Foreword

I’ve spent my life working in healthcare. For many years, I was involved in both devising and implementing many aspects of local and national health policy, and I’ve also experienced it first-hand, as a patient. From every perspective, there is clearly a mismatch between supply and demand. While resources can never be infinite, the demand for healthcare in Britain appears to be inexhaustible. This imbalance is a source of immense tension, and the situation is only getting worse. In this book, I will first assess this extraordinary challenge and then attempt to suggest how we might tackle it.

In the past few years, the NHS has faced a double whammy; first the government’s pursuit of austerity reduced its capacity and then the immense challenge of Covid-19 tested it to its limits. Even before this, it faced massive and unsustainable pressure. While increased funding is critically important, it cannot be the only solution to every problem.

The coronavirus pandemic has, to an unprecedented degree, devastatingly exposed the challenge that is facing us. For a while, it trumped everything else, and not just in Britain. All around the world, governments recognized the supreme importance of health and healthcare, as well as the key role that the state has to play in protecting its citizens.

In ancient Rome, the statesman Cicero wrote that ‘the health of the people is the supreme law’. Two thousand years later, as the UK stood on the brink of crisis in March 2020, the Chancellor of the Exchequer Rishi Sunak said, ‘Whatever extra resources our NHS needs to cope with Covid-19, it will get. Whatever it needs, whatever it costs, we stand behind our NHS.’ In countries around the world, politicians displayed the same sentiment. Funds somehow appeared, and no expense was spared. Repeated comparisons were made to the challenges of wartime. In March 2020, the prime minister Boris Johnson declared that his government would act ‘like any other wartime governments’ to support the British economy and take ‘steps that are unprecedented since World War II’.1 Other world leaders used similar descriptions. The US president Donald Trump referred to himself as a ‘wartime president’ and Andrew Cuomo, governor of New York, reportedly said that ‘ventilators are to this war what bombs were to World War II’.2

The battle with disease – with a single disease that spread easily and posed a particular threat to the eldest and most vulnerable – was in full swing. Humankind had to fight this virus with whatever weapons it could muster, which initially meant prioritizing healthcare over the needs of the economy and all the other various priorities that usually jostle for attention. It was extraordinary, but it was necessary. However, things were far from typical. Funds are not infinite, and they never can be. In more normal times, when we are not facing a global pandemic, we still find ourselves having to make life-and-death choices. After all, healthcare can be massively expensive. Every year, the cost of care escalates, and the money has to be found to pay for it. Even prior to the pandemic, in 2017, the UK spent £197 billion on healthcare, equating to £2,989 per person.3 Research scientists continue to develop new drugs and therapies; the potential benefits that they offer to humankind are phenomenal, but the accompanying prices almost inevitably go up and up.

Even before Covid-19, the proportion of national wealth that was spent on healthcare was increasing every year, and every prediction of future