University of Birmingham

Birthdays are normally a time for celebration, but there does not seem to be much to celebrate as the British National Health Service reaches its 75th birthday.

The NHS’s previous birthdays have been marked by a mixture of positive and negative sentiments, with its 70th anniversary in 2018 having fairly muted celebrations amid much talk of ‘crisis’. However, it could be also argued that the NHS has been in crisis at some point in each of its years of its existence, and yet, like Mark Twain, accounts of its death have been exaggerated.

In the run-up to its 75th birthday, a number of organisations and prominent individuals have provided the NHS with birthday gifts in the form of advice. First, most have stressed the importance of (and indeed need for) ‘birthday presents’ of increased resources – workforce and financial. Second, they have broadly considered that the NHS can’t be ‘fixed’ without ‘fixing’ social care. Third, they have argued that, while the NHS generally compares well to other health care systems in some terms such as equity, it does seem to lag behind other systems in health outcomes. Finally, they have broadly agreed that the NHS needs to be more focused on public health and prevention.

We can make two broad points about this advice. First, much of this ‘birthday’ advice could have been said for much of the period of the service’s history. Second, partly as a result of COVID-19, it seems that the crisis has deepened and is lasting longer than previous ones. The 75th anniversary may be a turbo-charged extension of the 70th anniversary, with the current crisis seeming to become a ‘permacrisis’ with the additional factors of ABC (austerity, Brexit and COVID-19). The perfect storm of endogenous factors, such as prolonged austerity and lack of workforce planning, and exogeneous factors, such as workforce issues associated with Brexit, COVID-19 backlogs, industrial action in a winter, spring and summer, and perhaps even autumn, of discontent. With high levels of inflation, this permacrisis appears to result in the ‘always winter’ of Narnia.

Across a range of the measures, the NHS is in crisis. First, public satisfaction is at its lowest recorded level (29 per cent). Second, waiting lists – a commonly cited metric – are at an all-time high (7.2 million). Third, staff vacancies are running at almost 10 per cent; vacancies in social care are even higher. Fourth, the extent of strikes affecting many staff groups has been unprecedented – for example, members of the Royal College of Nursing went on strike for the first time in over 100 years and consultants are currently voting whether to strike. Finally, while the strikes have been partly about pay, many staff have been affected by high levels of stress and burnout – in 2022, 45 per cent were unwell due to work-related stress and 57 per cent had come to work despite feeling unwell. Each of these is compounded by external factors such as the changing pattern of health needs, the prevalence of chronic care and slowing of increases in healthy life expectancy.

In 2023 as in 1948, the NHS is, in many ways, still trying to resolve the inherent tensions of delivering accessible, high-quality health services within overall budgetary constraints. While changing public expectations, rising health needs and the dynamic effects of new technology (from IT to pharmaceuticals) have dramatically changed the NHS landscape, many challenges are persistent. However, the NHS is increasingly seen as a complex adaptive system which extends into social care and is heavily shaped by the social determinants of health.

As we suggested above, the NHS has been in crisis before. In one sense, the term crisis implies deep-seated problems. However, in another sense, it suggests a watershed moment of problem and change, as in the crisis of a fever: either the patient will survive or not. The response to the crisis of the late 1980s was fundamental reform in the form of the internal market of the Thatcher Conservative government (which some have argued has contributed to the crisis since then), or in 2010 with the so-called Lansley reforms. On the other hand, the main response to the crisis in the early 2000s was more money after the ‘most expensive breakfast in history’ where Labour Prime Minister Tony Blair announced a significant increase in resources (to match the European average), anecdotally leaving his Chancellor, Gordon Brown, choking on his porridge.

The last few years have seen relatively large increases in financial resources for the NHS but the problems in the form of measures such as waiting times and ambulance delays do not seem to be improving. It is unclear if this crisis resembles that of the 2000s (more money) or the late 1980s (fundamental reform). If the former, how much is enough? If the latter, which reforms? These might include the long-suggested but little implemented measures above, or fundamental changes to the (tax-financed, universal) NHS model. Of course, it might be a mixture of both.

It would be a brave or foolish commentator who confidently predicts the state the NHS will be in at its 80th or even 100th anniversary.

Mark Exworthy is Professor of Health Policy and Management at the University of Birmingham. Russell Mannion is Professor of Health Systems at the University of Birmingham and is Honorary Professor at the Australian Institute for Health Innovation, Macquarie University, Sydney. Martin Powell is Professor of Health and Social Policy at the University of Birmingham.