The NHS and Britain’s healthcare system

The Shakespeare is well-located to serve as a crucial cog in Britain’s integrated transport network. The pub is just outside Victoria Station, between the grand, creaking railway terminus and the slightly less grand Coach Station. Convenient then, because when your train is cancelled and you’ve got to summon the courage to get back to Hove by National Express on a Friday after work, that courage might as well be Dutch, keenly priced, and efficiently delivered.

There’s a detail I admire even more than the pub’s convenience, though. A sign outside the door displaying such brazen chutzpah, such astonishingly unsubstantiated self-confidence, that it could have its own podcast. “Serving…” the faux-chalkboard announces, “London’s best Fish & Chips.”

I must confess, I don’t know this isn’t true. I, like everyone else, have not tried all the Fish and Chips available in London. I haven’t even tried those considered by Giles Coren to be the best. The point is it doesn’t matter what’s true. The Shakespeare says so. The sign does not accept feedback. There is no comment section. It’s a fact.

The Shakespeare, for our purposes, is Britain. Those Fish and Chips? They, of course, are our National Health Service.

It’s a peculiar relationship. We adore the NHS. We clap for carers. It’s inevitably top of any poll of what we’re proudest of as a nation. It made a cameo in the London 2012 opening ceremony alongside the Queen, Becks and Bond. It got a bigger cheer than any of them. 

We love it in that specific way we love a family member. Utterly, and unconditionally. We can find it deeply, profoundly infuriating at times. We see its faults, they literally cost and impact us, and we are more than willing to complain to others in the family. But if someone else, someone from outside were to attack our beloved NHS? Oh no you don’t. It’s perfect. World class. The best Fish & Chips.

This is the challenge facing any incoming (or incumbent) Secretary of State for Health. Many NHS outcomes are stubbornly sub-par, from cancer to sepsis. Waiting lists remain out of control, with a total population the size of Manchester and Birmingham combined currently waiting for an operation. That is one in ten of us. Waiting. A record number doing so for over eighteen months. A year and a half in old money. And old money was what they were spending when they started waiting, it seems. 

More acutely, day-to-day services are found wanting. Emergency care is increasingly battlefield medicine. One A&E consultant I spoke to, not predisposed to hyperbole, described his department as being on a ‘war footing’. This cannot possibly be sustainable. We have nowhere near enough beds. Nowhere near enough doctors, nurses, adjectives. Nowhere for patients to go once they’re ready to be discharged. There’s no connectedness to our care. GPs have less time to see ever more, and ever more complex, patients. The service offers little (great value) preventative medicine, preferring to treat the expensive outcomes of our hyper-processed lifestyles. The level of care can be, whisper it, dangerous. In fact, according to doctors both junior and senior, it is routinely so. The four hour wait target in A&E feels like Cameron’s ‘tens of thousands’ net immigration target or the annual Lawrence Fox mayoral run. A hilariously distant, almost entertainingly naive impossibility. 

The data reflects the scale of the problem. Long-term health trends from life expectancy to obesity even to the height of our children are all going in the wrong direction. More kids present to hospital with rotten teeth than for any other reason. Childbirth is getting more dangerous, particularly for women from ethnic minority backgrounds. Four in ten don’t start cancer treatment within two months of an urgent referral from a GP. Meanwhile, Melbourne and Sydney are increasingly awash with former NHS doctors once serving Maidenhead and Slough, and for understandable reasons. Things are not, objectively, going well.

Yet when it comes to the NHS, in a national masterclass of cognitive Twister, we somehow hold two utterly competing thoughts in our head at the same time. We all agree, it’s terrifying at times. But it’s also totally wonderful and you can’t possibly criticise or change anything at all about it. The NHS is unique in British politics. Not because it’s broken. Everything is. But because the idea of fixing and future-proofing it requires a willingness to challenge entrenched dogma and to suggest that, well, it might just be a bit imperfect in its design. And we can’t have that. It’s family, after all.

Treatment options, then, are limited by not just what is practical, but what is palatable. Informed as much by what’s emotionally acceptable as what’s empirically astute. Certain words, the p word (it rhymes with ryvetisation), are so toxic as to require a radiographer’s special shield even to utter them aloud. Yet, in the confines of this narrow corridor of possibility, alongside backed-up patients on trolleys, Labour and the Conservatives must set out respective treatment pathways as we approach the pre-op nil-by-mouth stage of the election campaign.

Fundamentally, both main parties agree on what success looks like. An NHS free and available at the point of use. Where care is high quality, equally distributed, and tackles with effectiveness and speed the diseases that cut short and curtail our lives the most. Longer, happier, healthier lives. Care in the community. Shorter waits. Newer hospitals. Delighted doctors. Gleaming teeth. A ruddy-cheeked Elysium of healthcare glory for all.

The hard bit, as ever, takes place following contact with reality. So, to keep it real, let’s follow the NHS’ own A&E process. 

So, our NHS calls 111, describes its various issues and is directed (because that’s what 111 does) to A&E. First up on arrival, after the slow-motion eye-roll that is the check-in process, is the glorious false dawn of triage. Oh I’m being seen already! This isn’t so bad. So, just how critical a case are we? 

