How Did We Get Here?

To understand how we’ve got to this desperate moment, we need to look back beyond this particular industrial dispute: far beyond the more immediate triggers of Covid-19, our cost-of-living crisis and rocketing inflation. The root cause is Thatcherite reforms—which reorientated the NHS away from a mission to maximise health outcomes, and to a mission to maximise cost containment. 

At its origin, the NHS had an outcome-based definition of efficiency. Bevan was very clear that his vision was of a healthcare service that would ‘universalise the best’ for all. That is, his was an NHS driven by a search for the best way to maximise health outcomes. 

This changed under the 1980s Thatcher governments. Spooked by the (now discredited) idea that an ageing population would substantially and irreversibly increase the size and cost of the NHS—locking in a permanently bigger state—her government’s reforms subtly changed the definition of efficiency. Outcome-maximisation was replaced by a crusade on cost containment: the question become, how can passable quality, standards and safety be achieved for the very lowest of bargain basement prices? 

Many of the ideas associated with the health policy of that era can be seen as contributing to the ordinance of short-term price over long-term outcomes. Led by policy reviews by the private sector—such as that by Sainsbury’s CEO Roy Griffiths—in came the era of quasi-markets, the provider/commissioner split, budget holding, and the redefinition of patients as consumers.

This was to form the foundation of extreme cost-containment introduced during austerity. David Cameron was very clear that austerity, to him, was a theory of efficiency: ‘what you call austerity, I might call efficiency’. Efficiency defined as the lowest possible cost rather than the best way to the best outcome.

Austerity would achieve its ends by combined the mechanisms of competition introduced by Thatcher with cutting new ‘efficiency targets’. The first was a £20 billion scheme—the ‘Nicholson challenge’—set in 2012. Another followed in the Five Year Forward View. Today, the NHS is still expected to find 2.2 percent of efficiencies each year—despite the fact global rankings already place it as the most efficient healthcare service in the world.

Decisions were once made based on what was best for the patient. Increasingly they became tested against what keeps costs at the lowest possible level—a project in small statism to permanently constrain the size of the NHS.

The Cost to Workers

This doctrine had severe consequences for healthcare workers. Implicit in a permanent crusade for cost containment is the suppression of pay and staffing costs. 

Pay controls have been the policy instrument of choice. In 2010, the NHS was subjected to the wider public sector pay freeze—and from 2012 to the public sector pay cap, which limited awards to 1 per cent per year.

Even outside this cap, pay awards have often been derisory. Following all the stress and strain of working on the frontline through Covid-19, the Department for Health and Social Care submitted a recommendation of a 1 percent pay award to the independent pay review body. After outcry, the actual award was larger—but still just 3 per cent.

Poor pay has begun a vicious cycle. Working for the NHS has increasingly become associated with financial struggles and a hard life. Healthcare staff like nurses have increasingly left the profession. Latest data shows the NHS has less than half the number of nurses in Norway or Switzerland per 1,000 inhabitants, despite the fact that every 10 per cent increase in degree-holding nurses reduces mortality.

As nurses have left in droves (resignations are now at their highest ever), the reality for those left behind has only worsened. The workload has risen, stress and burnout have rocketed, and IPPR research shows a shocking consequence for workers’ mental health. It is the worst embodiment of the NHS run at its very leanest—in the interest of keeping the state as small as possible rather than the nation as healthy as possible.

Fighting Back

Advocates of making cost containment the dominant consideration in NHS policy and practice contend it is vital to sustainability. They say that an ageing population will otherwise make the NHS unaffordable.

Their argument has little consideration of the human suffering it enables. Seven million on waiting lists for care, ambulances arriving hours late, and emergency departments creaking at the seams. These aren’t just statistics—they are stories of very real human suffering, of people’s lives cut short.  

But its lack of sense can increasingly be proven by the fact poor healthcare is undermining the economy. A record two and a half million people are now out of work because of long-term sickness. These are people being involuntarily excluded from work because of their health—and including because they haven’t received the healthcare or social care they need.

It exposes the idea of the NHS becoming ‘unaffordable’ as an arbitrary, subjective, and ideologically-driven judgement. The truth is, the combined human and economic value of brilliant care—delivering on Bevan’s vision of ‘universalising the care’—remains one of the best investments we can make. And of all investments, the very clearest case is for better pay and conditions for workers. 

That’s what drives safe, effective, and high-quality care when we most need it.

So if the strikes today were just about pay justice, they would be more than deserving of support. But they are also a broader battle: a fightback against the idea that we cannot justify investment in our NHS and its workforce. The nurses are taking action on behalf of the soul of our NHS, and we must all do all we can—in solidarity—to ensure their victory.