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ANC gets its ‘revolutionary’ NHI legislation adopted despite opposition criticism and likely litigation

ANC gets its ‘revolutionary’ NHI legislation adopted despite opposition criticism and likely litigation
From left: Health Minister Joe Phaahla. (Photo: Leila Dougan) | (Photo: Leila Dougan)

Opposition parties flagged as worrying the vast ministerial powers, potential for corruption and public health facilities’ general unreadiness, in rejecting the National Health Insurance Bill. But with the support of five one- or two-seat parties, the ANC got the necessary approval on Tuesday.

That the National Health Insurance (NHI) is a step closer to implementation comes at a crucial point ahead of the 2024 elections, allowing the governing ANC on the hustings to show it delivered on its 2019 universal healthcare election promise.

As far back as the 2007 Polokwane ANC national conference, and the 2010 ANC General National Council, NHI has been a key policy instrument supported across the tripartite alliance with labour federation Cosatu and the South African Communist Party (SACP).

South Africa cannot transform and upgrade its public healthcare sector without eliminating the imbalances between the private and public health sectors which are skewed in favour of the minority-servicing private health sector,” the SACP said in a statement four-and-a-half hours before the parliamentary proceedings.

“It (NHI Bill) is a milestone in what should be a continuing struggle for quality healthcare for all, against the background of the overall agenda by the reactionary opposition to NHI.”

It will still take some time for the legislative processes to run their course in the National Council of Provinces (NCOP) before it goes to the president’s in-tray for signing.

Cosatu called on the NCOP to now “move with speed” to also pass this legislation.

“It is critical government allocates sufficient resources to ensure the NHI Bill becomes a reality for all South Africans…

“South Africa cannot continue on a path where public healthcare is buckling due to under-resourcing, unfilled posts and long queues, whilst the private healthcare sector charges exorbitant rates and caters for the few who can afford it,” said Cosatu parliamentary liaison, Matthew Parks.

The political significance of the NHI Bill adoption in the National Assembly was signalled not only by the alliance statements of support, but also the attendance of both Health Minister Joe Phaahla and his deputy Sibongiseni Dhlomo in the House for the debate.

“We do understand some of the concerns about poor management, but we want to say even in the overburdened public services there are jewels. I can give you examples…” said the minister after, again, outlining the imbalances in South Africa’s healthcare where 84% of people rely on public healthcare.

“This has led to a situation where the public health system is under tremendous pressure, while the private healthcare is over-servicing its clients leading to ever-rising costs to the members of medical schemes while the investors are enjoying huge dividends including from the JSE.”

By pooling private and public health funding, the health minister said, “We can achieve access, equity and quality, but also drive down costs.”

Having described the NHI Bill that establishes the fund for universal health as “historic” and the “most revolutionary piece of legislation” since South Africa’s 1994 transition to democracy, Phaahla dismissed opposition criticism and concerns.

It was “untrue” to say the estimated nine million South Africans on private medical aid would now migrate to only the public health service, as DA MP Michele Clarke pointed out in her debate contribution.

“We all contribute to one pool (of resources) under one fund so we can access services both in the public health services but also in private health… The cost will be negotiated.”

However, the Bill forecasts medical schemes only offering services not available on the NHI, and is firm on set referral pathways. 

And while the health minister appoints the fund’s board, no parliamentary role is envisioned in that process, heightening concerns over the lack of accountability also among medical associations like Sama, which called for parliamentary supervision.

Exactly how the NHI would be funded remains unclear, although payroll taxes and personal income levies have been raised, even as value-added tax (VAT) hikes are understood to have been ruled out by National Treasury.

In Tuesday’s debate, Clarke also pointed out that government had yet to identify exactly what the NHI would cover.

“Will the department pay for hip replacements, dental care, appendix removals, dialysis, chemotherapy, TB and HIV treatments, or mental healthcare? We don’t know because you have refused to inform us. Possibly because you do not know.”

While the EFF called for the nationalisation of private hospitals and health facilities, opposition parties raised most of the public health facilities’ failure to meet the minimum standards necessary for accreditation for the NHI.

The 2022 fire at Johannesburg’s Charlotte Maxeke Hospital has deeply affected health services in South Africa’s richest province, while in May 2022, Rahima Moosa Mother and Child Hospital paediatrician Tim de Maayer penned an open letter describing horrendous conditions.

