Tricia Foster was undergoing treatment for cancer when the coronavirus pandemic struck. As doctors and scientists raced to unravel the fearful mysteries of Covid-19, her radiotherapy continued unabated at the Christie, a renowned oncology centre in Manchester.
Like most Britons, Foster has relied on the country’s taxpayer-funded NHS at big moments in her life: the birth of her children and the arrival 18 months ago of a grandson. But for much of her 59 years, she had scarcely given it a thought. Then came two searing reminders. First, her sister’s life was saved “virtually in an afternoon” when she was rushed into surgery after a heart attack. Months later, Foster received her own cancer diagnosis. Thanks to NHS staff, she says, her prognosis is good.
Her fealty to the world’s most famous and durable experiment in universal healthcare has been reaffirmed, the bonds stronger than ever. Foster, who lives in the prosperous Cheshire commuter enclave of Altrincham, says that at the Christie she saw “people from very poor parts of the north-west and people from very affluent parts . . . and nobody went ahead in the queue, nobody was left behind. Cancer is a huge leveller — anyone can get it. But now I feel not just ‘anyone can get it’, but everyone has got the same chance of being fixed.”
Britain’s response to coronavirus has been riddled with flaws — of hubris, ignorance and incompetence. Deep and short-sighted cuts to public-health budgets left England without the infrastructure to carry out mass testing and contact tracing. Successive UK administrations had planned for a flu pandemic and lacked sufficient personal protective equipment for a highly contagious respiratory virus. But one institution has emerged with its reputation enhanced: the country’s National Health Service.
A potent blend of safety net, cultural trope and political football, the NHS and the values of fairness and equity it embodies have been crucial to the way Britons see their country and themselves for more than 70 years.
Founded in 1948, in the teeth of intense opposition from much of the medical profession, which feared losing both autonomy and income, the NHS immediately uncovered a heartbreaking volume of unmet need. People who had delayed seeking treatment for conditions, sometimes for decades, finally dared to ask for help.
By one estimate, it now employs an astonishing one in 17 Britons; few families lack a relative or friend in the service. (The roster has included two of Foster’s siblings.) Roberta Bivins, a historian of the NHS who teaches at the University of Warwick, suggests this close connection and, in many cases, economic reliance on the service have nurtured a national possessiveness about the healthcare system: “It’s ours because we know the people who work in it. It’s ours because we pay for it in our general taxation. It’s ours because we depend on it absolutely.”
When the film director Danny Boyle placed a parade of dancing nurses and sick children at the centre of his opening ceremony for the 2012 London Olympics — a moment when countries seek to distil their essence for an international audience — the rest of the world was baffled but Britons understood, and revelled in it.
Indeed, at the height of the coronavirus pandemic, the country at times seemed transformed into one giant, performative tribute. Windows in suburban streets blazed with “I love the NHS” rainbows and blow-up letters with the message “NHS Hero”. Lots of countries clapped for healthcare workers. Britons alone clapped for a health system.
The story of Britain’s fight against coronavirus is, then, also the story of a country’s seven-decade love affair with its health service, and how politicians and health leaders weaponised that devotion to ensure the NHS was not overwhelmed at its moment of greatest peril. But the decisions taken in the name of that salvation have exposed the service’s fragility and structural flaws as nothing has since its foundation.
Now Britons, keyed up to a protective pitch, may have their loyalty to their beloved, but perennially overstretched, system tested as never before. Are politicians ready for the consequences of the tidal wave of emotion they have unleashed?
The first warning most Britons had of the toll Covid-19 would take on health services came in March in the form of TV footage from Lombardy in Italy, showing people breathing their last in horrifically makeshift conditions.
Chris Hopson, chief executive of NHS Providers, which represents the nation’s hospital leaders, says: “What we were seeing in Italy was a health service being overwhelmed to such an extent that people literally couldn’t get any treatment whatsoever and were lucky in some cases if they were able to be put up in the gym down the road with a temporary camp bed. The phrase used an awful lot was ‘a war zone.’”
