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How Decades of Neoliberalism Left the NHS on the Brink

NHS waiting lists in England have hit a record high. This isn't just an unavoidable outcome of Covid-19 – it's the consequence of years of neoliberal health policy.

Nurses’ real pay is down more than £5,000 since 2010, according to the TUC. (ER Productions Limited / Getty Images)

A steady stream of alarming data continues to emerge from the NHS. Last week, it was confirmed that waiting lists in England had hit 5.45 million, the highest since records began. A few days ago, it was documented that record numbers of children with eating disorders are being left waiting for help. And just yesterday, the number of Covid hospital patients in England hit their highest levels in five months.

The strain is showing. Major hospitals and ambulance trusts have declared ‘black alerts’—a (hitherto) rare signal that pressure on a provider has reached severe and unsustainable levels—as bed and staff shortages take their toll. Recent data on general practice has shown alarming numbers of people just unable to get an appointment – and either going without the help they need or turning to emergency departments. And in turn, A&E departments have seen record levels of non-Covid patients, with reports of 10+ hour waits becoming the rule for many.

Things are bleak. And if this is the situation in the summer, we must be greatly concerned about the months to come. Traditionally, winter is crisis-season for the NHS as it battles against rises in respiratory illnesses, like the flu. This year, we are going into the cold months with huge uncertainty and with absolutely no spare capacity.

Put simply, the NHS is at breaking point. But progressives should be careful in attributing that strain, exclusively, to Covid-19. While the pandemic has caused major problems, that must not obscure the fact that the healthcare disruption we face today is a political choice enacted in decades of distinctly neoliberal health policy.

A Crisis Decades in the Making

The pandemic continues to cause huge disruption. It is reducing our stock of hospital beds, making operational planning far more difficult. It is undermining the services designed to identify health need as early as possible, like cancer screening and GP services. And it is causing illness among our health and care workers, compounded an existing workforce crisis and making it very hard to draw up rotas.

But we cannot ignore the fact that the disruption faced by the NHS is exactly in line with the downward performance trends observed during the 2010s. By autumn 2019, at the height of the general election campaign period, the NHS was battling huge challenges.

At the time, the Health Foundation found that essential parts of the NHS were experiencing their worst performance since targets had been set. The highest ever proportion of people were waiting more than four hours in A&E departments since 2004. The highest proportion of people were waiting over eighteen weeks for non-urgent (but essential) hospital treatment since 2008. And the target for treating cancer patients within sixty-two days of urgent GP referral had not been met for five years. This was almost forgotten for much of the election campaign as focus was trained on the risks associated with the prospective USA-UK free-trade agreement.

There is a political convenience for this government in suggesting that all the NHS’s woes are down to Covid. It decontextualises the problem we face today from a much longer-term political project.

Austerity exposed a political faultline in health policy. It’s not the most well-remembered of the NHS’s founding principles, but Nye Bevan was very clear that his health service would be about ‘universalising the best’. He intended that NHS provision be so good, it would eliminate any need to supplement entitlements with insurance, or payments to skip waiting lists. It wasn’t conceived as a safety net, but as a way of collectively ensuring the best possible healthcare for everyone in our society.

As with other parts of welfare policy, the impact of austerity has been to transform the NHS into a safety net. In the last ten years, the government has enacted an NHS-wide search for anything that could be badged ‘spare capacity’ or ‘waste’. These services were then cut in the name of ‘efficiency’. The political justification was a leaner public service – ‘world class care, for less’. The reality is that the cuts have gone straight through the bone.

We can see this in the data on levels of capacity just before Covid-19 struck. On the eve of the pandemic, bed closures meant most hospitals in England had entirely unsafe occupancy levels, putting patients at risk and leaving little scope to deal with a surprise health shock. Three in five hospitals had an occupancy level over ninety percent, compared to an established ‘safe’ level of eighty-five percent.

A sustained campaign against health workers meant the UK had one of the most stretched workforces in the OECD. The public sector pay freeze, an assault on junior doctor conditions, and reforms to NHS pensions had created a crisis of both recruitment and retention.  As of 2019, we were tens of thousands of doctors and nurses short, compared to the kind of staffing levels seen in comparable countries.

And austerity-driven cost-saving exercises and bureaucracy had stifled innovation. The Conservatives often presents themselves as the party of innovation and science, but at the turn of the decade, the UK was well behind international standards on implementation of lifesaving technology, medicines, and digital tools. This is pure short-sightedness – it might save a small initial investment, but the long-term costs are felt in less efficient care pathways and the economic cost of a sicker population.

An Existential Risk

The progressive movement is often on the lookout for privitisation. Of course, it is absolutely right that this be opposed – it’s bad for quality, costs, equality, and accountability. But the transformation of the NHS from Bevan’s system of ‘universalising the best’ to a much more limited safety net comes with its own existential risk.

When NHS performance drops behind what it could feasibly achieve, it creates an incentive for people to ‘buy-out’ the system. This is happening at pace today. In 2020, Compare the Market reported a forty percent increase in health insurance sales compared to 2019. In 2017, research by Intuition Communications found a fifteen to twenty-five percent rise in people funding their own care. And analysts Laing Buisson’s analysis of the UK private healthcare market suggests all the conditions are in place for real and sustained growth.

If people buy-out the NHS and invest in private alternatives, electoral support for sustained investment in the health service is likely to decline. Our health service has been a remarkably popular part of the welfare state—compared, say, to benefit payments for the unemployed—because it provides such an overwhelming majority of us better care than we’d otherwise get at a far better price. This electoral support has meant defunding or privatising the NHS comes with huge cost to political capital. The risk is that this electoral support breaks down.

Dentistry provides a case study in how a two-tier, market-based system can be effectively naturalised over a long time-horizon. In Bevan’s conception of the NHS, dentistry was completely free. Indeed, he resigned from Atlee’s government when fees were introduced for dentures in 1951. Slowly since, dental fees have been increased and expanded – often, on the justification of cost containment. Today, many are now entirely excluded from NHS services. There are horrifying stories on the rise of home dentistry – from teeth removed with plyers to cavities plugged with Polyfilla.

The Progressive Project

The progressive movement must unite around a more explicit rejection of short-sighted efficiency drives, health service austerity and stagnation in its capacity. In its place, we must demand resilience, new innovations, an end to inequality, and thriving conditions for workforce. Today, saving our NHS demands more than a rear-guard action against privatisation – we also need a forward-looking campaign rooted in delivering health justice.

The NHS is only meaningful if it provides the best possible health and care to all: free at the point of delivery, based on need, funded through tax. If the legacy of Covid-19 is a growing acceptance of a gap between what the NHS could provide, and what it does provide, then those principles will be irreconcilably damaged. Our job now must be to map out a compelling and popular alternative – based on making our principles relevant to the healthcare realities of the twenty-first century.

If we don’t, there’s a very real risk we’ll be left with a two-tier system – the NHS a short-lived, humanising blip in the history of healthcare.