The winter has been the NHS’s worst ever, with the now all-too-familiar images of stationary ambulances outside A&E with patients that cannot be admitted, soaring lists for elective treatments and the largest ever nursing strike in its history.

While the long-suffering British public has ever thus put up with long waiting times and a bad January, this time it feels different with a palpable sense that people are getting worried.

The political reaction to the crisis initially ran true-to-form with some short-term announcements such as a ‘discharge fund’ to support Adult Social Care (actually first announced in September last year), a commitment to provide more ambulances and a hastily convened meeting of healthcare leaders in Downing Street.

What followed, however, was more interesting as, for the first-time, politicians started to ask publicly if the NHS founding ideology of being ‘free at the point of delivery’ is broken and whether the current endemic problems are in fact irretrievable without a fundamental reform of the model.

Leading the debate for that right was the former Health Secretary Sajid Javid MP, who acknowledged the stymied political narrative around the NHS, and then called for a cross-party consensus on co-payments for GP consultations with consideration given to new models of funding, such as the social insurance type systems used in Germany and France.

The retort from the left was swift, with former Prime Minister Gordon Brown opining that managing parity of access to healthcare has never been more important for governments to regulate as we enter the age of personalised medicines. Adding that co-payments for GP consultations would be the thin end of wedge for the creeping privatisation of healthcare.

Is the answer to the current crisis in the NHS the actual funding model and what an alternative might look like? Are our politicians really prepared to fundamentally rethink the founding principles of the NHS in the run-up to a General Election? And will the country really get to a consensus that the ‘dream’ of 1948 is irretrievably broken?

The root cause of the current crisis is certainly founded in funding. The austerity governments of David Cameron and George Osbourne oversaw a radical reduction in public sector spending – from 42% of GDP in 2009-10 to 35% by 2018-19.

While healthcare was somewhat protected during this period, largely flatlining in real terms, other services closely aligned to the NHS were not, with swingeing cuts to social care, local authorities and medical education training. If there is any lesson to our politicians past and present from the gloom of the winter of 2023 it surely is that you cannot divorce health provision from social care: they are part of the same system.

NHS spending is now well behind comparable countries and requires a significant injection of cash to adequately resource the expectations put upon it by politicians and the post-pandemic backlog, but in the longer term simply increasing funding it is unlikely to resolve its problems. The more fundamental issue for the NHS, and healthcare systems the world over, is the infinitely rising costs of healthcare.

Since 1949-50 UK health spending was 3.5% of GDP but had doubled to 7.3% by 2016-17, much of that in the last 40 years where spending has quadrupled in real terms since 1980. On current projections, if the NHS were to treat everyone to the highest possible standards of care, we would be spending close to a 100% of GDP on NHS by the late 2000s, a clearly unsustainable position.

The problem of ever-increasing healthcare costs for systems to stand still is not a new phenomenon, as recognised by the founding fathers of the welfare state, and neither is it unique to the NHS. Indeed, the UK has done comparatively well in capping costs to society in comparison to the US where healthcare spending has risen from 5% of GDP in 1960 to a staggering 19.7% of GDP in 2020.

The causal factors behind exponentially rising costs are well known with ageing populations, multi-morbidities and the spectacular success of life sciences to treat the previously untreatable.

The problem for politicians is how to manage escalating costs while simultaneously committing to optimal standards of care under a taxpayer funded system, which is famously ‘the closest thing the English people have to a religion’. One option would be to simply raise revenue, through either co-payment, as the former Health Secretary suggests, or more fundamentally rethink how as a society we pay for healthcare.

While co-payments have in reality been in the NHS for a long time, notably for prescriptions and car parking, actually paying for a GP appointment is unlikely to command the political support it would need to get through parliament, given it fundamentally undermines founding NHS ideologies. It could also quickly become unworkable as, even if means-tested, the policy would undoubtably skew demand.

The worried well would likely receive a good service from primary care but the system would store up problems for less forthcoming patients, which ultimately would increase mortality and require even more NHS resourcing to solve.

What might be more palatable is a move to a social insurance type arrangement, as typically utilised in continental Europe. In the classic social insurance model, employees contribute part of their salary, which would be matched by employers, with some kind of upper limit to make funding contributions equitable and protect high earners.

The advantage of such a move would be that care would continue to be ‘free at the point of need’ without any real change to face of the NHS.

To fundamentally change the mechanism of funding, however, would almost certainly lead to politically insurmountable chaos in the short term, detract the NHS from focusing on frontline care, and the tussle on employer contributions between the state and industry would more likely become the political legacy of the policy, as opposed to a better funded healthcare system. And social insurance healthcare systems still require significant top-ups from general taxation to work and increase the administrative burden.

And ultimately, the money for healthcare systems also has to come from somewhere. It is not so much about how you cut the pie, it is more the size of the pie and what as a society are we prepared to pay for given exponentially unaffordable healthcare costs.

While the urgency of this question is growing, highlighted by this winter crisis, in the medium term it has probably been successfully avoided by the Chancellor who committed an extra £16bn to the NHS to up 2024/5 in the emergency Budget of late 2022.

Probably just enough to keep the service afloat, albeit on the proviso that social care is also addressed, which is far from certain given workforce issues and the requirement for local authorities to maximise council taxes.

Fundamentally however our politicians and society more generally are debating the real issues on how we are going to manage our healthcare. In the aforementioned spat on the future of NHS funding the former Secretary of State for Health Sajid Javid MP did acknowledge the constraints around political debate on the NHS and called for mature dialogue.

Unfortunately, his assertion that some of the answer lay in GP co-payments dominated the message and the discussion then quickly reverted to type when Gordon Brown weaponised the issue pointing at Conservative privatisation. And this goes to the heart of the problem.

An examination of recent debates in the House of Commons on the NHS demonstrates a broad range of really important issues and diseases under consideration, from mental health to the clinical research environment to menopause and beyond.

There are also some very able and informed politicians in both Houses of Parliament, but they are unfortunately hamstrung by their inability to articulate the real issues around the NHS because if they did it would be seized upon by their political opponents or constituents as a criticism of NHS.

We are after all a nation that clapped the nurses once a week through the pandemic, used dancing NHS patients to open the Olympic Games to the world and are currently arranging for an NHS workers ‘choir to help crown the King this summer.

The fact that a Government Department has a ‘birthday’ is in itself remarkable. And this poses a problem for our politicians as anything other than unequivocal praise for the NHS is seemingly unacceptable, with questions over the long-term ability of the state to pay for the healthcare we all want nearly always seized upon by opponents as undermining the NHS and a personal attack on the integrity of our nurses and doctors.

What we are therefore left with is cost containment measures that tinker around the edges without addressing the real problems. Unfortunately for the pharmaceutical industry it has become an easy target for critics, despite only accounting for around 10% of the total NHS budget.

Although it is entirely appropriate that medicines for use in the NHS undergo robust health economic analysis, the debate around healthcare resourcing all too easily gravitates towards NICE and the pharmaceutical industry, the ideological tension between industry and the NHS a convenient distraction.

What is needed instead is a national debate on what as a society we are prepared to pay for healthcare, the limitations of that funding and how it is optimised for maximum gain across the population. As we enter a new era of genomic medicine the possibilities of personalised interventions are virtually limitless and the need for this debate will become more important than ever.

The real danger for the NHS is the political rhetoric itself as it is this what is undermining its very existence as our political leaders drive expectations, highlight specialist care and laud staff knowing that these expectations will be ultimately overrun by the inability of the state to fund it.

Jamie Holyer is a healthcare government affairs and public policy consultant.
Go to advocate-consulting.co.uk