Saturday Long Read: The NHS is Collapsing and Labour is Running out of Excuses
A system shaved to the bone, a winter crisis already unfolding, and a government furious because the arithmetic no longer works.
Fair Warning - this is a long read. Do feel free to pop the kettle on, make a coffee (or tea, if you must) and settle in. It is angry in places, but I promise, it does eventually go somewhere.
The NHS finds itself at an inflection point this week.
And I don’t mean an inflection point in the way that a DHSC minister does - that sort of cheerful, PowerPointy “inflection point” where there is an overly earnest admission that everything is immensely hard, absolutely, but optimism and derring-do is mandatory1.
No, I mean the real kind most closely related to the meaning of those two words. The kind of inflection point where a system that has been, for years, shaved down so aggressively financially, operationally, clinically and politically, that it now has the potential to completely fail. That this system, which has no fat left to burn, no slack, no buffer, no “we’ll just flex a bit more” is standing staring wide-eyed at a crisis knowing that this has the potential to cause it to not bend (yet again), but to snap.
We are, as a country, watching a major crisis unfold in real time. Hospitalisations have surged by more than 50% in one week on the back of an early and mutated flu outbreak, with an average of 2,660 patients per day in wards admitted on the back of this. NHSE has described this level of flu, which is the highest that’s ever been recorded for this time of the year it as the “worst case scenario” for December.
And while we’re being overwhelmed with flu cases, there is a not-unexpected Resident Doctor’s Strike precariously looming in the near horizon, which the Labour government has met with defensiveness. Lecturing. Moral theatre. They’ve met this with a full-fat serving of “how very dare you!” - and that tells me one very specific thing.
This government knows that it is completely out of room to manoeuvre.
I will say upfront that I am writing this piece in the context of my own resignation from the health service this week. After nearly a year of wrangling with it, this Wednesday I finally sent the resignation letter that was lurking in my drafts folder. I didn’t do so because I was bored, “in need of a change” or because I just didn’t enjoy my work anymore. I resigned because the pressures and the compromises and the obfuscation has become unbearable - and because I finally reached that point where either I stop being honest with myself, or I stop pretending that I would be able to do a job expected of me while not being given the tools with which to do so.
This is in no way a noble martyrdom speech, just an admission for context and a statement that if you ask people to deliver miracles without oxygen, you don’t get miracles - you just get attrition.
I should also make the caveat very early on to people who get annoyed with me for criticising the Labour government that yes, I know they inherited a bin-fire from the Tories. They took over a health service that had been hollowed out over the course of fourteen years, through underinvestment, ageing infrastructure, brittle staffing, demoralised teams and waiting lists that became a permanent feature of the service rather than the crisis they should have been on their own. All of this was given to Labour last year, and all of happened on the back of a decade of reforms introduced by the Tories that mostly rearranged management org charts while the clincial frontline was systematically starved.
The legacy belongs to the Tories. They lit the fires, kept them burning and tried desperately to convince us all that the smoke we saw was “efficiency.”
But.
Labour have now been in power for just about a year and a half, and my honest verdict on their performance is that they have not arrived with water to douse the flames - they arrived with clipboards2, a calculator and an incredibly weird confidence that if you tell the NHS to run even faster and even harder, while at the same time cutting its shoelaces, the spring will somehow look like “transformation.”
The issues introduced under this Labour government into the health systems have been manifold, but I want to start with one that seems paradoxical - the pay awards in 23/24 and 24/25. For anyone raising their eyebrow a bit at me and saying, “but, Bear - that was a good thing, no?”, I am happy to say yes - it was. It was well overdue and much needed.
But what it also was, very importantly, not fully funded.
While the pay awards definitely went some way towards acknowledging, however belatedly, that NHS staff have endured years of real terms erosion, which is a massively positive thing, the government did not centrally support those increases. The model used for the pay progression was done on a basis of “we’ll cover some, you find the rest.”
Which again, sounds fine - until you translate it into actions that a Trust CFO3 have to undertake to do so, which is basically take money out of beds, clinics, maintenance, equipment, recruitment, training and basic operational functions to plug a pay hole that should never have existed in the first place.
The systems we rely on did not respond well to this, and this inevitably led to it doing the only thing it really can do - hiring freezes. Posts held vacant. Bank and agency cuts. Training being trimmed. All of the things that organisations have to do when suddenly they have an unfunded cost that needs to fiscally survive the month.
On top of this, there is the ongoing saga of the NHSE abolition - a decision that I, for the whole, do not disagree with.
The argument for it is compelling, because the post-2012 architecture is an absolute disaster. The problem here isn’t that it was a bad idea - it’s that it’s an idea that was announced without forethought to how to actually manage the change.