Health leaders had been receiving alarming reports of the disease’s spread and lethality since the start of February. Stephen Powis, national medical director of NHS England, says the estimates he and his colleagues were hearing from expert committees pointed to “around 500,000 deaths over the course of the epidemic. The hospitalisation rates ranged from 2 per cent to 8 per cent. You don’t need to be a modeller to . . . work out that that level of death and hospital admissions would overwhelm any health system in the world.”
As one south London doctor told me: “We were just bracing for the hit . . . I was working alongside Italian doctors and they were in very close contact with their colleagues in Italy, so they were incredibly anxious, almost hysterical, because they were seeing what was happening in Italy and they knew it was coming our way.”
Any country and its leaders would have dreaded such a looming humanitarian disaster. But in the UK, the stakes were especially high because of Britons’ unusually intense relationship with their health service. And as the government prepared to order Britain into lockdown in March, prime minister Boris Johnson and his advisers had good reason to understand how that love for the NHS could be deployed to deliver political goals.
Four years ago, Johnson, then the insurgent leader of the anti-EU “Leave” faction, had sanctioned the message, devised under the aegis of his closest adviser Dominic Cummings, that a vote for Brexit could deliver an extra £350m a week for the NHS.
Richard Sloggett, a former political adviser to Matt Hancock, the health secretary, says: “It is clearly a Cummings playbook, where you use the NHS in a way which drives behaviour, because it has got such strong public support and public affection for it.”
It was scarcely surprising, then, that the government’s appeal to the country to observe the new national lockdown was framed in terms of safeguarding the health service: “Stay at home; protect the NHS; save lives.” The exhortation was instantly and stunningly effective, with supposedly individualistic Britons obeying the instruction more faithfully than ministers and health officials had dared hope.
Coronavirus may have been a new threat, but this was a message the nation had been primed to receive for more than 70 years, suggests Bivins. As the American daughter of insecurely insured parents, she knows first-hand the fear of medical bills. Bivins says her adopted nation has been “inculcated to believe, through successive decades, that if people don’t behave in a particular way the NHS will disappear or simply become impossible to fund and therefore we will be left often in the condition that poor people in the US are left.
“So that’s the implicit comparison that gets made and this has really been a deliberate political strategy because the NHS is so evocative and so emotive for British people.”
If there is a degree of self-congratulation about the assumed superiority of the NHS to other systems, there is a price to be paid for the decision to fund a developed nation’s health system almost entirely from its tax base. While the NHS often hymns the high marks it scores in a periodic ranking of health systems by the Commonwealth Fund, it rates far higher on access and efficiency than it does on the outcomes of the care it provides.
A period of austerity that began in 2010 had led to sustained, historically low funding settlements that have only increased its fragility. Just weeks before the pandemic began, the service had been enduring its customary winter trials, with thousands of patients forced to languish on trolleys for hours for lack of a bed.
A confluence of government failings, past and present, would have become concrete if the terrifying scenes of an overwhelmed health system seen in parts of Europe had materialised in the UK. “The NHS tops all public polls for big issues facing Britain and if you lose sight of that, then you lose everything as a politician,” says Jennifer Dixon, a former NHS doctor who has been scrutinising health policy for 30 years and now heads the Health Foundation charity.
But the service’s thin fiscal diet has left it well-accustomed to rising to emergencies, an attribute that was on full display in the earliest phase of the pandemic. While public health officials and ministers appeared slow to grasp the need to expand testing and contact tracing to halt the spreading contagion, the NHS showed a turn of speed markedly lacking elsewhere in the UK response.
Within days it had completed an extraordinary deal to take over almost the entire private health sector; within weeks it had erected vast field-style hospitals — the key logistics role of the army not greatly emphasised as ministers and health leaders alike presented the “Nightingales”, as they were christened, as a consummate achievement of an agile NHS.
Despite reforms set in train a decade ago that were designed to disperse power and localise decision-making, the service is still run with an iron grip from the top. David Hare, who as head of the Independent Healthcare Providers Network led negotiations with NHS officials, says: “We can argue whether that’s the right or wrong thing, but one of the advantages of ‘command and control’ is that when you need to communicate rapid instructions through a system, the connective tissue is there to enable that to happen very, very quickly.
