(NHS can't get no) Satisfaction
The British public is intensely unhappy with the health service. There is reason to think things could get worse
Where Voltaire once observed that “some states have an army, the Prussian Army has a state”, Britain is frequently described as “a health service with a country attached”. And not only by traditional sceptics of a system that provides care based on need and free at the point of delivery. Even that avatar of Blairite reforming zeal, Wes Streeting, employed the phrase when responding to Lord Darzi’s excoriating review into the state of the NHS in England1 last September.
Making international comparisons of health spending is difficult, due to different systems and discrepancies in data collection. But two things stand out about UK healthcare spending. First, it has risen significantly in recent decades, both in real terms and as a proportion of government spending.
Health spending as a share of spending on public services
Second, this has sent UK health spending as a share of GDP up the global charts. Over the last 40 years, Britain has gone from the lowest to the sixth-highest among 19 advanced economies, according to the Office for Budget Responsibility.
However, the UK is by no means an outlier. It has one of the lower levels of health spending per person across advanced economies, reflecting its lower GDP per capita relative to competitor nations.
Total real health spending per person across advanced economies
The charts above are the inputs. But what really matters to patients, families and politicians is outputs. And in this regard, the data is flashing red. Analysis by the Nuffield Trust and King’s Fund of the British Social Attitudes survey finds that public satisfaction with the health service has fallen to its lowest level on record. And the decline has been precipitous.
Two dates stand out. The first is the peak in satisfaction in 2010. One reason is funding. Health spending rose under Tony Blair and Gordon Brown, peaking during Labour’s second term, before falling under sharply the coalition. More recently, spending has increased but it remains significantly below the historical average.
Part of the reason for the decline in satisfaction is that successive governments have been borrowing from Paul to pay Peter. That is, cuts to capital spending since 2010 were made partly to help meet day-to-day spending pressures. The problem with this, of course, is that it leads to an accelerated deterioration of the NHS estate. The Institute for Fiscal Studies notes that the maintenance backlog has more than doubled over the last decade.
The second decline occurs in the aftermath of the Covid-19 pandemic. The waiting list for planned care in England hit a record high of 7.8 million in August 2023, nearly double that of five years before. But the combination of a pandemic and historically low spending increases has impacted all parts of the health service. For example, in January 2019, just 627 people in England admitted to accident and emergency had to wait over 12 hours on a trolley. In September 2024, the number was more than 38,0002.
Labour has promised to build an NHS “fit for the future”. Its election manifesto committed to delivering some low-hanging fruit, and it has already met its pledge to provide two million additional NHS appointments in England in its first year. The Budget last October poured in an additional £22bn over two years. But the long-term workforce plan remains unfunded. And there are plenty of reasons to be sceptical that satisfaction is going to rebound to late-noughties levels. You will likely be familiar with most of them.
The first is low growth. The last Labour government spent the proceeds of economic expansion on, amongst other things, the health service. That option, at least in the short-term, no longer exists. Not unrelatedly, government debt has soared, further reducing the government’s room for fiscal manoeuvre. For context, public sector net debt in May 1997 stood at 37.6%. By July 2024, it had risen to 95.7%.
Then there is tax. I’ve written previously that the UK is in some ways a high tax economy, in other ways a low one. What is without doubt is that the new government has decided to restrict its options by ruling out broad-based tax rises, most notably to income tax, national insurance and VAT.
Then there is defence. In May 1997, the world was a remarkably peaceful place for the average Western European. The Cold War was won, the peace dividend was being spent, Russia was an ally and Donald Trump a regular in the New York gossip columns. Today, spending on defence is planned to rise to 2.5% — and will likely exceed that.
Then there is climate change. The price of inaction may well massively outstrip the alternative, but the fiscal costs of a transition to net zero are real, while the price of adapting to a warmer climate will also be substantial.
Finally, there is the big one: demographic change, a polite way of saying that everyone is getting older3. Let me introduce you to what, at the Treasury, I once heard referred to as the graph of doom.
Projections for public sector net debt
That’s right. In the absence of policy change (admittedly a big if) — and while acknowledging that long-term projections are subject to massive error — debt would reach 274 per cent of GDP in 2073-74. At which point, forget health or defence. The UK would essentially be a Debt Management Office with a nation attached.
You don’t look older
Despite everything we like our NHS. It has many good points, but it could b e better and I am sure that many is wasted especially in IT which is fragmented into many companies, all with overheads and all with pieces of software that don't quite fit together.
Recently the national NHS system 'went down' and all over the country practices were stopped from treating patients: There was no shadow computer, there were no local on-site backups of their own patients data.
The wonderful skit by Bird and Fortune from way-back in 2004 and available on YouTube remains topical.
No Brexit effect?