Who Is Really Responsible?
For forty years we have been arguing about who is killing the NHS.
Labour blames Conservative austerity.
Conservatives blame inefficiency, bureaucracy and ever-increasing demand.
Clinicians blame politicians.
Politicians blame structures.
Managers blame resources.
Patients blame waiting lists.
And almost everybody occasionally blames “the other lot”.
Perhaps that is part of the problem.
Because the decline of the NHS cannot honestly be reduced to one political party, one Secretary of State or one catastrophic policy.
What we are looking at is something much more complicated:
decades of changing political priorities, repeated reorganisations, inconsistent investment, poor long-term workforce planning, the neglect of social care and a governmental culture that is often remarkably good at responding to disaster but much less capable of preventing it.
And there is an uncomfortable phrase that runs throughout the history of British public services:
missed opportunities.
We hear it following hospital scandals.
We hear it following safeguarding failures.
We hear it following public inquiries.
Someone was concerned.
Someone reported something.
Someone saw the warning signs.
Somebody knew that something was not quite right.
But nothing significant happened.
Then somebody died.
And suddenly there was evidence.
Was the NHS Really Underfunded for Forty Years?
If we want this discussion to survive contact with the facts, we have to start by challenging one attractive but inaccurate claim.
The NHS has not simply been financially starved continuously for forty years.
Health spending has risen enormously.
The more important question is not:
Did governments spend more money?
They generally did.
The meaningful question is:
Did funding grow sufficiently to deal with population growth, ageing, new treatments, rising expectations, workforce costs and increasingly sophisticated medicine?
That produces a much more interesting picture.
Nuffield Trust analysis adjusting healthcare expenditure for population growth and demographic change estimated annual increases of approximately 2.0% between 1979 and 1997, followed by an extraordinary 5.7% between 1997/98 and 2009/10 under Labour. The post-2010 period was dramatically different, with adjusted spending essentially flat across substantial parts of the following decade. (Nuffield Trust)
So the popular description of forty years of uninterrupted NHS underfunding does not really stand up.
Something more specific happened.
The Conservatives and the Market
The Conservative governments of Margaret Thatcher and John Major did not abolish the NHS.
Nor did they stop increasing its budget.
But they began fundamentally altering the way the organisation worked.
The introduction of the internal market separated purchasers of healthcare from providers.
Healthcare increasingly became something that commissioners purchased from organisations delivering treatment.
The language changed.
Purchasers.
Providers.
Contracts.
Activity.
Performance.
Efficiency.
Competition.
These ideas were intended to introduce discipline into an enormously complicated public service.
They also started creating the administrative machinery of what would become the modern NHS.
This is important because marketisation of the NHS cannot honestly be attributed solely to one party.
The Conservatives began much of it.
Labour subsequently developed significant parts of it.
Labour: Money, Reform and Contradiction
When Labour came to power in 1997, NHS funding increased dramatically.
Between 1997 and 2010, demographic-adjusted expenditure grew far faster than in either the preceding Conservative period or the decade that followed. (Nuffield Trust)
Hospitals were rebuilt.
Staff numbers increased.
Waiting times improved.
Diagnostic and treatment capacity expanded.
This matters because any serious discussion of NHS funding has to acknowledge that the Blair-Brown governments did not starve the NHS.
They poured money into it.
But Labour also continued reshaping the service through Foundation Trusts, Payment by Results, commissioning and increasing use of independent providers.
PFI allowed major new hospitals to be constructed without the government paying all the capital cost immediately.
The attraction was obvious.
Build now.
Pay later.
The problem, of course, was contained within those same three words:
pay later.
So Labour’s record presents an interesting contradiction.
It demonstrated what sustained investment could achieve.
But it also helped embed aspects of the increasingly transactional and managerial structure of healthcare provision.
Then Came 2010
If there is a point at which the financial history of the modern NHS changes direction, it is probably not 1979.
It is 2010.
The Conservative-Liberal Democrat coalition inherited the aftermath of the global financial crisis and embarked upon austerity across government.
The NHS was described as protected.
Technically, NHS expenditure continued increasing.
But healthcare does not stand still simply because its cash budget has not fallen.
The population grows.
The population ages.
People survive diseases that would previously have killed them.
Cancer treatments improve.
Cardiac intervention improves.
