In the 40 or more years I have worked with and for the NHS, I can’t remember a time when the government of the day has been so unwilling to act on credible evidence of service and funding pressures. On three previous occasions – 1974, 1988 and 2000 – Conservative and Labour governments heeded warnings of an impending crisis, and found extra resources, often substantial, to maintain and improve care. Why then has the current government turned a deaf ear to the entreaties to provide extra funding from the National Audit Office, the Care Quality Commission, the royal medical colleges, and many others?
Against the backdrop of a decade of austerity stemming from the financial crash of 2007, four explanations suggest themselves. The first is that the government is preoccupied with Brexit and has little time to address other pressing issues such as schools’ funding, housing shortages, resources to fight crime, and growing evidence of distress in the NHS and social care. Whereas in ‘normal’ times all these issues would be receiving widespread news coverage and sustained attention in Whitehall, the outcome of the EU referendum means that Brexit is preventing this happening.
The second explanation is that economic uncertainty linked to Brexit has limited the Chancellor’s room for manoeuvre. Specifically, with progress on the Brexit negotiations proceeding slowly, and an increasing possibility of no deal being reached, the Treasury will not want to commit to public spending rises to avoid being boxed in when the outcome of the negotiations is known.
The third explanation is that the government is not persuaded that an NHS crisis is around the corner. Some ministers take an even tougher line, believing that there is considerable scope to increase NHS efficiency and that this will only happen when leaders in the NHS realise that more money will not be found. Arguments that the NHS is a bottomless pit and will use whatever funding is provided and keep on coming back for more may not be a common view among the current crop of ministers but nor is it an exceptional view.
The fourth explanation is that neither the current Prime Minister nor her Chancellor share the commitment to the NHS of their immediate predecessors. David Cameron’s gratitude to the NHS for the care given to his family is a matter of public record and George Osborne’s support was evident in the additional funding made available in the last Spending Review. Both were involved with Jeremy Hunt in the appointment of Simon Stevens as head of NHS England and all of these individuals worked to the same agenda, based on the NHS five year forward view.
The outcome of the referendum tore this alliance asunder and the consequences were evident in the well-publicised spat between Stevens and No.10 earlier this year. Since then a modus vivendi has been re-established although whether it will survive Stevens’ recent warnings about the impact of continuing financial constraints remains to be seen. What is clear is that there are significant risks for the government in ignoring these and other warnings in view of the attachment the public feels towards the NHS and evidence that services are stretched to the limits.
What might unblock the current impasse? When I worked in the Department of Health between 2000 and 2004, I learnt that public attitudes towards the NHS are tracked closely and taken seriously by ministers. Judging by the annual British Social Attitudes (BSA) survey, the public remain positive about the NHS with satisfaction levels near an all-time high. The survey is, however, a lagging indicator, and recent Ipsos MORI polling reveals rising public concern about the NHS and fears that its performance will deteriorate.
If these fears materialise, the government may feel impelled to act but by that stage so much damage will have been done to services that it will be difficult to reverse the decline. Far better to intervene now and find the additional funding The King’s Fund and others have argued is necessary (£4 billion in 2018/19 as a down-payment on meeting a funding gap we estimate at £20 billion by 2022/23 based on current spending plans) thereby demonstrating that the NHS really is safe in this government’s hands.
A former Conservative Chancellor, Nigel Lawson, famously said that to govern is to choose. For Philip Hammond, the moment of choice is approaching rapidly, and on this occasion it will have far reaching implications both for the government and for the public for whom the NHS remains a treasured institution.
This blog first appeared here.