An exercise of this scale in organisational change has about a million moving parts, and this particular one is not only complex, but, again - unfunded. Redundancy planning was pretty much frozen on the back of a tiff between the DHSC and the Treasury about who is going to actually fund the £1bn bill for severance payments, only resolved in November this year. The end result of this is that you had a bureaucratic system that is left in complete paralysis.
People tend to stop making decisions because they’re not sure who will exist in three months. The most experienced staff leave without waiting for redundancy payments because the waiting around is a worse option for them.
Through this, the system loses exactly the people who hold it all together - the planners, strategic leads, finance teams and governance nerds, or in short, all those unglamorous but important people in the room who are best placed to stop crises becoming catastrophes.
And yes, I know - it all just sounds bureaucratic and unnecessary, and it is easy to sneer at what people imagine to be a man with a clipboard kicking the tyres incessantly, but, if you’ve worked in the system, you know that the functions that these Peter and Terrys do doesn’t stop being necessary - it just gets shifted to the frontline.
And then came the league tables - that incredibly British reflex to compulsively rank, punish and then “intervene.”
This oversight segmentation has been criticised, rightly so, for embedding perverse incentives into systems, including mechanisms that penalise organisations who find themselves in a financial deficit even if in a clinical context they are performing better than average. NHS Confed in their paper explicitly stated that:
“…many believe that the current binary - in deficit or not - approach is too blunt. It risks affecting a disproportionately large number of organisations, while also failing to account for legitimate, often strategic, reasons that a trust may report a deficit”.
It is, quite honestly, the most British approach I can imagine - when faced with a structural funding crisis, you turn the whole narrative into a moral story about “good trusts” and “bad trusts”4, as though the reason one trust sinking is that it hasn’t been sufficiently inspired by the concept of excellence.
The penalisation of trusts on the basis of carrying a deficit though is absurd - especially when you consider that it was the Government’s own choices that have helped make these deficits possible, including the already mentioned unfunded pay awards which have compounded the historic deficit causes like historic PFI burdens, capital backlogs and overall Tory hollowing out of the system.
And if you’re a trust that is looking at the league table and can see that you’re underperforming due to a deficit? You start becoming risk-averse. You choose the optics of compliance over the substance of good practice. You cut the programmes that might prevent next winter’s crisis, because next winter isn’t in the KPI window.
Which brings me to the subject of social care.
Again, I will be the first to acknowledge that Labour inherited a social care system from the Conservatives that was basically held together with optimism, exhaustion and, most significantly, migrant labour.
Labour which they then promptly closed the door on with their ban on overseas recruitment for care workers that came into effect in July of this year, instantly causing serious issues for the entire care sector. The problem with this, in turn, is that that care sector crisis bleeds directly into the health service in a massive cascade which basically goes like:
Care homes can’t staff beds, people can’t be discharged.
People that can’t be discharged jam acute beds.
Acute beds being full causes A&E to back up.
A&E being backed up means that ambulances stack.
Which leads to an increase in response times.
Which leads to people dying of entirely preventable things that should absolutely be survivable in a functional, 20th century system.
That deep integration between social and healthcare is an amazing thing when it works well - but when it doesn’t, like it hasn’t for many years in this country, it becomes a growing disaster of multiple points of failure.
Then, to put a cherry on this profoundly idiotic and incompetent cake, the government has just in the last few weeks made a commitment that carries staggering cost implications for the health system while, yet again, not appropriately funding it in any way or form.
The commitment in this case is a US-UK pharmaceutical deal in which we have agreed to increase the threshold in cash terms for our “Quality Adjusted Life Year” or QALY from £20 - £30k to £25 to £35k.
This is a highly technical issue that I don’t want to get too bogged down into, but what it ultimately translates into is an additional cost of between £1bn to £3bn a year on medicines spend which, because it appears to be unfunded, will almost certainly need to be carried by the health service.
The same health service that will need to reach even deeper into its own operational and capital budgets to cover these costs, meaning that we are likely to see even more cuts to frontline clinical services, maintenance and the general day to day running of operations5.
All of this brings me back to this week and the inflection point we stand at. We are being told that the NHS is facing one of its worst crises ever by every headline that flashes across our scene - and while this is happening, Labour has decided that the real enemy are resident doctors, rather as though the upcoming strike is a cause of the crisis rather than a result of it.
The Prime Minister has been telling everyone who will listen, in fiercely condemnatory terms, that the planned strike is “reckless” and “beyond belief”. The Health Secretary has been warning us all that the NHS could collapse under the tidal wave of flu6 and is leaning with all his might into the idea that the strikes will push the system over the edge - even invoking a clumsy Jenga analogy.
And they’re also not wrong - the system, as we’ve already established is precarious. They’re just spectacularly dishonest about why that is.
Because if your health system cannot survive five days of industrial action, that isn’t evidence that striking resident doctors are immoral villains out to destroy the NHS - it’s evidence that you’re running a health system with the resilience of wet tissue paper.
