It seemed a good idea at the time. A National Health Service, free at the point of need, funded through taxation, offering high quality care irrespective of ability to pay. But as all too many pundits are now saying: “It’s an idea whose time has passed. We need to think again.” When they put forward so-called solutions, and comparisons with other systems, the underlying principles of the NHS become threatened.

While the pandemic exacerbated the problems in the NHS, it did not cause them

At a time of crisis – and despite governmental denials, this really is a crisis – there is a tendency to search for simple solutions. We are at risk of ignoring HL Mencken’s brilliant aphorism, “For every complex problem there is an answer that is clear, simple, and wrong.”

The Covid-19 pandemic focused all our minds on healthcare. Early on, we watched terrifying reports of overwhelmed intensive care units. The Chief Medical Officer appeared daily alongside the prime minister. Our focus was on protecting the NHS – ensuring it would be there when we needed it. The pandemic left healthcare staff exhausted and drained, demonstrating the parlous state our NHS had reached.

But while the pandemic certainly exacerbated the problems in the NHS, it did not cause them. Successive Governments claimed the NHS was getting a budgetary increase, yet over a decade this failed to keep up with inflation, let alone increasing demand and complexity of care. Those who look admiringly at social insurance systems in continental Europe need to be aware it’s not how money is provided that has ensured their success, it’s how much. Germany has more than eight hospital beds per 1000 citizens, while the UK has 2.7. If the UK had invested as much per capita as Germany, health and care would have received an astonishing £73 billion extra per year. It’s little wonder we are in trouble.

But we are where we are. Getting out of the current crisis will require money, and more than anything it will require staff. While increasing recruitment into the clinical professions is essential – and Treasury restriction of medical student numbers is sheer madness – losing established and experienced staff is a disaster. When exhausted, demoralised, burnt-out NHS staff quit, they leave their remaining colleagues under even greater pressure, and the most vicious of vicious cycles spins ever faster. Focusing on staff retention must be a number one priority in the short term.

But in the long term we have an even bigger problem. In my recent book, Side Effects: how our healthcare lost its way, and how we fix it (2022), I explored trends in healthcare, not just in the NHS but around the world. The cost of every healthcare system is escalating year on year – a trend that is ultimately unsustainable. For instance, in 1949 the NHS issued 25 million prescriptions. By 2016, this had increased to 1.3 billion, with the number of available drugs escalating from 250 to an astonishing 18,000. Between 2011 and 2017, hospital spending on drugs almost doubled from £4.2 billion to £8.3 billion. We have simultaneously invested massively in drugs and underinvested in the workforce, perhaps forgetting that healthcare is a people business.

Between 2004 and 2021 the number of hospital specialists grew by 83%, while the number of GPs fell

As populations age, more and more of us live with increasingly complex medical burdens. Nearly 60 years ago, my dad died of a heart attack. Despite being a doctor, he was an overweight smoker with high blood pressure. I am now much older than he was when he died, and – whether through luck, statins, or not smoking – I have avoided a heart attack. Which gave me time to develop cancer. And have a hip replacement. One side-effect of my not having died at my dad’s age has been dramatically increased costs for the NHS. And I’m very grateful indeed.

More and more of us are collecting multiple health problems – eight long-term conditions in an individual is far from unusual – and yet the focus of healthcare over the last few decades has been on individual conditions, rather than skilled generalists being able to care for the whole person. Between 2004-2021 the number of hospital specialists grew by 83%, while the number of GPs fell. On average, every GP is responsible for 300 more patients today than in 2015. But no one decided we should reduce the number of GPs. It was another side effect, this time of an over-concentration on the apparently more dramatic role of hospitals. We need both.

A while ago, a senior UK politician enthused to me about a new cardiac unit that had opened in his constituency. A friend of his had suffered a serious heart attack and had been admitted to this new unit. Within hours, he had been assessed and treated. Within days, he was out of hospital, with a prescription for exercise at the gym.

I agreed that the unit was indeed a stunning development and something to be proud of, but I then asked my political colleague a simple question: would he personally prefer to have a heart attack treated rapidly and effectively, or not to have had one in the first place?

He made it clear that this was an absurdly naïve question, but it illustrates one of the key challenges for any healthcare system. Do you invest in prevention? Is it better to set up an effective system that ensures blood pressure is kept under control, and addresses smoking and high cholesterol, thereby preventing many heart attacks – or should you focus on providing the high-tech kit for treating heart attacks when they happen?

Which would you prefer – a heart attack treated speedily, or not having a heart attack? No-brainer, isn’t it? So why does policy always focus on the opposite approach? Maybe it’s because there’s no story. After all, even the people who don’t have a heart attack don’t realise they didn’t have a heart attack. Is it overly cynical to note that the impacts of prevention occur outside the political cycle? Those who support prevention are unlikely to get any credit.

Much prevention is carried out in general practice, and currently general practice is in a critical state, understaffed, under-supported, and exhausted. The NHS has depended on skilled GPs, but they feel constantly under attack, handling unsustainable workloads. Getting general practice right could make an extraordinary difference. Getting it wrong has been massively damaging.

For instance, before the pandemic, political policies on waiting times almost destroyed continuity of care. No-one likes to wait for an appointment and waiting times had become a controversial focus in many elections. To hit access targets, patients were told they had to see any doctor who was available within a set time frame and were denied the option of waiting to see their preferred doctor, even if this was what they wanted.

Does this matter? A research paper from Norway in 2021 showed that patients who stayed registered with the same GP over many years had fewer acute hospital admissions, as well as a 25% reduced risk of premature death. If drugs produced benefits of this scale, massive investment would be found to provide them. Instead, nothing has been done to support continuity of care. Increasing demand on hospitals has led to a focus on hospitals, rather than downstream where so many problems could have been averted. As Archbishop Desmond Tutu said, “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.”

The solution does not arise from yet more restructuring of the NHS, nor changing the funding model

And they often fall in because we have underinvested in so many aspects of the public’s health. We close swimming pools and playing fields, then wonder why the NHS is overwhelmed by the unfit. We forget that housing, nutrition, sleep, stress, education, exercise, social isolation and poverty are key determinants of our health. We focus on the dramatic rather than the effective. The headlines get the attention. This does not always lead to the wisest of choices.

So, is there a way forward? The solution does not arise from yet more restructuring of the NHS nor changing the funding model. Whichever pocket you take the money out of, it is still the same money. None of the solutions are straightforward, but they are all immensely achievable.

• We need to retain our skilled, exhausted, experienced, and underappreciated staff
• We need to focus on prevention, rather than simply talking about it
• We need to unpick the overmedicalisation of so many aspects of normal life
• We need to ditch the absurd and illogical division between health and social care
• We need to recognise the vital importance of care and well as cure
• We need to enhance, support, and develop primary care
• We need to have some clarity as to what it is we want the NHS to achieve

If we do all that, our dream of a National Health Service, free at the point of need, funded through taxation, offering high quality care irrespective of ability to pay, could be here for many decades to come.