Intended for healthcare professionals

Analysis Essay

The NHS in the age of anxiety: rhetoric and reality—an essay by Rudolf Klein

BMJ 2013; 347 doi: (Published 21 August 2013) Cite this as: BMJ 2013;347:f5104
  1. Rudolf Klein, emeritus professor of social policy
  1. 1University of Bath, Bath, UK
  1. rudolfklein30{at}

A dangerous gap is opening up between rhetoric and reality as the NHS faces a grim fiscal future, Rudolf Klein argues. High flying ambitions for transforming the NHS are not matched by achievement, and austerity will compel a new agenda of minimising harms rather than maximising benefits

Statistically there does not seem to be much wrong with the National Health Service. At the turn of the year, the Department of Health could report that “key performance standards” had been maintained even as fiscal austerity began to bite.1 Some, such as hospital infection rates, had even continued to improve. Further, the department expected the NHS to have passed the halfway mark towards achieving its £20bn (€23bn; $31bn) savings target by the end of the 2011-12 financial year.2 A more recent sample survey also suggests that there has been no deterioration in performance, bar a marginal increase in the number of patients waiting for more than four hours in emergency departments.3

Organisationally, too, the NHS seems to be a success story. It has successfully implemented the disruptive and distracting Lansley programme of change. This involved closing down 170 organisations, creating 240 new ones, making 10 000 staff redundant, and then re-employing 2200 of them.4 NHS England, as the NHS Commissioning Board has chosen to style itself, is now in charge of the service, churning out instructions, consultations, and exhortations at a manic rate. Yet it would be surprising if the public and patients noticed any difference in the way the NHS operates, so smoothly managed has been the transition; it is those working in the service who have absorbed the shocks and pain of change.

Bad news stories

But, of course, there is another story to be told: that of the NHS stumbling into crisis. The three volumes, 1781 pages, and 290 …

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