Read more in Daily Maverick: A wake-up call for Health Department heads: Children are dying because of horrendous state of our public hospitals

The former health ombud, Malegapuru Makgoba, was recently scathing about the state of public health in Gauteng, also describing the Eastern Cape as a shambles.

Read more in Daily Maverick: ‘They change CEOs like panties’: outgoing ombud lashes ailing Gauteng, Eastern Cape health departments

Freedom Front Plus MP Philip van Staden called the NHI a “political gimmick” and called on President Cyril Ramaphosa to withdraw it rather than imposing it on the “mess” that is public healthcare.

“It is not able to deliver healthcare to people,” he said, adding: “The NHI will not pass a constitutionality muster… This law will stall in the courts if it is passed…”

But ANC MP S’dumo Dlamini, a one-time deputy minister, former Cosatu president and nurse by profession, said the NHI, once implemented, would supply “more resources for staffing, infrastructure, equipment and medicines and supplies… Healthcare will never be a marked commodity, it is a public good”.

And the speech of the last ANC lawmaker, Annah Gela, dressed in ANC colours and an NHI T-shirt, was met with applause and cries of “Phambili (forward) NHI, phambili!” from the governing party’s benches – and silence elsewhere in the Good Hope Chamber.

And that illustrated the divisions in the House and South Africa’s body politic – even as everyone agreed on the need for accessible quality healthcare. DM


Comments - Please in order to comment.

  • rmrobinson says:

    They cannot run state hospitals. Can these people not read? There is a book out there, written by a man called André de Ruyter. Read it to understand why Africa is poor and without hope. Then visit the Netherlands. Walk through Keukenhoff. Dan begryp jy.

  • Bradley Welcome says:

    “pool resources” meaning draw ALL available funds into one pot to provide easier access for grift, rebt-seeking and the like. The appointment of the board offers the minister the opportunity to appoint stooges as has been done in every other State directed entity.
    Ministerial oversight has yielded zero positive results for South African citizenry.

  • Gavin Gerber says:

    So how long before Ramaphosa et al. commandeer SAA planes for private healthcare in Singapore?

  • David Mark says:

    This will be another success of the ANC government, just like Eskom, SAA, Transfer, Prasa, SAPO, SAPS, etc etc.

    This is the final straw for most of my social circle, who I suspect will now seek emigration.

    I despise the ANC government and their pathetic policies. Destroying the country brick by stolen brick.

    • Berthold Alheit says:

      Wholly agree.

    • andrea96 says:

      Utterly agree with you, but the madness is understood if one recognizes that the anc has run out of stolen funds. They need another source, and are too cretinous to realize that appropriating private medical funds would be unconstitutional. Dumb and dumber.

  • Jennifer D says:

    The ANC running all healthcare for all is a death knell (literally) for South Africans. The quality of care in government hospitals is shocking. This is yet another way for the ANC to steal – they need more money to fund their own private trips to private hospitals in Zurich – or is that Russia?

  • Ed Richardson Richardson says:

    All those who voted in favour of the legislation should immediately resign their medical aid membership and make use of the taxpayer-funded medical care. Not going to happen on this gravy train.

  • André Pelser says:

    A populist move, driven by Socialists in the ANC, geared toward the 2024 election.

  • Nicoleen Schuld says:

    In Canada, a first world country, family members wait 2 years for back surgery and in the UK 5 years for a hip replacement thanks to NHI. How on earth can the NHI work in a 3rd world country?

  • Georg Scharf Scharf says:

    Ai, Ai, Ai, as a doctor who worked over 30 years full or part time the State hospitals that worked, were the hospitals during the National Party regime. Everybody was dedicated, cared for the patients and walked the extra mile. Even my mother who had a good medical aid went to the local academic hospital. Those were good days. 1 Military Hospital was considered one of the best military hospitals in the world and definitely the best in the Southern hemisphere. Since the ANC regime freed us all, it all fell apart. Mainly due to maladministration. It is hell to be a patient and a doctor in a State Hospital (with very few exceptions). Never the less, at present NHI as envisaged, will just become a nightmare worse than the one now. Incompetence, lack of knowledge, arrogance, and corruption will rule. If it was not due to the fact that I have a good medical aid, I would have already died of a rare disease. So, NHI, take off your pink glasses and put it up in a hole where monkeys put their rotten peanuts. Listen to those that know how to give a good medical service. Watch this space, NHI will become bankrupt with all the medico-legal litigations. Medical legal lawyers will be the only ones that smile Sad but true. ANC, go play doctor-doctor somewhere else. You all will do good in fertility clinics, I’m sure.

