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It is clear that the provision of public services in England is in crisis and the underlying cause is a decade and more of Tory policies which have under-resourced services. Crucially, this situation over time has knock-on adverse impacts of the funding provided by all-powerful Westminster to governments in Belfast, Cardiff and Edinburgh.

Every decision – every example of under-resourcing described in what follows – has had a consequence for those voters looking to governments in NI, Scotland and Wales to meet their needs and wants. I focus here on funding for health services. However, when one adds in, as examples, the additional effects of Tory austerity on resourcing of schools in England and the substantial shift in local government financing in England away from central government funding to an increased load on Council Tax payers, it should be obvious to all reasonable, clear thinking people (but too often isn’t) that the devolution settlements for NI, Scotland and Wales simply cannot buck the trends set by a Westminster government’s political choices!

On 16 November, 2022, the Health Foundation – ‘an independent charity committed to bringing about better health and health care for people in the UK’ – published a report entitled: ‘How does UK health spending compare across Europe over the past decade?’

Here are its key findings (with my emphasis):
– ‘Average day-to-day health spending in the UK between 2010 and 2019 was £3,005 per person – 18% BELOW THE EU14 AVERAGE OF £3,655

– If UK spending per person had matched the EU14 average, then the UK would have spent an average of £227bn a year on health between 2010 and 2019 – £40BN HIGHER THAN ACTUAL AVERAGE ANNUAL SPENDING DURING THIS PERIOD (£187BN)

– Matching spending per head to France or Germany would HAVE LED TO AN ADDITIONAL £40BN AND £73BN (21% TO 39% INCREASE RESPECTIVELY) of total health spending each year in the UK.

– Over the past decade, the UK had a LOWER LEVEL OF CAPITAL INVESTMENT in health care compared with the EU14 countries for which data are available. Between 2010 and 2019, average health capital investment in the UK was £5.8bn a year. If the UK had matched other EU14 countries’ average investment in health capital (as a share of GDP), the UK WOULD HAVE INVESTED £33BN MORE BETWEEN 2010 AND 2019 (AROUND 55% HIGHER THAN ACTUAL INVESTMENT DURING THAT PERIOD).’

It goes on: ‘.. the magnitudes of the yearly differences in spending and investment between the UK and these other countries may point towards SUSTAINED SUBOPTIMAL SPENDING PER HEAD ON HEALTH CARE IN THE UK. The knock-on impact of this underinvestment could affect access (longer waiting lists), quality (overstretched staff or lack of investment in technology), in turn LEADING TO A LESS RESILIENT SYSTEM.

‘Even before the pandemic, THE PROPORTION OF PEOPLE IN THE UK SELF-REPORTING THAT THEY NEEDED TREATMENT BUT COULD NOT ACCESS IT WAS ONE OF THE HIGHEST IN EUROPE. So, systems that are already running at capacity may become reliant on emergency funding or on having to redeploy resources and deprioritise certain services to deal with surges in demand.’

And: ‘This analysis shows that OVER THE PAST DECADE THE UK HAS SPENT LESS ON BOTH DAY-TO-DAY CARE AND INVESTMENT SPENDING ON HEALTH CARE COMPARED WITH THE AVERAGE EU14 COUNTRIES. This is mirrored by less capacity, fewer physical resources and therefore greater vulnerability to sudden surges in demand. This meant the UK had to increase spending more rapidly than other countries to respond to the pandemic.’

Finally from the Health Foundation: ‘Overall if the UK had matched EU14 levels of spending per person on health, day-to-day running costs would have been £39BN HIGHER EACH YEAR, ON AVERAGE, OVER THE PAST DECADE (£30.5bn of which would have been additional government spending).

‘For capital spending, matching the cumulative EU14 average over the past decade WOULD HAVE RESULTED IN THE UK INVESTING £33BN MORE IN HEALTH-RELATED BUILDINGS AND EQUIPMENT. These are significant gaps in spending. Had UK spending kept up with European neighbours IT IS FAIR TO ASSUME THE NHS WOULD HAVE BEEN MORE RESILIENT AND HAD GREATER CAPACITY TO PROVIDE CARE DURING THE PANDEMIC AND REDUCE THE LARGE BACKLOG OF CARE THAT IS ITS LEGACY.’

On 24 November, 2022 the health thinktank, The Kings Fund published an article focused on England entitled: ‘The health and care workforce: planning for a sustainable future’. Note, it is staff that most of the health and care budget is spent on.

‘The workforce crisis has been a prominent issue for years, but there has been LITTLE CONCERTED ACTION FROM GOVERNMENTS TO TACKLE THE CHALLENGE.‘

‘.. SINCE 2010 A PROLONGED FUNDING SQUEEZE COMBINED WITH YEARS OF POOR WORKFORCE PLANNING, WEAK POLICY AND FRAGMENTED RESPONSIBILITIES MEAN THAT STAFF SHORTAGES HAVE BECOME ENDEMIC.’

‘FROM 2010 ONWARDS, demands on health and care services and the available workforce began to diverge and performance and outcomes began to slip backwards.’

The Institute for Fiscal Studies has also examined this subject: ‘NHS funding, resources and treatment volumes’ (published on 14 December 2022). It reports:

‘ the (NHS England) maintenance backlog has been growing for a number of years. This represents A FAILURE TO INVEST ADEQUATELY IN HOSPITAL INFRASTRUCTURE, AS WELL AS A TENDENCY TO USE CAPITAL FUNDING TO COVER SHORTFALLS IN DAY-TO-DAY FUNDING IN THE 2010s.

‘The total cost of the backlog has continued to rise during the pandemic, and the estimated cost to eradicate it fully stood at £10.2 BILLION IN 2021–22. THIS IS 7% HIGHER IN REAL TERMS THAN IN 2019–20, AND DOUBLE THE 2010–11 LEVEL. Most concerning is the rise in the high-risk maintenance backlog (‘where repairs/replacement must be addressed with urgent priority in order to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution’), which NOW STANDS AT £1.8 BILLION AND IS 13% HIGHER IN REAL TERMS THAN IN 2019–20 AND 355% HIGHER THAN IN 2010–11.’

Every spending decision taken by governments in Westminster has a consequence one way or another – directly or indirectly – for the governments in Belfast, Cardiff and Edinburgh and their abilities to meet the needs and wants of their voters over devolved matters. When too often these decisions, these impactful political choices, are being taken by governments rejected by majorities in Scotland and Wales the situation becomes intolerable.