Intended for healthcare professionals

Views And Reviews No Holds Barred

Margaret McCartney: The NHS’s slow decline is a preventable disease

BMJ 2018; 361 doi: (Published 25 June 2018) Cite this as: BMJ 2018;361:k2740
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}
    Follow Margaret on Twitter at @mgtmccartney

The NHS is 70, and although I want to celebrate the endurance of a moral pact that illustrates our collective best, I feel so dismayed at the way it’s treated that pride hardly feels appropriate.

The NHS’s formation was contested by many doctors and, famously, by the BMA. Charles Hill, BMA secretary at the time, found “no reason whatever to bring doctors into the position of the civil service as full time officers,” with “the cold hand of bureaucratic control . . . administered by the state.”1

The first wave of the NHS was about caring for people’s unmet needs. The early organisation of district general hospitals, general physicians, general surgeons, and GPs (who did some obstetrics and anaesthesia on the side) was primarily about doing just that.

Then came Thatcherism, the 1990s, and the creation of the internal market. Fundholding allowed practices to pick and choose the healthcare on offer for their patients and to keep the profits, ostensibly to improve their own practices. Although the subsequent Labour government abolished fundholding, in its place came a series of redisorganisations and competition, as primary care trusts and strategic health authorities were brokered.

We had hospitals trying to become foundation trusts, independent sector treatment centres competing with the NHS, and new hospitals, courtesy of private finance initiatives. The Health and Social Care Act 2012 made the secretary of state no longer responsible for citizens’ health.

Organisations that provide checks and balances are seldom listened to, even after events

After 70 years we have four devolved NHSs, and general practice is in a slow state of understaffed and overworked collapse. Young people with mental illnesses are often sent hundreds of miles for an inpatient bed. Management consultancies are paid hundreds of thousands of pounds to tell the NHS where to save money (but they never recommend spending less on management consultancy).

Despite poor pay and conditions for many, NHS staff cite vocation as a reason for staying late and giving more than their contract requires. We all—patients and staff alike—deserve better.

The NHS has been characterised in recent decades by the political philosophy of the day, the political need to make quick gains, and the increasing interest of private companies in the financial opportunities the NHS presents. There is less concern for assessing the known evidence of policy, realising the unknowns, or finding out whether policies work. Organisations that provide checks and balances, such as the National Audit Office, are seldom listened to, even after events.

If we’re to give the NHS a birthday present could we please insist that every new policy is based on evidence and has been tested (or is being tested) and that its opportunity cost has been assessed and included? The vocation of staff is too good to waste. The social good of the NHS would be a disaster to lose.

Yet I fear that it’s already been squandered, that the slow decline of the NHS is the UK’s largest preventable disease—and it’s staring us in the face.



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