  • cathy.wardle says:

    What an absolute travesty! The very thing I feared has come to pass. If I was hopeless before this is the last straw

  • Andrew W says:

    This is the doomsday weapon the grifters are wanting. Those that pay private Healthcare are not going to readily ‘pool their resources’, that’s just another tax for not benefit. The private sector will bleed professionals (Cuba as a reference point) and those that can across all tax paying groups will emigrate. The spiral accelerates. Why do we yearn so to be Russia in the 70’s. greedy elite stealing our children’s future

  • Craig A says:

    This is probably going to become one of their election campaign slogans. ‘We are going to give everyone medical care’. Just like they gave everyone houses, water, electricity, security, jobs……
    Have they considered how many medical practitioners would emigrate or change careers. Almost every young doctor I know is considering leaving. That is a not a good reflection on your country when your young professionals can’t wait to leave.

  • R S says:

    “But with the support of five one- or two-seat parties, the ANC got the necessary approval on Tuesday.”

    Which parties supported this farce?

  • NICK GREENE says:

    I believe that the the proposed legislation will bet bogged down in the courts, and then the ANC will blame the courts for NHI mot being implemented. The best and fastest way to improve public health care is to stop the corruption that burdens service and infrastructure within the sector.

    • Anton van Niekerk says:

      This is a government that can not reliably issue drivers licenses. They will not get out of the starting blocks with a health management system.

  • Gary Palmer says:

    The corruption, dismal apathy and sick culture of the ANC to achieve anything positive in it’s existence is killing South Africa and the moral of it’s tax paying citizens.

    The NHI and Karpowership sagas (amongst others) are the ANC’s tickets to more stolen taxes and destruction of Southern Africa.

    There is very little patience left for this thievery!

  • Alastair Moffat says:

    Another huge pot for pilferage

  • Soil Merchant says:

    Brought it to its knees in order to push through their agenda … clever (Not!)

  • Sydney Kaye says:

    It’s understandable that DM welcomes advertising but carrying a “sponsored” article from BINANCE on the merits of crypto and “myth” of it being for tax evasion is a much, even with the investment warning, What next, a sponsored article by Bernie Mafoff on the “myth that Ponzi schemes are illegal”

  • Thinker and Doer says:

    It is necessary to gear up and support litigation against the legislation, because the Bill is being rammed through as a populist measure before the elections to try and shore up falling ANC support. They are so determined to do so, without any prospect of brining the public sector facilities up to standard, or remotely quantifying how much this will cost, which will be astronomical, and will be a focus for untold looting and corruption. This approach is so disastrous and ill-advised, and will effectively destroy all health care in the country, because all of the funding will be sucked into a black hole of the NHI Fund. The government fails to acknowledge the corruption and maladministration that has brought the public facilities to the brink of collapse, and there are no longer any “jewels” in the public health system, only collapsing facilities with horrendous service to patients. They could not even get any of their “pilot projects” that they started implementing years ago to work. If we can all support litigation against the legisaltion, perhaps that is about the only hope left to avert this catastrophe from being implemented.

  • Dale Galloway says:

    The mind boggles! But I did learn a new word today, thank you: “hustings”

  • fairuzmullagee says:

    Corruption and graft is a serious problem that needs to be tackled head on. But so too is unequal access to basic services. Privatisation is not the answer. Clear out the rot in the system as we move forward with the National Health Initiative.

  • Peter Dexter says:

    The current (failing) state healthcare system is funded largely by the taxes of the same people who also pay for private medical aid. If the state decides they must give up their private healthcare but still continue funding the bulk of services, the response is obvious. Those who earn a lot and pay a lot of tax will simply leave the country and contribute to another country’s economic activity. Tax collections will crash. The ANC has made a lot of silly decisions but this could result in the financial collapse of the state and conversion of SA into a Venezuela like situation.


    Of course this is not going to work. There are too few contributors and far too many people drawing on the resources. Added to that is the inevitable corruption and inevitable maladministration that are going to swiftly follow.
    The proposals (soon to be law) are a recipe for a self-inflicted disaster.

