Junior doctors protest against contract changes. But is there actually a chance the NHS will collapse? Photo: Flickr/Rohin Francis

The financial pressure facing the NHS has never been greater. The decision to cancel all non-urgent operations in January signals that it can no longer guarantee universal access to comprehensive care. Nurses are leaving in droves, and below the radar, the status of the NHS as the habitual provider of medical services to the great bulk of British citizens is beginning to crumble, with more patients going private—even for things like cancer care. For 70 years, the idea that the NHS is “there for us all” is what has sustained it politically, and so here, perhaps, we are starting to see the outlines of an endgame for the service.

Nobody in the political crucible yet puts it that way: it would provoke outrage. Instead, voices are being raised in favour of a Royal Commission to examine health funding, including sources beyond taxation. The idea has been proposed by the right-wing Centre for Policy Studies and has  won support from the Sun, the Mail, the Telegraph and several Conservative MPs.

Despite its unprecedented severity, the current winter crisis will pass. Its cause—a sustained deterioration in NHS capacity in an ageing society—will continue to wreak havoc. Funding has simply grown too slowly for too long: at an average of a little over 1 per cent a year since the Cameron government arrived in 2010, compared to an average of 4 per cent over the life of the NHS. This sustained slowdown occurred while the population was growing, so real spending per head has actually fallen.

The effects have been brutal. Taking account of inflation, an average hospital is given just £760 this year to treat a patient they’d have received £1,000 for in 2010, according to the Nuffield Trust. The little relief offered in the Budget (amounting to a modest funding boost of 0.7 per cent per head next year, and next to nothing after that) will be overwhelmed by huge cuts to public health and social care.

Unsurprisingly, rationing has increased. Four million people were waiting for hospital admission in England in November—50 per cent more than five years ago, the King’s Fund says. Many affluent middle-class people—especially those aged over 60—are choosing not to wait, and making their own arrangements in the private sector.

This always happened to some degree, although as recently as the early 2000s, private spending actually fell. The difference now is the scale of the shift from public to private. All the big players are reporting double-digit growth in self-pay—sales to people who are uninsured but choose to pay out of pocket (or on a credit card). A study by Intuition Intelligence, a consultancy firm, found this market growing by 15 per cent per year nationally, and 25 per cent per year in London, as the NHS applies restrictive criteria for access to orthopaedics, ophthalmology and even cancer treatment.

This exposes more and more patients to the vagaries of the previously peripheral private healthcare market. Traditionally focused on providing convenience and amenity to an affluent few, its services are costly and lightly regulated. When the Blair government moved to outsource more NHS work, it looked at this wild-west sector, balked, instead enlisting big corporates from overseas.

It is an industry dominated by just five providers: General Healthcare Group, Spire, HCA, Nuffield and Ramsay. Patients are often in the dark about clinical quality, and what they will eventually pay. A new body, the Private Hospitals Information Network, does publish some data, but it is funded by the sector itself. The industry is also heavily represented in its own governance regime. Private hospitals do not employ their consultants directly, and are not legally liable when things go wrong.

The lack of accountability was thrust into the spotlight when 750 private patients (mostly at Spire hospitals) who had fallen victim to the disgraced cancer surgeon, Ian Paterson, were awarded less in compensation on average than Paterson’s NHS victims. The Royal College of Surgeons has called for a review to improve safety standards and transparency in the private sector.

Those arguing for a wider Royal Commission insist that they are not seeking privatisation by stealth. Politics still mitigate against calling time on the status of the NHS as a near-universal provider, free at the point of use. But there’s no clear plan—among any party—to provide a scale of taxpayer funds that could allow the NHS to sustain that status. No party, explicitly at least, is proposing a rerun of the New Labour era, when NHS spending and service volumes grew at the fastest ever rate. And yet a health service characterised by long waits and diminishing amenities will find it harder to command the loyalty of a middle England that is used to having its wants and desires swiftly gratified. If public healthcare is inadequate, recourse to private treatment will rise more, and even the moderately well-to-do may feel the NHS is “there for us” no longer.

Royal Commissions, Harold Wilson quipped, “take minutes and waste years.” They have often been used to postpone awkward discussions. If this one goes ahead, then by the time it reports, new funding solutions, and a redefinition of the NHS as a safety net for those who can’t go private, may not be the taboos they are today. Capping the liabilities, and reducing the risks, of the burgeoning self-payers could have moved centre-stage. Those calling for an entirely different kind of healthcare model may then find themselves pushing at an open door.

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