In the NHS’s long lifetime, people have consistently made the same two assumptions. The first is that the health service could at any minute cease to exist. The second is that the NHS is so important in Brits’ view of their country and wellbeing that it wins, or loses, elections.
Even when the health service was being set up, its founder Nye Bevan was asking the medical profession to see it as an experiment and give it a go. Within a decade, there were gloomy sounding BBC documentaries marking 10 years of the NHS, asking how much longer it would last. There had already been standoffs within government over how much money it was sucking from other public services. And in so many of the ensuing elections, the Labour party has assumed it will win on the NHS, while the Tories have feared they will lose.
Last week’s shocking British Social Attitudes survey results, showing satisfaction in the NHS at a record low, only strengthens those assumptions. Just 24% of people in England, Scotland and Wales said they were satisfied with their health service, and 52% said they were dissatisfied – also an all-time high. It also found that 91% of the public believed the NHS should remain free at the point of access, and 82% said it should be funded primarily from taxation and universally accessible.
There have been two reactions from the political world to these numbers. One is to argue that Brits are finally falling out of love with the NHS – which is contradicted by the continuing high support for its principles. The second is that because voters still believe in a taxpayer-funded, free-at-point-of-access universal service, then the only problem will ever be whether the health service is being funded properly and well run. Neither are quite right.
There have been previous existential crises. At the turn of the millennium, New Labour figures became so worried by what were then record-breaking falls in satisfaction and high waiting lists and times that they started to fear the drop in satisfaction would be followed by a loss of consent from taxpayers for the NHS altogether. They were concerned that, as people began to realise that they were paying twice for their healthcare – once through taxes for the NHS and again to access private treatment quicker and in a hospital that wasn’t falling down – taxpayers would start to question where their money was going. Back then, support for the founding principles of the NHS remained high, but the fear was that it was only a matter of time before that started to fall, too. Tony Blair and his health secretaries, particularly Alan Milburn and John Reid, set about on a programme of huge reforms and massive investment in the health service to try to turn things around. They largely succeeded, but today’s crisis is of a completely different order.
Waiting lists are still higher than 7 million, and were already going up before the pandemic. The industrial action has made matters much worse, but underlying much of it is a feeling among healthcare workers that their employer and the government has treated them appallingly for too long. Even when the next election does come along and waiting lists are finally starting to move in the right direction, there will still be voters who have received care who are nonetheless angry that they were kept waiting for so long and that their lives ended up on hold in the meantime.
This then leads to the second assumption, that the NHS is a decisive factor in elections. Many Labourites have long believed that, not least because they are still wedded to the mantra that because the Tories voted against the legislation on the NHS back in 1946, you can’t trust them with it today. Blair’s “24 hours to save the NHS” line in 1997, coupled with a meaningless pledge to “cut NHS waiting lists by treating an extra 100,000 patients”, has become totemic, too. But the truth is that Labour has always campaigned hard on the health service in every election, win or lose, and while it is always salient, it doesn’t win elections. Just look back five years earlier from 1997, to the “war of Jennifer’s ear”, a bizarre fight in the 1992 election over a young girl who had been kept waiting for a year for an operation to fix her glue ear. At the time, Labour thought the health service would swing the election at the end of 13 years of Conservative rule. It didn’t.
Of course, the state of the NHS can have an impact on how voters feel about a governing party. That’s why Conservatives who have been complaining internally about their government’s failure to meet the manifesto commitment to spend 2.5% of GDP on defence have been given a riposte from those around chancellor Jeremy Hunt to the effect that defence doesn’t win elections, but the health service does. This kind of argument always winds up Conservative backbenchers, who point out that defence is one of the few areas where their party out-polls Labour.
Labour’s strategy this time around isn’t to make the NHS the centrepiece of its campaign, although it will clearly use it as a device in its wider argument that the Tories have broken public services. Instead, economic security and tight fiscal rules are more important than promising to turn the spending taps on right away. The shadow health secretary, Wes Streeting, has had to think of more inventive ways of talking about the health service than merely promising lots of money to fix it, which will probably be to the NHS’s benefit, given it has structural problems that hold it back both in times of fat and thin.
But no matter how prominent the NHS is or isn’t in the general election campaign, the chances are that Streeting will then find himself in government trying to deliver the reforms he has been talking about.
Money is definitely not the only answer to the health service’s woes, but it is one of a number of solutions. Streeting has been clear that he wants to rebalance the way care is delivered so that it isn’t all focused on acute hospital services, but on preventive and primary care models. It’s hard to disagree with that notion, given it would lead to many people being seen before they are sick enough to need hospital treatment. But the implementation of it is a different matter because, unless Rachel Reeves unchains the public purse, there is not going to be enough money to fund both primary and acute care. Hospitals may have to close, which always causes huge ructions in local areas and tends to lead even quite sensible MPs to panic that they’ll lose their seat unless they campaign against the closures.
There may well come a point where Keir Starmer and Streeting, like Blair and Milburn in 2000, do want to turn on the spending taps. Starmer is highly unlikely to emulate the former Labour prime minister in ambushing Gordon Brown as chancellor and announcing spending increases live on breakfast TV. But there is a growing worry among some of those Labourites who were in government last time around that Reeves could be more like Brown than much of the hype around her acknowledges.
So the maximum point of danger for the NHS itself is not now, but after five years of a Labour government, which is closer than it has been for a long time. Milburn has a saying that, when it comes to the NHS, Labour has permission to reform, but lacks the volition, whereas the Tories have the volition to reform it, but lack the permission. After a campaign about broken services, the public will be expecting Labour to repeat its late 1990s/early 2000s repair job on the NHS. If, by the end of five years of government, there isn’t a strong sign that this rescue is underway and showing results, then the loss of confidence in the NHS could be catastrophic. It may well be that this is the point at which the support for the underlying principles of the service starts to mirror the trajectory of the satisfaction with service levels.
If Labour can’t fix it, then maybe the health service is properly broken for the present day and needs retiring. At the moment, there is still a belief among the public that higher taxes and spending could fix it. If that belief goes, then the whole experiment really could, after 75 years of people predicting it, start to fall apart.
• Isabel Hardman is assistant editor of the Spectator and a presenter of Radio 4’s The Week in Westminster