    • I would support a law that forces all the ministers and their families to only have access to public hospitals, public education and the SAPS alone for protection. Maybe this is when we might see rapid change!

  • Michele Rivarola says:

    Damned if you do and damned if you don’t. Access to a decent health care is a basic human right however politicians should be careful not to throw baby and bath water out in one fell swoop simply to appease outdated and antiquated political ideologies. There are countries with functional NHI systems and we should rather learn from them then trying to reinvent the wheel and ending with a looming disaster once doctors and specialists start moving to greener pastures.

  • Geoff Krige says:

    NHI is great in an idealistic world. Quality health care for all is dream the world-over. But with the ANC in charge, NHI is doomed to be a disaster. Just take a quick look at the current condition of state health. No ANC MPs use state health facilities – choosing Russia, China or Private in South Africa. Why does anyone, even the ANC, expect that NHI will some how be a magic potion. NHI will become another feeding trough, and very soon will go the way of Eskom, Transnet, policing, education, etc, etc

  • Rae Earl says:

    If everybody is entitled to quality health care this is not the way to do it. The ANC government has chucked huge amounts of money into state hospitals and the nett results? Instead of the money being used to buy quality health care, millions (possibly billions) has been squandered and/or stolen by corrupt officials (ie Tembiso Hospital). Lack of maintenance is rife, widespread devastation has been caused by numerous hospital fires, and, tellingly, unspent budgets are frequently returned to treasury. Shocking procedures like the suspension of Dr. Tim de Maayer simply for reporting diabolical transgressions by medical staff at a state hospital beggar belief. A national NHI will simply become another SOE designed to assist ANC looting.

  • Craig Cauvin says:

    A new trough, because the others are becoming sparse….

  • Caroline Rich says:

    This makes my blood boil. Being involved through an NGO in the health sector we worked on the Presidential Health Summit. Through this compact all the current issues were identified showing the current system is near collapse. All the government needs to do is sort out the shocking state of the government hospitals, eradicate corruption, and hire the right people. Once this is done, there would be no need for this idiotic policy which opens the door to even more corruption and maladministration. These ANC members are absolutely delusional and the problem is that they have the ultimate say. For crying in a bucket will people stop voting in this horrendous political party. Also, we need one strong main opposition. Having 1000’s of small parties is an absolute waste of time and effort. Wake up SA, You are your own worst enemy.

  • John Forbes says:

    The UK NHS is by all accounts a disaster and failing.

    Understanding the NHS Crisis  ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌

    Open in app or online

    How bad does it need to get?Understanding the NHS Crisis

    Sam Freedman

    Jun 14



    Back in January, at the peak of the 2022/23 winter crisis, I wrote a post asking “whether the NHS is in a death spiral”? It was gloomy. I didn’t see much evidence that the government had grasped the severity of the situation or were focusing on the right levers.

    I’m not feeling any less gloomy now. If anything this year is going worse than I expected. We are now in the summer, when things should be quiet, and from the lack of media coverage you might think they were, but sadly not. In May over half a million people waited more than 4 hours in A&E. Not much more than a decade ago that number was negligible. Tens of thousands are waiting 12 hours or more. There can be no doubt this is killing many thousands of people. Excess mortality in 2023 is running above the 5 year average, which includes the pandemic years.

    Meanwhile elective waiting lists continue to rise with over 7.4 million people now waiting for treatment, 220k more than when Rishi Sunak pledged to bring numbers down in January. What happens next winter will depend, in part, on how bad covid and flu seasons are, and whether they coincide. But there is no reason to believe 2023/24 will be any better than last year, and it could well be even worse.

    Despite the relative lack of attention in Westminster it remains a key issue for voters, only narrowly behind the cost of living. Patient satisfaction with the NHS is the lowest it has ever been. Worsening health outcomes are also harming economic growth and at least partly responsible for the extremely constricted labour market. The number of people who are economically inactive due to ill-health is now at a record high of 2.55 million. Fixing the NHS should be a top priority for the government, and Labour.

    Since the start of the year I have been working with colleagues from the Institute for Government, and my co-author Rachel Wolf, on a project to figure out what’s going on. What follows is my own interpretation of the key findings, and should be taken as a personal view and not that of anyone else who worked on the project. (All stats are taken from the report and not linked to separately).