“The NHS is one of the best systems in the world for reacting to an emergency situation,” he adds. “And the pace at which it moved was phenomenal. We did a very complex deal with NHS England in less than a week, which has stood the test of time.”
At one level, this is a tale of triumph, of a health service that against the odds found beds for all who needed them, where clinicians huddled on video calls with colleagues, learning at warp speed how best to keep patients alive and disseminating that knowledge with a rapidity and generosity that only a universal public health system could. But it also revealed a system with a severe shortage of beds, nurses and doctors, contributing to the decision to stop all non-emergency surgery and discharge anyone deemed medically fit, simply to ensure the UK health system was not overwhelmed when the pandemic struck.
Martin Vernon, a geriatrician and formerly a senior official in charge of care for older people at NHS England, says ministers and health leaders delivered a “stylised, very narrow-field view of ‘protection’”, which in effect defined “the health service as ‘the hospital’”. Everything — hospital care, general practice, outpatient appointments — was “skewed into one particular narrow field of medicine, namely respiratory support during Covid”.
Morning after morning, living the hermetically sealed existence of lockdown, I would sit and watch grieving relatives and survivors alike tell their stories on national television. And each at some point was invited to pay obeisance to the staff — the NHS staff — who had tended to them.
The national mood found expression in a genial centenarian, second world war veteran Tom Moore, who raised £32m for NHS charities after walking 100 laps of his garden and, in a wonderful moment of pandemic theatre, was knighted by the Queen (at an appropriate social distance) for his efforts. This feat, it was clearly understood, was motivated by one thing and one thing only: his gratitude to the health service for the care it had given over his long life.
But as staff struggled with a devastating lack of PPE and testing, this myth-making sometimes felt dissonant. One consultant described to me the “hellish, hellish” early weeks of the crisis, when two-thirds of the patients in the 18-bed psychiatric ward he oversaw — as well as himself and three junior doctors — came down with the virus. “At one point, for an entire hospital of hundreds of patients, we had six testing swabs and the guidelines were you need to test two or three times to rule out Covid-19 . . . For the whole of March we had a really catastrophic shortage,” he says.
Stephanie Snow, a University of Manchester academic who is leading an oral history project recording staff and patients’ memories of the NHS since its foundation in 1948, says that initially staff had experienced the weekly “clap for carers” as “a very positive thing and it seemed very supportive”.
“But as time went on . . . some of the testimonies that we’ve had from NHS staff showed they were less keen on that. One said, ‘If you create a narrative about NHS staff being heroes, then does that mean you’re creating a narrative like in a film when it’s OK for the hero to die as part of the greater good?’”
There have long been contradictory aspects to Britons’ love for their health service. When asked whether they are prepared to pay more tax to fund it, most agree. But there is little consensus about what form this should take. Nor is it clear that they would support tax rises of the magnitude required to bridge the gap in expenditure. Even amid the swell of pro-NHS sentiment, Nigel Edwards of the Nuffield Trust think-tank says he is “not a great believer in the idea that we’ve had a seismic shift in public opinion”. People have “always been quite willing to hold two completely incompatible beliefs at once”, wanting more money for the NHS but voting against political parties that propose tax rises, he suggests.
Austerity was officially declared at an end by the previous Conservative administration in 2018. Yet the consequences of one of the developed world’s most aggressive exercises in deficit reduction have rarely reverberated so loudly as in recent months.
Nowhere was this truer than in the care-home sector. Even during the years of attrition, the core healthcare budget received above-inflation increases, although population growth and the demands of an ageing society meant that funding remained broadly flat. By contrast, local government, which includes social care, did not receive even paper protection, opening up a gap between resources and demand which the Health Foundation forecasts will have risen to up to £12.2bn by 2023/24. Vernon says coronavirus has shone “a bright light on the underbelly of the health and social-care system [in which] the most vulnerable people in society are actually in receipt of the least comprehensive care”.