Intensive care improves.
Premature babies survive.
Patients live for decades with diabetes, renal disease, cardiovascular disease and complex multimorbidity.
Modern medicine’s triumph is frequently also its financial problem.
Keeping people alive creates future healthcare demand.
Nuffield Trust’s demographic-adjusted analysis found that the post-2010 settlement left remarkably little additional resource per person after accounting for changing need. (Nuffield Trust)
This is why politicians could truthfully say:
“We have increased NHS spending.”
While clinicians could equally truthfully say:
“We don’t have enough capacity.”
They were measuring different things.
Starving the Future to Pay for Today
Then there was capital.
Buildings.
Operating theatres.
Scanners.
Ventilation systems.
IT.
Diagnostic equipment.
Hospital estates.
These things rarely win elections.
Nobody opens the newspaper and becomes emotionally overwhelmed because an NHS trust successfully replaced an electrical distribution board before it failed.
Yet healthcare cannot function without them.
Lord Darzi’s investigation found that approximately £4.3 billion was transferred from capital budgets between 2014/15 and 2018/19 to deal with day-to-day deficits. (GOV.UK)
That is the institutional equivalent of using the money intended to replace your leaking roof to pay this month’s electricity bill.
Eventually the electricity bill gets paid.
But the roof is still leaking.
By 2024/25, the maintenance backlog in the English NHS estate had reached approximately £15.9 billion, having been £6.7 billion in 2014/15 in real terms. (House of Commons Library)
This matters clinically.
An obsolete scanner means fewer patients scanned.
A theatre closed because of ventilation problems performs no operations.
A broken lift can disrupt patient flow.
An ancient computer system consumes clinical time.
Capital expenditure may look boring in a Treasury spreadsheet.
At three o’clock in the morning in a hospital, it becomes healthcare.
You Cannot Staff a Hospital with a Press Release
Healthcare is fundamentally delivered by people.
Doctors.
Nurses.
Operating Department Practitioners.
Radiographers.
Paramedics.
Physiotherapists.
Midwives.
Pharmacists.
Biomedical scientists.
Healthcare assistants.
Porters.
Cleaners.
And countless others.
You can announce money almost instantly.
You cannot manufacture experienced clinicians overnight.
A consultant takes years to train.
A registered nurse takes years.
An ODP takes years.
Professional experience takes longer still.
That means workforce planning requires politicians to think beyond the next election.
A failure to train enough people now may not become obvious for another decade.
By then the ministers responsible may be writing memoirs explaining what somebody else should have done.
The NHS and Social Care: The Fiction of Separation
Perhaps one of the most successful political illusions is the idea that health and social care are separate problems.
They aren’t.
Consider an elderly patient who no longer requires acute hospital treatment but cannot safely return home without assistance.
They need carers.
Perhaps rehabilitation.
Perhaps equipment.
Perhaps a residential placement.
If those services are unavailable, the patient remains in hospital.
The hospital bed remains occupied.
The emergency department cannot transfer another patient to that ward.
The ambulance waiting with that patient cannot return to the community.
Another ambulance call remains unanswered.
Suddenly what appears to be an ambulance problem is partly a hospital-flow problem.
And the hospital-flow problem is partly a social-care problem.
The King’s Fund warned as early as 2011 that restrictions in social-care funding could create additional emergency admissions and delayed discharge pressures for the NHS. (The King’s Fund)
By 2014/15, delayed-transfer days were already rising substantially, with delays attributed to social care increasing markedly. (The King’s Fund)
You cannot meaningfully repair the NHS while pretending social care is somebody else’s department.
Then COVID Arrived
COVID did not create every problem in the NHS.
It exposed and magnified many that already existed.
Elective activity collapsed.
Diagnostics were delayed.
Staff became ill.
Cancer pathways were disrupted.
Patients accumulated.
Waiting lists became enormous.
The pandemic was catastrophic.
But it hit a healthcare system whose spare capacity had already become limited.
COVID was therefore not simply the cause of the NHS crisis.
It was also the stress test.
And it found weaknesses that had been accumulating for years.
But Money Is Only Half the Story
There is another weakness within British healthcare and public administration that rarely receives the same attention.
We are very good at reacting.
We are much less comfortable acting before disaster provides incontrovertible evidence.
