Intended for healthcare professionals


Politicians must confront big choices on tax and spending to reverse the crisis in health and care

BMJ 2023 ; 381 doi: (Published 12 April 2023) Cite this as: BMJ 2023;381:p826
  1. Chris Ham , senior visiting fellow
  1. The King’s Fund

The NHS’s 75th anniversary is an opportunity to renew its purpose

The 75th anniversary of the NHS threatens to be a wake rather than a celebration. The implosion of the NHS is the result of the failure of politicians to address pressures that have built relentlessly in the last decade. On the basis that a good crisis should not be wasted, what should be done on the occasion of the anniversary to renew the purpose of the NHS?

High on the list is a commitment by the government to provide the resources needed to tackle current pressures and lend credibility to the long awaited workforce plan. These resources must include funds for capital investment as well as running costs and cover the time it will take to work through the backlogs of care that built up before and during the pandemic. Investment in social care is equally important alongside a plan to put social care on a sustainable footing for the longer term.

While additional resources are necessary, they are not sufficient. Much more needs to be done to address the underlying causes of the current crisis by doing more to prevent illness and tackle inequalities in health. 1 This means taking seriously the warnings in the Wanless Review in 2002 that the NHS would become unsustainable unless the population was “fully engaged” in preventing illness and promoting health.

Action is also needed to moderate rising demand for care by investing in primary care and community services. The proportion of the NHS budget spent on hospitals has increased in recent years while the share allocated to primary care and community services has fallen. 2 Hardly surprising therefore that it has been difficult to develop services in the community on the scale required to support people to remain independent and reduce pressure on overstretched hospitals.

With chronic conditions increasing in importance, and multimorbidity responsible for a growing share of demand, the need to invest in primary care and community services has never been greater. This includes restoring community nursing services to levels achieved in 2010 and redoubling efforts to recruit and retain staff in general practices. It also means valuing the role of the allied health professions and creating teams to respond rapidly to crises.

Another priority is to recognise the contribution of patients and the public in improving health and care. Research showing that patients who are most able to manage their health conditions have fewer emergency hospital admissions and emergency department attendances than those who are less able to do so demonstrates why this is important. 3 Enhanced primary care as part of a compassionate communities intervention in Frome, in Somerset, led by a general practice and involving the voluntary and community sectors, showed similar results. 4

Changing the relationship between patients and those who care for them is essential if people are to become active agents in their care. This means enhancing people’s capabilities to make informed decisions through self-management support and shared decision making. Care providers, as well as patients, must be willing to work differently to ensure that patients’ preferences are taken into account. 5 Support should be tailored to the needs of different individuals and communities.

As this happens, the goal should be to promote shared responsibility for health and wellbeing. Shared responsibility is quite different from personal responsibility, which has been criticised for not recognising that people’s behaviours are influenced by the environment in which they live and work. Government must create the conditions in which people can thrive through regulation, taxation, legislation and other means.

Crucially, there must be acknowledgment—as Don Berwick has argued in the United States context—that claims to increase health care spending may result in “the confiscation by health care of opportunities for growth and success in other sectors.” Placing “improving health” at the heart of the purpose of the NHS is essential to secure its future drawing on the work of Michael Marmot and others. A cross-government strategy to tackle the wider determinants of health is an essential first step in this process.

Whether any of this is possible depends on politicians being willing to address issues that for too long have been in the “too difficult” box. The improvements in health and care that occurred between 2000 and 2010 show that the NHS is capable of reform if the political will exists and governments take a long term perspective. Today’s challenges are greater because they encompass social care and a public health system starved of the resources needed to tackle the underlying causes of the current crisis in care.

Successive governments since 2010 failed to respond adequately to rising pressures in health and social care despite compelling evidence of the adverse impact on patients and staff. 6 When they did respond, it was in the form of short term fixes rather than long term solutions. They were also reluctant to be seen to be acting as a “nanny state” by taking action on obesity and other risk factors. The 2010s were a lost decade in public health policy as the health and care system went into decline.

Resolving these issues requires politicians to confront big choices on tax and spending and understand that change takes time. This is what happened between 2000 and 2010 when the Labour government increased national insurance contributions to help pay for additional NHS spending and committed to a long term plan for improvement. The health and care levy proposed by Boris Johnson to fund social care reform had a similar intent but was abandoned by Liz Truss when she became prime minister.

History shows that politicians must be willing to face up to difficult trade-offs and be honest with the public about the consequences of their decisions. Surveys indicate that the public continues to support the founding principles of the NHS but is increasingly negative about the state of health services. 7 Unless the political failure that caused today’s crisis can be overcome, there is little prospect of improvement and no cause for celebration on 5 July.


  • Competing interests: CH is co-chair of the NHS Assembly

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