The structure of social care is also a problem. Unlike the NHS, which offers free-at-the-point-of-use care to all, social care is means-tested and largely delivered by a fragmented network of private providers, for which, as became brutally apparent during the Covid-19 crisis, neither health leaders nor ministers have ever taken full responsibility.
Michael Macdonnell, a former senior executive at NHS England, describes social care as “strikingly divorced from the health system. It was very foreseeable older people were going to suffer very badly [during the crisis] yet nothing was done, partly because nobody thought it was their job to do it.”
The dependence of many care homes on the NHS for their business created a dynamic in which operators felt powerless to refuse to take patients, even though the shortage of testing kits meant they were often flying blind on their Covid-19 status. One care home operator told me: “If the NHS says, ‘You will take this person’, and we have not got a clue what the person’s Covid status is, I would say 95 per cent of those homes took these residents because they didn’t want to rub the NHS up the wrong way.”
Chris Hopson, chief of NHS Providers, strongly denies that any trust systematically discharged patients they knew or suspected had Covid-19 into care homes. “That implies there was a deliberate piece of malfeasance on behalf of the NHS, which is just not true,” he says. But he acknowledges that the long-standing weaknesses of social care — including its lack of scale or national heft — were revealed during the crisis. “We’ve tried to deal with this pandemic the best way we could and the care sector has done the same; it’s just that it’s massively suffered from those huge structural disadvantages and that is a scandal, but that is not the NHS’s fault.”
As autumn sets in, ahead of what could be a brutal Covid-19 winter for the NHS, the rainbows are gone. Now the windows in my neighbourhood display posters with a harder-edged message: “This home supports a pay rise for NHS heroes.” Tricia Foster agrees. “At a point in time when everyone’s concern is about a pandemic, it seems as if the right place to spend money has to be in the NHS. It is a huge employer as well,” she says. But she wants to see some of this money spent on top-flight managers, noting that the health service is not always as “streamlined” as it could be.
Britons’ enthusiasm for protecting their NHS has assumed a darker aspect as it becomes clear that many of those who stayed away to spare staff have delayed seeking treatment for serious conditions. One cancer expert told me that the toll from people presenting late with the disease would eventually exceed that of Covid-19 itself.
A government likely to be judged harshly in the eventual public inquiry for manifold failures in the UK’s response has a vested interest in framing victory narrowly, emphasising its role in ensuring that no Covid-19 patient who needed a hospital bed was denied one during the crisis. Richard Sloggett, now head of health for think-tank Policy Exchange, says: “They want to be primarily judged on the NHS not being overwhelmed, not on some of these other issues which have gone far more awry and where they were underprepared.”
Ministers may have difficulty maintaining that narrative, however, as the NHS struggles to make up the ground lost during the pandemic, while depleted staff brace themselves for a possible second wave. Before coronavirus, the service was missing its waiting time targets by record margins.
The National Audit Office had estimated that by March of this year waiting lists for treatment would be 400,000 higher than they had been two years earlier. Vernon points out that this equates to “4.5 million people waiting by March 2020 for various things to be done in NHS consultant-led care . . . and then the pandemic hits on top of that.”
The fragilities that affected the NHS’s capacity to respond to coronavirus have also left it in perilous shape to deal with its aftermath. Hospitals, starved for years of capital expenditure — some still occupying buildings that pre-date the service’s very foundation — must now divide those antiquated premises into separate Covid-19 and non-Covid-19 treatment areas.
If the NHS is to continue to offer the quality and volume of care it has done for the past decade, warns Vernon, “we have somehow got to find a way of operating a health service not just at its previous level of capacity but at substantially more than that.”
This may mean recapturing a bit more of the spirit and structure of the service in 1948, by diminishing the dominance of hospitals and strengthening the care people receive in their own communities. Vernon adds: “[NHS founding father] Nye Bevan’s conception was very much around providing a core, localised health offer to people that dealt with things like basic access to a doctor, dental care, eyecare, spectacles and cheaper access to medicines.”
