Why we can’t have a proper debate about the NHS


They were surprised. And I was surprised that they were surprised.

I was giving a talk to some senior business people and pointed out that there is a trade-off between organisations being efficient and them being resilient. They were surprised because efficiency has always been the driving force to which they were working.

As an example, I said that it is much more efficient to have all one’s data stored in a single, efficient server farm but, if that farm went down for any reason, a lack of duplication and redundancy means that the organisation would be brought to a grinding halt. The organisation would be efficient but not resilient.

We only need to look at nature. Nature is not particularly efficient, but it is highly resilient. When a thousand flowers bloom, many of them are redundant. But it also means that unforeseen circumstances such as bad weather, lack of pollinators, etc, have limited adverse effect because of the huge amount of redundancy.

The issue with excessive ‘efficiency’ is highlighted by the current state of our National Health Service.

It is widely accepted that the NHS has become pretty efficient – delivering more services with more limited resources (relatively). But at what cost? A surge in NHS demand through the winter months is perfectly predictable. Yet the NHS is unable to cope. The response has been that there is no crisis because there is a plan. That plan involves the cancellation of some 50,000 routine operations. In other words, a withdrawal of service. Hardly a welcome one.

It is one thing to be unable to cope with unforeseen circumstances – though, of course, that is exactly what some public services like health, fire services, police, are meant to be able to do. And quite another when, in the name of efficiency, a health service is unable to cope with perfectly predictable situations like a spike in demand during the winter months.

What would we all think if our energy providers decided that their plan to cope with the surge in energy use in the winter was to cancel energy supply to tens of thousand of households?

There seems little doubt that the NHS is unable to cope any longer with normal demands for its service. And that calls for even greater efficiency are not going to get anyone very far. They may well make things much worse. But that doesn’t move us towards a solution – if one exists.

More NHS funding is almost certainly needed – though how much is reasonable if far from clear. Extra funding will provide much needed relief. But it will not solve the long term issue – that all health services in all developed countries are under pressure because demand rises inexorably and supply will always be limited.

Calls to ‘properly fund’ the health service are meaningless. Nobody knows what ‘properly fund’ means – either today or in five or ten or fifteen years’ time – or how that should be assessed. The Lib Dems argue for a penny on income tax to raise an extra £6bn for the service. This is a reasonable short-term fix. But it’s not clear what happens when that money runs out, as it surely will, and services are still under pressure and perceived as inadequate.

A health policy guru recently told me that we should be spending less, not more, on the NHS by stopping the use of resources, for instance, where a few weeks are added to the life of the terminally ill at substantial cost.

It is notable that, although the issues faced by health services are not unique to the UK, there are few other countries, except maybe the USA, where there is so much political mud slinging (I won’t edify it by calling it a debate) around health as there is in the UK. In the UK, it seems politically impossible to have a proper debate on health – largely because the NHS has been lionised as an icon of national achievement.

Combined with claims that this sound-bite approach or that one will magically fix the problem, expectations have been raised to a point where it is unlikely they can ever be met. And because cheap political points are easy to score around the NHS, the nature of what passes for public discussion has become hugely damaging.

At some stage, we all need to accept that health services will always be rationed (which means it will be ‘inadequate’) and that we need to discuss openly what form that ‘inadequacy’ should take. But it is a brave, if honest, politician who, in the UK, would dare to say that.

Those who keep coming out with simple one-line fixes are taking us all for fools.

Help us lay the intellectual foundations for a new radical politics. Sign up to get email notifications about anything new in this blog.

Rate this post!

Average rating 0 / 5. Vote count: 0

No votes so far! Be the first to rate this post.

Radix is the radical centre think tank. We welcome all contributions which promote system change, challenge established notions and re-imagine our societies. The views expressed here are those of the individual contributor and not necessarily shared by Radix.


  1. Stephen Gwynne says

    Now that is what I call radical centre thinking. Living well within our means, recognising that there is a balance between quantity and quality and having realistic expectations that incorporate reasonable efficiency and reasonable resilience.

  2. Paul Gregory says

    Heinz was a lovely man, a German with a wickedly English sense of humour. When, aged, he fell ill with a cancer which is usually quickly terminal, with his wife’s approval they put him through – was it three or four? – operations each lasting many hours. Got to the rehab home, his wife appeared and he dropped down dead. Is this approach humane, or is it just for the benefit of ideology and medical vanity? Or cash flow? (This was Germany.)
    We need to have proper and representative debate about issues surrounding the beginning and end of life. Create a separately elected assembly, without political parties, to address these and other so-called ethical matters (law on recreational drugs, treatment of animals, tolerance or not of religious indoctrination). With time there could then be cultural change such that medicine is used only when it is life-enhancing or at least to alleviate suffering, rather than for its own sake.
    Or else create a small representative assembly dedicated to governing all matters related to health.
    Elect the representatives using multiply transferable power of political attorney (explained at http://www.fuzzydemocracy.eu

  3. nigel hunter says

    As far as making the NHS more efficient and targetting the money that goes into it HOT SPOTS ie Cardiff NHS got info from its patients confidentially about which bars were the worst for crime activities to work with police etc to reduce both crime and injuries and therefore costs to the NHS.. If info was given and analysed as to where the worst problems were prevention tactics could be put in place to reduce costs (that does not mean stop investing in the NHS)ie.who are at risk of hip replacements. Detailed information then those people targetted for prevention methods. via a visit or a letter from the Local NHS team. In time prevention is ALWAYS better than cure.

  4. Stephen Gwynne says

    Might need to get the moral argument clear before re-educating the public towards the need for realistic expectations.

    The fact of the matter is that we live in a zero-sum reality which is constituted by the laws of conservation of matter and energy.
    This means the Natural World is either green infrastructure or grey infrastructure not both.
    This means available grey infrastructure is always limited to some relative degree.
    This means resources are always limited to some relative degree and also means goods and services are always limited to some degree.

    Therefore fairness centres on how the limited availability of resources, goods and services are distributed with the underlying understanding that each constitutive unit of a resource, good or service cannot be shared, only used on an individual basis.
    Therefore, whether privately or publicly owned, any resource, good or service can only ever be used by a limited number of individuals.

    Contested notions of fairness, therefore, argue (democratically) who is to access the limited availability of resources, goods and services AND WHY bearing in mind that the equal access to the resources, goods and services created by a nation is impossible due to the zero-sum nature of reality and the subsequent limited availability of resources, goods and services.

    Since equality in any meaningful sense is impossible, then notions of equity is the only other way to morally manage the distribution of resources, goods and services which means notions of fairness will always be highly contested for ever more. The challenge then is how to decide how to manage fairness in order to produce the greatest utility within planetary boundaries.

Leave a Reply

The Author
Latest Related Work
Follow Us