The NHS is Collapsing. Part 3: The collapse is a choice, not a necessity

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the part 1 here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In part 2 here we saw exactly how this isn’t happening and the catastrophic effect it’s having on the National Health Service.

Now we examine why.


It’s clear the trend of rising demand and falling budget is not compatible with a sustainable health service, and after six years, the NHS is about to collapse. The question we have to ask is why would our leaders stand by and ignore, even exacerbate, the demise of the one of the safest, most efficient and equitable healthcare systems in the world?

Medicine is all about making choices: when you are faced with two courses of action, how do you decide which to take? What do I think the diagnosis is? What is the probability it is? What is the benefit of treatment? What is the risk if I don’t treat? What is the risk if I do? Standing by and allowing the collapse of the NHS is a choice, not a necessity.

The popular myth about the NHS, and the words certain elements are already chiselling into it’s tombstone, is that it is ‘inefficient’, ‘bloated’, ‘out-dated’, and we simply ‘cannot afford it anymore’.

The entirety of that belief is simply untrue. The NHS is ranked as one of the industrial world’s most efficient healthcare systems, and amongst the sleekest in terms of money spent/individual. Far from ‘out-dated’, NHS researchers and hospitals have pioneered some of the world’s greatest medical advances;  Tuberculosis treatments and the first successful kidney transplant*, we invented surgical robots and participated in the world’s first lab grown organ transplant. Most recently we are the first country in the world to vaccinate against Meningitis B.

So the real question is “Can we afford it?”. The short answer is Yes.

The long answer is more complex. Every pound spent on a public system is a choice; it is an ideological choice, a financial choice and a political choice. When the NHS was first created in 1948, the political and financial situation was dire: the UK debt was twice the size of the economy (214% GDP), and politically Nye Bevan faced extreme opposition, including, shamefully, from the professional body of doctors at the time. Here a difficult financial and political choice was trumped by an ideological one; the idea healthcare provision should be available to all. Flash forward to 2008 and the global economic crash required another financial choice; to bail out the banks – at a total potential cost to the UK economy at the time of £1.162 trillion, which meant UK debt doubled from 39% of the economy in 2008 to 84% in 2016. 

So the choice to fund the NHS today is actually three choices: political, financial and ideological.

Financially, if we compare 2016 to 1948 – our countries debt is a third of what it was when the NHS was created. Our international counterparts in similar financial circumstances have made a financial choice to spend more of their economy on healthcare. By 2020, that gap will be much more, and we will be spending amongst the lowest in Europe. And remember spending on healthcare isn’t an economic black hole – in areas such as public health every £1 spent to prevent disease saves as much as £5 on future health costs. More on this below.

Politically the NHS remains very well supported. It was even a part of the Olympic opening ceremony. However, the last government made a political choice to stake their reputation as leaders on reducing government spending, for no good financial or economic reason. Many economists and the IMF reject austerity as a means to increase growth in a country.

So what’s the issue?

It’s ideology. George Osbourne and Cameron believed in a small state, and that private competition is the most efficient means to achieve the best allocation of resources, a principle of economics that has no evidence base in healthcare. Despite politically promising no ‘top-down’ reorganisation of the NHS, in 2012 the largest ‘top-down’ reorganisation in the history of the NHS was pushed through in the guise of the Health and Social Care Act. This made it much, much easier for private companies to take publicly funded contracts away from public hospitals. Privatisation of services increased 500% last year.

As public services decline due to lack of public funding, further private companies will come in, and without intervention will eventually take over the entire service. Re-nationalising our hospitals and GP surgeries once this happens will be nigh impossible.


So what can be done?

Well the choice to maintain a publicly funded NHS isn’t as simple as “are we willing to keep spending more money on the NHS?”

There are many areas in the NHS where vast amounts of money could be saved and redistributed, without an extra pound from the Treasury. I’ve written about this before.

The two predominant areas of waste in the NHS are not how care is given, but where care is given. Currently private finance initiative deals provide £11 billion pounds of worth to the NHS, in the form of buildings and maintenance, but will end up costing the taxpayer £80 billion in interest. Hospitals like Barts Health in London pay £2.7 million a WEEK in interest on these deals. Why hasn’t this been addressed? Again it’s a choice not to. An alternative choice would be to nationalise this debt and renegotiate it – even restructuring it to paying 1/3 less would save the NHS £23 billion – enough to fund it fully for the next ten years.

Similarly the cost of administrating competing private companies and contracts in the NHS has a huge cost – estimated at around £5 billion/year. Reverting back to a purely state-funded and public model isn’t an ideological dream of left-wing liberals – it’s a sound money saving effort. Again, it’s a choice not to do this, because ideologically the government has chosen to create a system that prefers private competition, without any good financial, economic or scientific reason.

And if we don’t plan in the long-term to prevent diseases; diabetes, obesity, falls in the elderly, stroke and heart attacks – we are shooting ourselves in the collective foot. But a political choice was made to save short-term money on public health. Cutting social care costs us 2-3x much as it saves: I regularly have patients waiting for relatively cheap social care in highly expensive hospital beds, or contracting easily preventable conditions in inadequate social situations that develop into hugely expensive and life-threatening disease.


This is what happens when an unstoppable force meets an immovable object. Demand for healthcare is currently unstoppable; it rises 3-4%/yr, and without taking preventative measures, will continue to do so. The government is apparently immovable; they steadfastly refuse to meet this demand, which every year creates larger and larger problems as patients suffer in underfunded and understaffed hospitals. Between the two the strain on the NHS has reached critical mass – it will collapse without drastic intervention.

Neither of these forces are truly immutable; we can curb health inflation with proper prevention and better social care, and we can both fund the NHS to an equivalent level for a modern industrialised country, and save vast amounts of money through removing deals that are criminally expensive and wasteful.