That seems strange because modern clinical practice increasingly does the opposite.
We treat hypertension to prevent stroke.
We manage diabetes to prevent renal failure.
We vaccinate to prevent disease.
We identify a difficult airway before anaesthesia.
We prepare blood before expected haemorrhage.
We conduct risk assessments.
We analyse near misses.
Medicine increasingly attempts to identify deterioration before catastrophe occurs.
Government often operates differently.
Evidence-Based Change Has a Dark Side
Evidence-based practice is one of modern medicine’s greatest achievements.
Treatments should not be introduced simply because somebody important believes they work.
We expect evidence.
Trials.
Audit.
Outcome measurement.
Incident reporting.
Research.
That principle is entirely reasonable.
But evidence-driven public policy has a potential weakness.
Sometimes the evidence necessary to force change is generated by the very catastrophe we should have prevented.
Someone dies.
A scandal develops.
A coroner raises concerns.
The press becomes interested.
A public inquiry is established.
Hundreds of pages of recommendations follow.
Government promises change.
Guidance is rewritten.
Training is introduced.
Forms appear.
Then everybody announces:
“Lessons have been learned.”
Until the next inquiry discovers remarkably similar lessons.
Victoria Climbié
Victoria Climbié died in February 2000 following prolonged abuse.
Her case became one of the defining safeguarding failures in modern Britain.
The subsequent public inquiry led by Lord Laming examined profound failures across the agencies that had encountered her. (GOV.UK)
The political response was substantial.
The Labour government’s Every Child Matters Green Paper explicitly followed Victoria’s death and the subsequent investigation and proposed major reform of services for children. (GOV.UK)
The system changed.
Safeguarding structures changed.
Information-sharing became a major concern.
Multi-agency working became central.
But beneath all the organisational complexity sat a painfully simple question:
Why did Victoria have to die before the system changed?
The problems were not incomprehensible.
Different organisations possessed pieces of information.
Professionals had concerns.
Opportunities existed.
Nobody assembled the complete picture effectively enough to protect the child.
The evidence existed in fragments.
The death assembled it.
Then Came Baby P
Seven years later Peter Connelly—Baby P—died.
Again, the child was not unknown to public services.
Again, professionals from different agencies had encountered him.
Again, a Serious Case Review followed.
And the uncomfortable connection with Victoria Climbié was impossible to ignore.
The subsequent joint review raised concerns that included failure to comply adequately with requirements arising from the Victoria Climbié inquiry, together with weaknesses in leadership, professional practice and challenge within safeguarding arrangements. (Northern Ireland Assembly)
Think about what that means.
A child dies.
An inquiry is established.
Lessons are identified.
Government reforms the system.
Guidance changes.
Organisations create action plans.
Training follows.
Seven years later another child dies.
And investigators discover that some of the lessons from the previous catastrophe had not been properly embedded.
The first Serious Case Review into Peter Connelly was itself subsequently judged inadequate, leading to a second review. (GOV.UK)
This is where the reassuring phrase:
“Lessons have been learned”
starts sounding rather hollow.
Perhaps lessons are not learned when they are written into a report.
Perhaps lessons are learned only when the same failure stops happening.
The Never-Ending Story of Missed Opportunities
Read enough serious incident reports and safeguarding investigations and the same language begins appearing.
Missed opportunity.
Failure to escalate.
Poor communication.
Information not shared.
Failure to challenge.
Failure to recognise cumulative risk.
Failure to see the whole picture.
The language sounds administrative.
The consequences frequently are not.
This creates one of the central problems of enormous organisations.
Information can exist everywhere while understanding exists nowhere.
A GP possesses one piece.
A social worker another.
The emergency department another.
The police another.
The school another.
A health visitor another.
Each encounter may appear explainable when examined alone.
Taken together, they may describe impending catastrophe.
The challenge is ensuring somebody sees the whole patient—or the whole child—rather than simply completing their individual part of the process.
Compliance Is Not Safety
One predictable consequence follows almost every major failure.
More policy.
More paperwork.
More mandatory training.
More reporting.
More governance.
More checklists.
Some of that is necessary.
But organisations can gradually confuse documenting safety with creating safety.
The question becomes:
“Has the form been completed?”
Instead of:
“Is the patient safe?”
Or:
“Is this child safe?”
