Intended for healthcare professionals


NHS is picking up the pieces as social safety nets fail

BMJ 2019; 365 doi: (Published 30 May 2019) Cite this as: BMJ 2019;365:l2360
  1. Selina Rajan, research fellow,
  2. Martin McKee, professor of European public health
  1. London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to: M McKee martin.mckee{at}

Health professionals have a duty to speak out

The United Kingdom is the fifth largest economy in the world. For almost three years, this has been repeated endlessly by politicians and media commentators celebrating the country’s achievements and looking forward to an even better future outside the European Union. In May 2019, the same fact featured prominently in two important reports that present the UK in a less positive light.

Nothing Left in the Cupboards, by Human Rights Watch,1 describes a country in which tens of thousands of families lack enough food to live on. The second report, by Philip Alston, the UN special rapporteur on extreme poverty and human rights,2 also examines food poverty but goes much broader, covering the many ways in which successive British governments have been “dismantling the social safety net.” Neither report makes comfortable reading for the British government. The Human Rights Watch report talks of “a grim picture of the grinding reality that teachers are dealing with,” with children arriving at school hungry, without warm clothes or dry shoes. Alston describes a situation that is not just “a disgrace, but a social calamity and an economic disaster rolled into one.”

Consequences for the NHS

Those working on the frontline in the NHS should be concerned. The concept of “health in all policies” recognises that many of the determinants of health lie outside the health system in areas such as employment, welfare, education, and housing.3 When they fail, it is left to the NHS to pick up the pieces. And, as both these reports show in graphic detail, in Britain today they are failing on a grand scale. Alston is especially critical of the government’s flagship welfare policy, universal credit. He concedes that the principle of consolidating different benefits into a single system is good but points to growing evidence that its implementation has been chaotic, with many of the most vulnerable people falling through the cracks.

This will resonate with the general practitioners in the north east of England, who have described how their workload is increasing because of universal credit, with at least one consultation in every surgery “universal credit based.”4 Their local council published a report describing how universal credit was worsening the health of people with long term conditions, with some considering suicide.5 Alston’s condemnation of the enormous growth of foodbanks6 will be no surprise to the general practice in Salford that has partnered with a local one, with one general practitioner describing food insecurity as “a life-and-death situation” for some patients.7

Alston’s criticism of “cruel, inhuman, and degrading” sanctions, imposed in a manner that is “harsh and arbitrary” on people receiving welfare payments, will be welcomed by the doctors in Liverpool who fought on behalf of a man who was assessed as able to work and had his benefits removed despite multiple illnesses that left him emaciated and barely able to walk.8 The decision was eventually overturned by an independent tribunal, shortly before he died. And Alston’s observations on the precarious existence that comes with insecurity of housing, income, and food insecurities in the UK9 will not surprise those in public health who have documented the growth in “deaths of despair.”10

The government’s reaction to the UN report was predictable. A government spokesperson described it as “a completely inaccurate picture of our approach to tackling poverty,”11 and the secretary of state for work and pensions is reported to be making a formal complaint to the UN. Alston was unimpressed with this response.11 He knows that his reports are often controversial, with governments challenging his conclusions. However, as he notes in a rebuttal of the British government’s comments, these are usually backed up by evidence. For example, a recent report on Laos elicited a 20 page response. Instead, the British one consisted of, in his words, “a total denial of a set of uncontested facts,” so that his initial thought was that “it might actually be a spoof.”11

Worrying outlook

In 2002, Derek Wanless published a landmark report12 commissioned by Gordon Brown, then chancellor of the exchequer. It concluded that sustainable NHS funding into the future required a “fully engaged” scenario, with investment in action on the determinants of health allowing people to live longer in better health. Yet, since 2010, mortality has been stagnating13 and, for some groups, increasing.14 Noting these developments, Alston recalled the words of Thomas Hobbes, writing about England in the 17th century, describing life as “solitary, poor, nasty, brutish, and short.”15 Without action to rebuild a caring and supportive society, things can only get worse. Yet the British government is currently in a state of near paralysis as it struggles with the Brexit process. And as Alston notes, “If Brexit proceeds, it is likely to have a major adverse impact on the most vulnerable.” When added to the damage that any Brexit will do to the NHS,16 the outlook is extremely concerning.

Over 150 years ago Rudolf Virchow said that doctors are “natural advocates of the poor.” When, as Alston argues, “the government has remained determinedly in a state of denial,” it is time for all health professionals to stand up for those who are falling through the increasingly large holes in our social safety nets. We must do so not only for the individuals concerned but for the future of the NHS, which, as Wanless pointed out, cannot continue to pick up the pieces following failures by others.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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