I hope you now see the NHS is collapsing, and in dire need of help. This doesn’t have to happen. It is a choice.

What will you choose?

juniordoctorblog.com


Read the other parts in this series: The NHS is Collapsing.

Part 1: A Life in a Day of the NHS

Part 2: If the NHS were a patient, I’d be pulling the emergency alarm

Part 3: The collapse is a choice, not a necessity.

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11 Comments

  1. This is a brilliant analysis of the reality of what this government is doing to the NHS. It breaks my heart& makes me mad as hell. What can we do to save it? How can I help?

  2. My short answer to your question is ACT! and it is what every single one of us must do I believe if they truly “LOVE our NHS”

    Our politicians have and always will do as they choose. Therefore it is we the people who need to change

    While some of your points are factually incorrect, (£1,162 billion is what the bank bailouts could cost us, if all the loan guarantees provided by the government are called in, rather than the amount it has actually cost us) I agree entirely with your sentiment that the failure to properly fund our NHS is a political choice, rather than a necessity

    Another important point to mention is that in 2014, an estimated £119.4 billion in tax went unpaid http:bit.ly/119billion so the tale that we cannot afford our NHS is as you correctly point out, a myth.

    Since it’s formation in 1948, successive governments have had on their agenda the destruction of our NHS and for an excellent analysis of how this has been achieved, I suggest the viewing of videos made by GP and NHS campaigner Dr Bob Gill and public health specialist Dr Lucy Reynolds. I have created youtube playlists of their efforts https://www.youtube.com/playlist?list=PL-1yRFehckJBVTlba5eoqXOODZoPehcts and https://www.youtube.com/playlist?list=PL-1yRFehckJB4N1kPCiuImGk05Pj9epRR

    There is only one group of people with more power than the government who can Save our NHS, if indeed that is what’s desired and the is the people of Britain. We elected them to their positions of privilege and power and we can, if we so choose, just as easily remove that power from them. The people of Iceland have done it on two separate occasions within the past eight years, so why can’t we? Because a) we are lazy and always want someone else to do it for us and b) those among us who are willing to act, are far too concerned with fighting and arguing over how it can be saved, but more critically, in being right

    Yes, it is our politicians making the decisions, but it is we who are allowing them to do so through the refusal to take responsibility and act of the vast majority of us. The PFI contracts you referred to, are linked to LIBOR and the banks have already been fined for manipulating it, therefore every single contract based on it, is legally unsound. We could choose just one of those contracts, lets use the example you gave of Barts and crowdfund the cost of launching a legal challenge against the contract on the basis of LIBOR having been manipulated. I have tried to take the lead on such action, but have had so many doors slammed in my face, been attacked, ignored and insulted so many times, that I dropped the idea

    We have the CEO’s of some of our NHS trusts, being paid up to £2,500 per day as private contractors, £millions being spent on financial compensation, when all those affected really want to know is what actually happened to their loved one. Millions more being spent on fighting former NHS staff, who have been treated so appallingly, for simply telling the truth. One of whom, Dr Chris Day, is a member of your own profession and when I mentioned that the rep from your union was overheard asking how Dr Day could be declared mentally deranged, I was attacked, insulted and vilified by many from your profession. All of these FACTS can be challenged through the courts

    So how do we Save our NHS? By dropping the over inflated egos, insults, attacks and vilification of those among us who are trying to do what they can. By coming together in unity and listening to everyones point of view, regardless of how uncomfortable it makes us feel, or how “stupid” someone thinks it is. By waking up and realising that our politicians from whatever political party are not going to and have no intention of Saving our NHS. By supporting each other to pursue their ideas, rather than attacking, vilifying and insulting them, which only leads to a potentially excellent idea being left unpursued.

    So while it is indeed our government who are trying to destroy our NHS, it is we the people who are enabling them and even helping them along their path

      1. Not a major issue. I just believe it’s important we are giving out accurate information

        Thanks for everything you and your colleagues are continuing to put up with. It must be so disheartening….

  3. I’ve always been confused by the £1 on public health now saves £5 in the future. Does that really apply to the U.K. where most of the health spending is on the retired/elderly and in the last year of life? Does it not just transfer the cost in to the future?

    A 55 year old is prevented from getting diabetes so instead of dying of an MI from accelerated atherosclerosis at 65 they die of an MI at 80. During the additional years they’ve drawn pension and in the last couple required a degree of social care.

    This is obviously not an argument for how to develop public health policy but I wonder if the £1 to £5 argument ignores other costs?

    Also, the PFI deals are commercial contracts. You would have to buy the owners out of them. They may not sell or may sell at a too high a price. Expropriation of these assets would be illegal.
    And, their linkage to LIBOR doesn’t void them, although it may allow you to seek compensation from those who manipulated the rate.

    1. Preventing early diabetes for example would help cut the £10 billion deficit- in you example they have an additional 15 years of cardiovascular health. That cost alone is massive- including potentially extended working and contribution to the economy. Social care costs are lessened for patients that remain well for longer- the ultimate public health goal in this society would be to minimise disease burden, but not to put off the inevitable. Everybody will die of something, much of it isn’t avoidable ultimately.
      As for PFI deals – yes they are commercial. But they are a tremendous waste of money. We could nationalise them, structure the repayments to a more efficient and accelerated scheme, and lift the burden of debt off struggling hospitals. It would be a huge legal battle costing millions, but the savings are so huge we couldn’t afford not to try.
      I don’t know about the Libor link, but they are certainly scandal enough on their own

    2. Thanks Dan,

      I’m Very interested in where you’ve got your information from about LIBOR having been manipulated, as I’ve had legal advice from a top QC who confirms it does make the contracts “unsafe”

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