And yes, the government has come to the table with a deal that focuses heavily on training places, exam fees and prioritising medical graduates for speciality training - but with absolutely zero mention of pay restoration.
Yes, training bottlenecks are real, and yes, they do matter - immensely. But, what the government is now doing is framing the whole dispute as though it’s wholly about career progression and that the doctors who will be striking are merely being petulant about timing.
What we’re really seeing though is a workforce that has been told, for a decade and a half, that they need to accept pay erosion as a patriotic imperative - and who are now being called selfish when they refuse to smile through it anymore.
Labour’s defensiveness in this situation is the tell - governments that honestly believe they’re fixing something do not respond in this way. They don’t go to a moral condemnation and fling “cruel timing” at a workforce they rely on to keep patients alive. They don’t act like the public’s anger at the NHS should be redirected into anger at the staff who work day-in-day-out to keep them safe and cared for.
I realise that I’m rambling now, and I worry that I will soon move fully into incoherence mode (if we’re not there already), so let me start pulling this to a close.
Yes, the Conservatives actively burned the NHS to the ground. That is a fact and one that is pretty much undisputed - but Labour has done very little to make material improvements to the overall structure of the health service. They took one look at the fire that the Conservatives left, and decided to get rid of the fire exits, extinguishers and firemen and women to balance the books, all under the guise of “difficult decisions”.
That is not acceptable governance - and I am done pretending that it is.
I am done pretending that “difficult decisions” are a good excuse for decisions that are simply incompetent. I am done pretending that a government which talks about “patient safety” while running a system so close to the edge of collapse that even a minor incident now risks pushing it over.
And I wholesale reject the assertion that the resident doctors striking next week are the threat rather than the massive alarm bell telling us all that we’re in grave danger.
The inflection point is very real at the moment, and the government has urgent decisions to make.
They can either rise to the occasion and actively start working on building resilience again - funding, staffing, buildings, social care, planning capacity.
Or, they can accept that crisis will become the status quo and that we will keep living in a rolling state of emergency in the health service.
They can choose, but choosing will also mean doing something that they seem terrified of - admitting that the plans they introduced have made the current situation worse and that they, themselves, need to do better.
This crisis now belongs to Labour.
They know that the health service has no resilience left, that the pay awards were unfunded and their restructuring has paralysed decision making.
They know that social care is buckling and that the rest of the system is being dragged down with it.
And they know, above all, that the NHS should never, ever be so fragile that five days of industrial action can push it towards collapse.
Their fury at striking doctors is in no way or form moral clarity - it is outright panic.
It’s panic that’s born of the knowledge that the maths don’t math anymore, that their excuses are running out and the moment when they are no longer able to blame the wreckage on their predecessors is very rapidly approaching.
This is not a government being sabotaged by resident doctors - it’s a government terrified of being exposed at having taken over a broken system and having made choices, consciously, to make it even more brittle.
And if for any reason you’re not optimistic or derring-do enough, you’re probably “resistant to change” and need a values refresher.
As someone who has been a clipboarder, I can 100% attest to their usefulness - but also to just how dangerous they can be when they’re mistaken for fire-extinguishers.
A clarifying note: NHS CFOs are rarely villains - they’re simply the people who are forced to choose which limb the system can most afford to lose that month, and I do not envy their work.
This way of framing things is especially helpful and comforting because the government can imply that a structural failure is moral instead of a funding decision they themselves have made.
I am not even going to go into the fact that this decision was made completely outside of parliament and was done with the pure intent of appeasing the geriatric orange game show host currently sitting in the White House.
Someone somewhere called it a “Flunami” and I cannot tell you how much I hate that term.
I feel that the less connection the NHS has, whether that be pharmaceutical or any other way, with the orange t*rd's US, the better. This government seems to think that sucking up to this ethical drain is frightfully important but, my feeling is that this is a bully best ignored until he's gone. Perhaps, this government would be better advised to build better relations with our closest neighbours and allies in Europe.
Speaking for myself as a pensioner who will soon be sucked back into the income tax system which, incidentally, I paid into my whole working life I would be more than happy to pay a little extra tax if it meant that the NHS could go back to the functioning system I once nursed in during the 1970s!
The NHS and a welfare state are anathema to the One Per Cent. If you doubt the veracity of that statement just check the front pages of the Daily Torygraph or Daily Wail. Old people in particular are seen as a "nuisance" as they are heavier users of the health service and, heaven forfend, actually expect a state pension. Not, as some journalists would have you believe, a "benefit" but something they have contributed to all their working lives. All of which explains the total neglect of the social care system for the elderly. Just look at the way care homes were treated during the covid pandemic. Nothing will change until we change the UK system of feudal governance.