Back then, “there wasn’t a culture in the country of using hospitals in that way that we’ve seen in recent years. The culture was very much your local doctor.” Born less than a decade after the NHS was established, I remember this GP-centric era well. Our family doctor, silver-haired and avuncular, was a regular fixture in my life. He had even delivered me in a local nursing home, then driven to my parents’ house after midnight to convey the tidings to my father, whose diary entry for the day records that he and the doctor “both drank enormous whiskies”.
As always in the NHS, money is going to be a problem. Ageing populations and policy choices have reshaped the UK welfare state over the past 60 years or so. Health is now the largest single item of government expenditure and has swallowed up a steadily increasing portion of all public spending.
Calculations by the Institute for Fiscal Studies before last December’s general election show health’s share increased from 7.7 per cent of spending in the mid-1950s to 17.9 per cent in 2018-19. Any significant increase for health would put the squeeze on already hard-pressed areas, such as education, justice and local government.
The expansion of the state in recent months, to shore up jobs and the economy, has left little room for additional investment in the NHS, suggests Edwards from the Nuffield Trust. Yet the risk for the government is that the public — pumped up with NHS worship for the past six months — will demand more than it is prepared, or able, to provide.
Edwards says the higher cost of running a Covid-compliant health system means “we are going to be paying what we are paying but getting significantly less than we were”. He does not believe ministers have yet grasped just how devastating and lasting a hit to NHS productivity the pandemic has delivered: “I get the strong impression they have been in a bit of denial about it.”
The NHS’s leaders believe the crisis has made the case even more strongly for changes that they wanted to implement before the pandemic struck. Powis points out that the government won the last general election on a manifesto commitment to big increases in nurses and GP appointments. “In general, I think what Covid has taught us is that most of the things that we wanted to do prior to Covid were exactly the things that we need to do, and we just need to do them harder and faster and Covid has shone a light on that.”
UK governments often want to leave their mark on the NHS. Already there are mutterings in Westminster about whether its operational independence should be curtailed and ministerial control strengthened.
But even as the blame game gathers pace, little direct criticism has so far accrued to the service and its chief executive Simon Stevens, who is known as a skilled operator in the Westminster jungle. Not often seen publicly at the height of the pandemic, Stevens appeared only once at the daily Downing Street briefings. Instead, he became the face of the Nightingales, closely identified with the rescue mission that ensured the NHS never ran out of beds.
He was not involved in some of the more contentious aspects of the government response, such as testing, contact tracing and the supply of PPE. One NHS figure said: “I think it was evident from the outset that this was going to be a shambolic response and I think he’s done quite well to emerge unscathed and focus on the NHS’s priorities. NHS England is a commissioning organisation — it wasn’t his job to deliver some of this stuff in the way that it was for Public Health England [the public health agency] or the health department, and I think he’s quite rightly stayed out of it.”
Sloggett adds: “The Department of Health is where the responsibility for pandemic response ultimately sits, so Simon’s not as in the firing line as he would be, for example, on performance targets, where clearly the operational power sits with him to deliver improvements.”
Jennifer Dixon argues that, while she cannot predict how long the “aura” around the NHS will last, for now the service is “pretty untouchable in many respects. Governments often justify major reform off some kind of narrative of disaster or failure . . . and I just don’t think that narrative can wash for some time, given what’s happened.”
The bond between Britons and their health service has only tightened over the past six months — and, even when the pandemic fades, its newly enhanced place in the public imagination is something that the government will have to reckon with for years to come. Looking back to that first Thursday when people clapped for the NHS, Dixon recalls: “I have to say I found myself being very emotional in clapping . . . and I surprised myself because I’m pretty hard-bitten.
“I think what people were clapping for — it was the NHS, of course it was — but I think they were clapping with relief that something somewhere would hold you if everything else failed. Other kinds of welfare provision have all sorts of provisos and small print but the NHS is just there, no matter what. It’s social protection writ large.”
Sarah Neville is the FT’s pharmaceuticals correspondent
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