just never came.

This is just one example, but it represents how our status quo approach to public service efficiency has failed on its own terms.

The 2008 financial crisis offered us an opportunity to reassess how our economy, society and public services work. Radical change has not been forthcoming. Now, in Covid-19, we have a second chance.

In health, it is tempting to think more money is key – that once we end austerity things will improve by default. But that is over-simplistic. The real problem is the shallow definition of efficiency has infiltrated the health service and must be rooted out. That is the structural change that we need.

After Covid, we need a new health paradigm. At its core, it must reprioritise quality, sustainability and people. Simply put, it is time to exorcise the neoliberal logic that has infiltrated our healthcare service.