Those are not equivalent questions.
A perfectly completed safeguarding form cannot compensate for poor professional judgement.
An immaculate risk assessment cannot make an understaffed ward safe.
A mandatory-learning certificate does not magically create clinical competence.
And another governance committee does not automatically prevent the next catastrophe.
Professional Curiosity
One of the most important protections against this is professional curiosity.
Something doesn’t fit.
The explanation seems possible but improbable.
The pattern is changing.
The story has altered.
The injury does not make sense.
Several minor concerns have appeared.
Individually they prove almost nothing.
Collectively they begin to suggest something else.
The professional response should not automatically be accusation.
It should be:
Why?
What am I missing?
Who else knows something?
Has this happened before?
What does the complete history look like?
Clinicians use precisely this reasoning when managing deteriorating patients.
A single abnormal observation may mean very little.
Several abnormal observations moving in the same direction may indicate impending catastrophe.
We do not wait for cardiac arrest before deciding deterioration was real.
At least, we shouldn’t.
Yet Politically We Often Do
Imagine managing a patient the way Britain sometimes manages its public services.
The oxygen saturation begins falling.
We document it.
The blood pressure falls.
Someone expresses concern.
The respiratory rate rises.
Another report is written.
The capnography changes.
A committee considers whether sufficient evidence exists to intervene.
Funding is uncertain.
Further assessment is requested.
Eventually the patient arrests.
Suddenly everybody agrees that urgent action is required.
No competent anaesthetic team would work like this.
Yet politically we sometimes tolerate exactly this approach to complex systems.
Why?
Because changing a clinical decision and changing national policy are profoundly different things.
If an anaesthetist identifies danger, they can frequently act immediately.
Major public policy may require:
evidence;
consultation;
funding;
Treasury approval;
ministerial agreement;
parliamentary time;
primary legislation;
secondary legislation;
regulation;
implementation;
inspection;
and continued political support.
Evidence therefore does not automatically create change.
Evidence requires political will.
And political will has competitors.
Budgets.
Manifestos.
Elections.
Public opinion.
The Treasury.
Other government departments.
Newspapers.
Lobbying.
Competing crises.
And one enormously inconvenient fact:
preventing a catastrophe rarely creates a dramatic headline.
The Political Problem with Prevention
Imagine a government announcing:
“We spent £5 billion and nothing happened.”
Politically, that sounds unimpressive.
From the perspective of safety engineering, it may represent extraordinary success.
No bridge collapsed.
No hospital ran out of oxygen.
No maternity disaster occurred.
No cyberattack crippled the NHS.
No patient died.
Prevention creates a peculiar political paradox.
When it works perfectly, the event you were trying to prevent never happens.
And once it never happens, people begin asking whether spending the money was necessary.
The successful intervention removes its own evidence.
Incident, Inquiry, Reform, Repeat
This creates the familiar cycle.
Warning signs.
Concern.
Incident.
Scandal.
Inquiry.
Recommendations.
Political reaction.
New policy.
New paperwork.
New assurance.
Then organisational memory fades.
Pressure grows.
Resources tighten.
Different staff arrive.
And eventually:
another incident.
This is not unique to healthcare.
It is a weakness of complex human systems.
But healthcare makes the consequences unusually visible because those consequences have names.
Victoria.
Peter.
And countless patients known only to their families and to the staff who cared for them.
Are the Conservatives Responsible?
For the decisions taken while they governed, yes.
But that statement should not be confused with saying they alone created the NHS’s problems.
The post-2010 period saw exceptionally weak growth in demographic-adjusted health spending compared with the previous Labour period. (Nuffield Trust)
Capital budgets were repeatedly raided to support revenue expenditure. (GOV.UK)
The hospital-estate maintenance backlog subsequently became enormous. (House of Commons Library)
Social-care pressures increasingly affected hospitals. (The King’s Fund)
These are documented historical facts.
But NHS spending still increased in cash and generally in real terms.
Later Conservative governments also provided additional funding.
Therefore saying simply that “the Conservatives cut the NHS” does not adequately describe what occurred.
The stronger criticism is more precise:
for much of the 2010s, funding growth was insufficient to create the capacity, workforce and infrastructure required for the NHS’s increasing workload, while capital and social-care pressures accumulated.
