Is Britain ready for Wol Kolade’s “big conversation” about the NHS?

Public satisfaction with the NHS has fallen to the lowest levels since records began in 1983, according to the latest edition of the British Social Attitudes Survey (BSA), which was released this week. A majority of respondents (52%) are dissatisfied with the health service’s performance, and only a quarter (24%) are satisfied.

That is a major change compared to the recent past. For years, the share of respondents who were satisfied with the NHS used to fluctuate around 60%, and the share who were dissatisfied around 25%.

And there is something else which has changed alongside. Five years ago, there was hardly any public figure who would openly criticise the NHS, or at least not on a fundamental level. In the meantime, it has become much easier to find dissenting voices. Just last week, the deputy chair of NHS England, Wol Kolade, said that there was ‘a big conversation’ to be had about how to provide and fund healthcare in the future, floating the ideas of ‘social insurance’ and ‘some sort of private solution’. Four or five years ago, it would have been unthinkable for someone in such a position to say something like that.

For those of us who agree with Kolade, it would be tempting to see a connection between the BSA survey results, and this broader shift in the terms of the debate. It would be tempting to believe that the public are finally falling out of love with the NHS, and that they are ready to have that ‘big conversation’ Kolade is talking about.

But that would be wishful thinking. We are not there yet. We are not even close. Most people still love the idea of the NHS in the abstract, even if they are dissatisfied with its current performance.

The same BSA survey also shows that among those who express dissatisfaction, about half (47%) say that the problem is that “[t]he government doesn’t spend enough money on the NHS”, and one in five blame unspecified “[g]overnment reforms that affect the NHS”. An overwhelming majority (83%) of respondents approve of the principle of a tax-funded health system, most of them strongly so. So let’s not read any appetite for fundamental, system-level reform into those figures. That would be projection.

Nonetheless, while the BSA results do not show that NHS-sceptics are winning the argument, they may still mean that we have a foot in the door. At least, most people now agree with us that the NHS is not “the envy of the world”. That’s progress!

What NHS-sceptics need to do now is challenge the ideas that the NHS is just “underfunded”, and that its problems have only arisen in recent years.

In 2022, public spending on healthcare in the UK was 9.3% of GDP, and total spending was 11.3%. These figures put us comfortably into the global top ten.

Nor was there ever a golden age during which NHS was much better than today. It is true that waiting times have shot up in recent years, even before the pandemic, and all the more so since then. However, even in the early 2010s, when waiting times were at a historic low, they were still considerably longer than in many neighbouring countries. More importantly, measurable clinical outcomes were at least as bad as they are now, and more often, worse. Then as now, the NHS was behind most of its peers, in terms of outcomes and waiting times.

If you accept that the NHS is currently performing poorly, you cannot sensibly claim that this was ever very different. If we really want better outcomes, we need to finally have that ‘big conversation’ Wol Kolade wants us to have, break out of the insular bubble of the NHS cult, and learn from international best practice.


Head of Political Economy

Dr Kristian Niemietz is the IEA's Editorial Director, and Head of Political Economy. Kristian studied Economics at the Humboldt Universität zu Berlin and the Universidad de Salamanca, graduating in 2007 as Diplom-Volkswirt (≈MSc in Economics). During his studies, he interned at the Central Bank of Bolivia (2004), the National Statistics Office of Paraguay (2005), and at the IEA (2006). He also studied Political Economy at King's College London, graduating in 2013 with a PhD. Kristian previously worked as a Research Fellow at the Berlin-based Institute for Free Enterprise (IUF), and taught Economics at King's College London. He is the author of the books "Socialism: The Failed Idea That Never Dies" (2019), "Universal Healthcare Without The NHS" (2016), "Redefining The Poverty Debate" (2012) and "A New Understanding of Poverty" (2011).

1 thought on “Is Britain ready for Wol Kolade’s “big conversation” about the NHS?”

  1. Posted 21/04/2024 at 14:48 | Permalink

    I think people should have to pay towards all public services at the point of use. I am presently standing in the Local Elections. I am inundated with requests for more convenient and better and safer and cleaner public transport, buses in particular. This is always from people with free Senior Bus Passes. The Services are never good enough where they are free. At the same time there are never ending empty busses going past and regular complaints from fare payers when asked for high fares they feel they are the only person paying for everyone else.
    The NHS falls into this category. It seems clueless to react and adapt it’s operation to demand in the way a private company would and it is certain to always fail in practically everything it does by its very nature accordingly.
    However many services could be provided, I feel, privately that people may choose to use. Just like dentistry where private dentistry is hardly more expensive than the NHS and pre pandemic was very successful and accessible until practices near me started going out of business it seemed and have not recovered.
    School vouchers and an adapted National Curriculum could revolutionise education giving parents a host of choices for their Children.
    Whilst I agree that there is a cultural demand that urgent health care is free at the point of need I feel sure it is possible to achieve this whilst we have free choice and healthy competition.
    It’s very hard when preventive medicine is factored in. There is a huge Industry in treating healthy people in this country on the NHS. There is a massive private industry in fact in treating well people, through all forms of media for example newspapers, TV, on-line. Thankfully we have not got to making everyone pay for other peoples fads yet, or have we?

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