Tories underfunded the NHS – but that isn't its only problem

For those on the frontline, however, the situation is more than “challenging” - it is frankly unsafe.

Read more: Short-term, the focus must be on staff retention and fixing social care 

The week running up to Christmas Day saw a record 1,925 people in Scotland spend over 12 hours in emergency departments despite the fact that the number attending (22,892) was the lowest since January last year.

By the end of November 2022, at least 1,488 patients are estimated to have died in Scotland as a result of waiting too long in emergency departments.

The number of people spending over four, eight and 12 hours in emergency departments has been exceeding pre-pandemic levels and increasing since mid-2021 (Image: PHS)

However, this figure is based on research carried out before the pandemic, when overcrowding, delayed discharge, and ambulance handover delays were much less severe than they are now. The reality is probably much worse.

This is just one snapshot of the harm coming to patients as a result of a health service critically short of beds - and the nurses needed to safely staff them.

Add to that the impact of ambulances unable to respond to 999 callouts because they are queued up outside A&E and patients deteriorating in the community while they languish on waiting lists or struggle to cope at home without adequate social care, and it is easy to see why many feel the NHS is at a tipping point. Maybe even in an existential crisis.

The question of whether the NHS recently is, and has been, funded sufficiently is an important one, because it goes to the heart of how much of our problems now could have been avoided.

Read more: Doctors have 'never been more concerned' about safety of NHS care 

A recent report by the King’s Fund, a respected health think tank, rebutted the suggestion that the NHS is a “bottomless pit”.

Historically, spending on healthcare has grown by around four per cent per year in real terms since the NHS was founded. A growing and ageing population inevitably increase demand, as does the proliferation of new drugs and medical technologies.

However, the annual increases in investment shrank to just 1.5% on average between 2009/10 and 2018/19.

While health is devolved - and the Scottish Government now has its own tax raising powers and decides how to divide its budget - what the UK Government chooses to invest in healthcare in England is largely mirrored north of the border (and in Wales and Northern Ireland).

As a result, the NHS arrived at the pandemic severely weakened. Subsequent increases in spending fall well short of reversing that damage.

Critics argue that the UK is already pouring more than 40 per cent of day-to-day public spending into the NHS, but as the King’s Fund also notes the UK has comparatively low tax revenues to begin with compared to other countries.

Furthermore, as a percentage of GDP the UK invests around 9.9% on health versus around 12% in France and 13% in Germany.

UK healthcare spending compared to 14 EU countries (Image: The Health Foundation)

According to the charity, the Health Foundation, if the UK had matched its health spending per head to France or Germany, an extra £40 billion or £73bn would have gone into healthcare between 2010-2019 than actually did (uplifts of 21% to 39% respectively).

Germany has 42% more physicians per head of population than the UK, and more than three times as many beds per 1000 people.

A recent analysis by the FT also demonstrated stark differences in investment depending on the party in power at Westminster.

From 1979 to 1996 (Conservatives) spending on healthcare as a percentage of GDP largely flatlined - as well as lagging behind the average for peer nations in western Europe and North America.

From 1997 to 2009 (Labour), this reversed - the percentage of GDP spent on healthcare increased by 3%, outstripping the levels of growth seen in all but one of the peer nations.

From 2010 onwards (after the global financial crash, with the Conservatives back in power), investment fell back.

While most of Britain’s peers continued to growth health spending in spite of the credit crunch - albeit modestly - here, austerity policies saw it steadily decline.

During the decade after the credit crunch, similar nations continued to increase healthcare spending as a percentage of GDP but the UK did not (Image: @johnburnmurdoch/FT)

Circumstances change, but what we choose to invest in healthcare - and how we generate revenue for public spending in the first place - remains a political decision.

This is not to say that healthcare systems in Europe are not also under strain, however.

Many face similar predicaments to the UK: recruitment and retention (France has fewer doctors per head now than in 2010, for example) with flu and Covid squeezing occupancy across the continent.

In Madrid, thousands of GPs and paediatricians were on strike for over a month at the end of 2022 in protest over workload and underfunding.

Hans Kluge, the WHO regional director for Europe, warned that the region faces a “ticking timebomb” of doctor shortages, especially in rural and deprived areas.

Read more: 'It's falling apart' - Scots GPs on their fears for the future of general practice 

Yes, debate is certainly needed on the future of the NHS: what it should provide, the investment needed, and how we fund it.

However, some of the biggest dilemmas facing healthcare are universal across the West: an ageing population relative to a proportionately smaller working age population able to fund public services through taxation, compounded by increasing levels of frailty, chronic illness, and obesity.

When the NHS launched in 1948, barely 10% of Scots were over 65. Now they account for nearly a fifth of the population.

Living longer is a good thing; less positive is that healthy life expectancy in Scotland is just 61 - meaning that an average male and and average female will spend the final 16 and 20 years of their life in poor health, respectively. Even halving that would deliver huge savings for the NHS.

If healthcare is to remain remotely sustainable, we will have keep people much healthier for much longer.

It is difficult to see how that can be achieved unless diets and lifestyles are radically altered through state-led interventions.

Long-term, prevention is the best cure.