Intended for healthcare professionals


The new government’s plans bring the sustainability of the NHS into doubt

BMJ 2022; 378 doi: (Published 27 September 2022) Cite this as: BMJ 2022;378:o2339
  1. Chris Ham

Last week’s announcement of the government’s plan for the NHS followed by a mini-budget, which was seen by many commentators as the most radical for many years, have worrying implications for the future of the NHS. They suggest that there is no early prospect of resolving what amounts to a humanitarian crisis affecting patients waiting for an ambulance or admission to a hospital bed, or at the end of a long queue for investigation and treatment. Ministers seem to hope that sticking plaster solutions will suffice when more fundamental and long term changes are required.

Thérèse Coffey’s plan for the NHS fell well short of what was needed.1 Her well trailed ABCD priorities—to improve performance in the ambulance service, deal with backlogs that built up during the pandemic, increase spending on social care to reduce delayed transfers of care from hospitals by redirecting funds from existing budgets, and review pension tax rules to remove disincentives to senior doctors undertaking additional work—largely repeated previous commitments. Failure to commit to a date for producing a credible workforce plan was a major omission.

Kwasi Kwarteng’s mini-budget was of much greater significance. In a rejection of policies that he and Liz Truss supported under previous prime ministers, Kwarteng announced tax cuts of £45bn and policies to stimulate economic growth funded by substantial increases in public borrowing in a package widely seen by economists as a gamble.2 Although Truss identified the NHS as one of her top three priorities during the Conservative Party’s leadership contest, there was no suggestion of additional support for health and social care despite growing evidence of failures in patient care highlighted by the Academy of Medical Royal Colleges and others.3

The mini-budget had the appearance of a draft manifesto in which the government is seeking to reduce the role of the state and boost the economy ahead of the general election expected in 2024. Kwarteng has promised further details on the government’s plans in a budget next year and he will also be under pressure to explain the implications of these plans for public spending. The priority given to tax cuts and the impact of vastly increased public borrowing limit the options available for increasing planned funding to tackle shortcomings in public services. Long standing suspicions in the Treasury about the ability of the NHS to use resources wisely are a further obstacle to be overcome.

As winter approaches, the NHS will be under intense scrutiny to demonstrate that everything possible is being done to use resources effectively and to bring about measurable improvements in care. Ministers will be keen to show that they understand the public’s concerns and are unwilling to tolerate poor performance. This could bring them into conflict with the leadership of the NHS if politicians seek to replace leaders of hospitals and care systems who find themselves in difficulty “pour encourager les autres.” They also face conflict with trades unions over pay and conditions of staff.

Critics of the NHS will continue to make the argument that alternative ways of funding and providing care should be considered. Commentators are already suggesting that countries like France and Germany have superior systems that offer advantages over the NHS model.4

In making this case, they overlook the impact of many years of underfunding in the United Kingdom and a failure to plan for the workforce that is needed. Improvements in care in the decade up to 2010 show that the NHS can deliver good value if there is the political will to do so and sustained increases in funding to make it happen.

To make this point is a reminder that the crisis affecting the NHS is as much political as it is humanitarian. The failure of successive governments since 2010 to face up to the challenges in the NHS, and social care, is an indictment of a political system geared to short term thinking and an unwillingness to deal with long term challenges that are relegated to the “too difficult” box.5

As well as the impact on patients, there are growing concerns about staff who have been used as the shock absorbers of an underfunded system with consequences for their health and wellbeing that are evident to anyone involved with health and social care.

In exhibiting wilful blindness, the government risks fundamentally damaging services to the point where the very sustainability of the NHS is brought into doubt. The political crisis in the NHS may not be new but it has taken an acute form in the hands of a government with, as yet, limited understanding of the realities of the NHS and social care. If the prime minister and her chancellor have their sights set on the next election, they would do well to remember that the public’s attachment to the NHS remains strong notwithstanding the difficulties it faces.6


  • Competing interests: Chris Ham was chief executive of The King’s Fund from 2010 to 18

  • Provenance and peer review: not commissioned, not peer reviewed.