The past few days have seen some welcome candor about the NHS in England and Scotland. English Health Secretary Steve Barclay has been preparing the English public for long waits that will continue to be a major issue in the upcoming election. Meanwhile, NHS Scotland has been discussing the possibility of a ‘two-tier NHS’ ending up as the norm.
Barclay also wants to scrap as many goals as possible in the health service, which is partly an admission that many of the most prominent have not been met for years. It is also a sign of a major change in the treatment of the health service by higher-ups.
Barclay made his pitch on waitlists and targets in the Sunday morning broadcast round. It has been reported in some quarters as the end of ‘pen pushers’ in the NHS, with Barclay and Chancellor Jeremy Hunt seeking to cut budgets and staff in England’s central NHS by up to 50 per cent. It’s always worth noting that our health service is relatively poorly managed: much of the national bureaucracy would have to be replicated locally to keep hospitals and wards running.
The problem Barclay was pointing out with the targets was not that there was a monstrous regiment of clipboard-wielding managers, but that the targets themselves distorted the priorities of the NHS trusts and led to gaming of the system. ‘There is a place for goals, but if everything is a priority then nothing is a priority and this is best evaluated in my opinion [locally].’
It’s no surprise that he’s taking this stance given that Hunt was calling the targets “evil” just days before he resigned as chairman of the Health and Social Care Select Committee and re-entered government. It is also not surprising that Barclay was willing to talk about the NHS being under “severe pressure” and that the chances of him getting back on track any time soon were slim.
Stories of long waits in ambulances, people dying before being treated or trapped in hospital when they are fit to be released are now almost meaningless because they are so common. But with waiting lists for elective care so long, everyone will either be in treatment or know someone who is waiting for treatment.
That’s not something voters tend to value in an election. So ministers need to find a way to acknowledge that and get some sort of drive on the narrative, rather than seem totally out of sorts.
What no minister, either in England or Scotland, can admit is that the NHS principle that the British hold so dear it is already eroding informally. Scottish Health Secretary Humza Yousaf has insisted that the “fundamental principles” of a free NHS must be upheld after leaked minutes of an NHS meeting in Scotland showed they had discussed the potential of “designing a two-tier system in which people who can afford to go private’.
Those papers pointed out that people are already doing this: they are, in increasing numbers, in health services in all four UK nations. The suggestion here seems to be that this could be formalized. The chances of a formal change happening are almost nil. But what the ministers don’t really want to talk about is that point made by the officials in those confidential documents that there is already a two-tier system.
In the 1980s, having private healthcare was considered a badge of honor by Margaret Thatcher and several of her ministers. They bragged that it was a way to make more space in the free health service for those who couldn’t pay. That kind of argument was controversial then and not something any minister, even those who use private care for themselves and their families, would make now.
But the two-tier system has always existed, particularly for mental illness, where the NHS has never really existed in a meaningful sense for many patients. It’s just that now the waiting lists and the results are also deteriorating due to physical conditions, people are noticing it.
The political problem with Thatcher’s argument is that if a large enough proportion of the population takes out private health insurance, then they will question paying for a health service they no longer believe in through general taxation. Currently, most of the increase in people going private is in the ‘self-pay’ sector, where someone pays upfront instead of an existing insurance plan. That has its own problems for private healthcare companies.
But if patients decide to start paying for regular insurance as well, then they are moving away from the principle of health service. Politicians may be blamed for that at first, which is why Barclay and Yousaf have been so busy trying to prepare people for the long waits. But whoever is in power in the next few years will have to figure out how to deal with the possibility of diminishing public support for an NHS.
There may be a party with a stomach that Thatcher never really had to scrap the service and go for something else. But in its absence, a much more meaningful debate on health service reform and its interrelated sectors, including social care, is likely to be needed than any we have at the moment.