The vitals aren’t good. As well as that huge population awaiting operations and missed targets for urgent referrals, numbers elsewhere paint an equally bleak picture. The 1% target of people waiting for more than six weeks for an urgent diagnostic test is missed 25% of the time. That four-hour albatross of a goal for A&E is missed on one in three occasions. Our patient, strapped to the monitors in triage, doesn’t love those odds.

Let’s be honest though. This isn’t all down to Tory neglect. Undeniably, it’s also the product of societal trends and events well beyond the remit of health policy; covid, war-triggered inflation, limited access to good food, people living longer and their more challenging healthcare burdens. This triage process isn’t here to apportion blame but merely to assert the level of intervention required.

Equally, credit where it’s due. That megacity-sized waitlist is, at least, falling. GP appointment numbers are up. Delays for diagnostic tests, for consultant appointments, for elective surgery… falling. Doctors talk about the direction of travel being as key as the number. In that respect, things are at least not as bad as they could be. The patient does not appear, in triage, to be getting rapidly sicker.

Nonetheless, Labour’s triage report is clear. The NHS is “on its KNEES”, an unwise pose given any resulting knee injury is not likely to be repaired for over a year. Focusing on waiting times (eighteen weeks, not months, for surgery), access (to social and community care, to GPs), recruitment, intervention, and outcomes, there are clear actions they argue will make a difference.

What’s notable is how, for want of a better word, sensible those actions are. This is not the promise of the fawning acolyte, the Trump physician denying the obvious while blinking under duress. It’s not a kid’s picture of a rainbow in a front-room window manifested as policy. It is centrist. Pragmatic. 

That pragmatism runs through the details. A bureaucratic bonfire of what Streeting calls a “ridiculous amount of red tape” and overhaul of “outdated IT systems” that means GPs are spending on average a full clinic’s time per week not seeing patients but doing admin work. More radically sensible still, Starmer and Streeting have pledged to transform the primary care provision, opening GP walk-in hubs every evening and at weekends to ease the burden on both appointments and unnecessary A&E visits. 

The virulent strain of Labour sensible-ness is contagious. There’s a focus on filling vacancies and job creation in critically under-staffed sectors from health visitors and district nurses to GPs and midwives, even if (and indeed, particularly) with foreign medics and medical students, and the accompanying incentives. On retaining them, not just recruiting and training them for a post-NHS career in sunnier climates. A realisation that emergency care is only as good as the social and community care into which patients can be discharged, and the need better to connect them. Application of new technologies for diagnostics, for booking routine checks, for patient control of data. These are not miracle interventions. Nor, though, are they miracle promises. They are, though, representative of a willingness to challenge and change what rather obviously needs changing. To treat the facts, rather than be blinded by the Atlee-cosplay feels.

But in reality how different is Labour’s approach to what is being promised elsewhere? 

More GP appointments. More nurses, doctors and primary care professionals, attracted by a £5,000-£8,000 annual grant while training, which they won’t be required to repay. An ‘NHS Visa’ to attract qualified doctors, nurses and medical professionals from overseas to fill the vacancies here. Upgrading every hospital trust with the latest diagnostic technology to aid early detection and hasten treatment. Any of this sound… familiar? It constitutes the Conservative, as opposed to the conservative, approach. 

However there is one fundamental vulnerability at the core of the Conservative position on the NHS. Credibility. To say something is different to being believed. To promise it is not to deliver it. We return to the Shakespeare in Victoria (another train canceled, the prospect of a midnight Megabus to Portsmouth at least slightly improved by the promise of London’s finest fish). 

The claim that The Shakespeare can be relied upon to serve the best Fish & Chips in London would be hard enough to believe in itself, but to those who have tried it (I am assured, by Tripadvisor) it is laughable. ‘Worst fish ever’, ‘awful fish and chips’, and best of all ‘fish… that had NO FISH in it’. 

Fish with no fish in it. Glorious stuff.

We know good fish just as we know good healthcare, it turns out. So no matter the promise, no matter how correctly the current landlord may identify what needs to be done (some fish in the fish, perhaps), those who have tried the current offering no longer trust them to deliver anything good. 

This, then, is the opportunity facing Labour, and also the trap. To remain calm. To remain clear. To remain conservative. We don’t expect the best fish and chips in London, particularly when we’re emerging from the healthcare equivalent of a rainy Victoria station. In these circumstances, we just want an NHS that works, informed by an honest approach that will face up to what’s wrong, delivered by people we can trust to keep realistic promises. This is, of course, exactly what we also want from a trip to the GP or hospital, too. No miracle cures. No snake oil promises. Access to pragmatic, effective, honest treatment, communicated clearly, without hyperbole or an emotional disregard for the facts.

It may not be the best fish and chips in London. But we don’t expect that right now. At least it’s got some fish in it, and that’s a good start.


This blog is part of media strategist Alex Hesz’s ‘Mission Messaging’ series for Progressive Britain. Check out the previous instalment, The Economy, here.