That is harder to put on a placard.
It is also considerably closer to reality.
Is Labour Innocent?
No.
The Labour governments after 1997 provided historically rapid increases in healthcare funding.
But Labour also expanded aspects of the market model, introduced and developed Payment by Results and Foundation Trusts, and made extensive use of PFI.
And despite repeated political recognition that social care required long-term reform, the underlying problem remained unresolved.
The same broader criticism therefore applies across governments.
Britain repeatedly announces long-term strategies through a political system operating on short-term electoral cycles.
We expect twenty-year workforce planning from governments whose immediate horizon is often the next general election.
Then we are surprised when long-term planning proves difficult.
And Labour Today?
The Labour government elected in 2024 inherited a deeply pressured service.
Its 2025 Ten Year Health Plan describes three major shifts:
hospital to community;
analogue to digital;
sickness to prevention. (GOV.UK)
The last of those is particularly interesting.
Because “sickness to prevention” should perhaps apply not merely to patients.
It should apply to the NHS itself.
A genuinely preventive health service should not simply prevent diabetes, cardiovascular disease and cancer.
Government should attempt to prevent:
workforce crises;
estate failure;
unsafe capacity;
social-care collapse;
technology obsolescence;
and predictable patient-safety failures.
The 2026 capital strategy recognises that long-term infrastructure investment is required to support the health service’s future model. (GOV.UK)
Whether that political commitment survives the competing pressures of future governments is another question entirely.
Perhaps “Criminal Underfunding” Is the Wrong Charge
It is tempting to describe the last forty years as criminal underfunding of the NHS.
It makes a magnificent headline.
But history is more awkward.
Some periods saw huge increases in expenditure.
Some saw constrained growth.
Some governments invested heavily while simultaneously introducing reforms that created other problems.
Some expanded capacity.
Others inherited the consequences.
Almost every government reorganised something.
Almost every government promised efficiency.
Almost every government promised integration.
Almost every government promised to shift treatment from hospitals into communities.
And almost every government discovered that healthcare stubbornly refused to behave like a normal industry.
Perhaps therefore the greater accusation is not simply underfunding.
Perhaps it is political short-termism combined with reactive governance.
We Keep Treating the Arrest
The NHS has become extraordinarily sophisticated at rescuing individual patients from catastrophe.
Perhaps government needs to learn something from the clinicians working inside it.
We don’t deliberately wait for septic shock before treating infection.
We don’t wait for renal failure before managing diabetes.
We don’t wait for the difficult airway before finding the difficult-airway trolley.
We don’t wait for the patient to bleed to death before thinking about blood products.
Good healthcare identifies trajectory.
It recognises risk.
It intervenes before catastrophe.
Public policy should be capable of doing the same.
Because Victoria Climbié should not have had to become evidence.
Peter Connelly should not have had to become evidence.
A hospital should not need to become unsafe before its estate is repaired.
A workforce should not have to collapse before somebody notices that training numbers were inadequate ten years earlier.
Social care should not have to fail before hospitals discover that they cannot discharge patients.
And the NHS should not have to approach institutional cardiac arrest before somebody accepts that the observations have been deteriorating for years.
The Strange Death of the NHS
Perhaps the NHS is not dying.
Perhaps what is dying is the assumption that we can continue running a twenty-first-century healthcare system using political thinking designed around five-year electoral cycles.
The NHS was founded through an extraordinary act of political will.
Its survival will require the same.
Not another slogan.
Not another reorganisation.
Not another promise that “lessons have been learned.”
And certainly not another inquiry discovering that the warning signs were there all along.
What the NHS requires is something much less glamorous.
Long-term investment.
Workforce planning.
Capital replacement.
Functional social care.
Clinical leadership.
Professional curiosity.
Institutional memory.
And governments prepared to act when the warning signs appear rather than when the body count finally makes inaction politically impossible.
Because perhaps the most dangerous phrase in British public policy is not:
“We don’t know.”
It is:
“There isn’t enough evidence yet.”
Sometimes there isn’t enough evidence because the catastrophe hasn’t happened.
Yet.
And if seventy-eight years of the NHS and repeated decades of public inquiries have taught us anything, it should surely be this:
the purpose of evidence is not merely to explain why somebody died.
It is to recognise the trajectory early enough that they don’t.