    What’s Going On?

    Since the pandemic there has been a big increase in funding and staffing in the NHS. Over 16% more junior doctors and 11% more nurses are employed than in December 2019. This is not widely appreciated, even within the system. Many of the practitioners we spoke to were surprised to hear that staffing had increased. And you’d be forgiven for not realising given activity levels – in terms of patients seen – are more or less the same as they were in 2019. Given the size of the backlog built up during covid this is nowhere near enough. NHS England estimates its needs to be operating at around 130% of the 2019 level to make significant inroads.

    Our exam question was why hasn’t activity increased? We couldn’t find much evidence for some of the potentially plausible explanations. There is no data to support the idea that patients are now sicker on average. Covid protocols that caused delays have been largely, though not completely, abandoned. Instead we ended up with a three part explanation:

    1.      There is simply not enough physical capacity to support an increase in activity

    2.      Even though overall staffing has increased, many experienced doctors and nurses have left; and

    3.      The system is catastrophically undermanaged, both in terms of quantity of people and the operational constraints they face.

    Physical Capacity

    I noted back in January our lack of hospital beds compared to other countries. Germany has six for every thousand people, Belgium has five, we have two. This helps explain why our system was so vulnerable to the pandemic. It was already running on the edge of capacity before it was hit. This is exacerbated by having 10% of beds taken up by people who have no medical need to be in hospital. They are mostly there because of capacity problems beyond any hospitals’ control, such as the lack of social care provision or the fall in community nursing numbers. Lack of management is also a factor with discharge processes often taking much longer than they should.

    But even if you invested in, and improved, social care, which is a huge and expensive task in itself, we would still be seriously short of beds. The calculations on which historic bed reductions were made have simply not come true. Since 2010/11 available beds have fallen by 5% but admissions have risen by 15%. Improved surgical procedures and so forth are being counteracted by an aging population. The resistance to accepting this basic and obvious fact across both main political parties, and much of the NHS hierarchy, is genuinely baffling. It’s almost as if people don’t want to accept such a boring and old-school solution is the answer. Surely technology will intervene to mean we don’t need to build more hospital space? Surely there must be a cleverer answer?

    I really don’t there is. Health Foundation analysis suggests we will need somewhere between 23,000 and 39,000 beds by 2030/31 just to maintain 2018/19 levels of care – a 15-25% increase on now. There are no plans to build anything like this number. Nor is using private capacity the answer. We already do and there isn’t much of it in the UK.

    Beds aren’t the only physical capacity constraint. A large part of the outpatient waiting list is caused by lengthy delays for diagnostic equipment. Some of this is due to vacancy rates in key roles – like radiology – but much is just a lack of machines. The UK has the fifth lowest number of CT and PET scanners and MRI units per capita in the OECD: 16.5 per million people, compared to an OECD average of 44.8. It’s the same story on IT. I was astonished to find that well over 20 hospital trusts are still using paper records in 2023. Elsewhere doctors and nurses are wasting inordinate amounts of time on computers that should be in museums.

    The root cause of all this is that we have never invested enough in physical capital. Our day to day spending is around the OECD average, and has been higher in recent years, but our capital spend has been around half the average. Even the budgets that have been allocated to capital have been raided for emergency needs. The basic laws of economics will tell you that if you put all your investment into labour and little into capital then productivity will get worse and that’s what is happening. It’s an appalling misuse of taxpayer funds and classic short-termism. As a result we are employing more doctors and nurses and then wasting their time while they try to free up a bed; or sit with an A&E patient for whom a bed cannot be found; or spends hours trying to book a diagnostic test; or wait for the agonisingly slow computer to wake up.


    Data on NHS staffing is limited. We can see overall numbers are up a lot. We can see churn has increased, with more people leaving than ever. Naturally this means many more staff are relatively inexperienced. For instance there are 35% more registered nurses with less than 5 year experience than in September 2017, but slightly fewer with over 20 years’ experience. Increasingly the most experienced consultants are not working full time – up to a quarter now according to a Royal College of Physicians survey.  

    This all means that capacity problems are made worse as the lack of experienced staff creates bottlenecks. For instance experienced ward nurses are needed to manage bed flow in extremely constrained circumstances. A&E consultants told us they were having to spend time on triage and routine tasks like blood tests as there were not enough experienced nurses to do them, which stopped them from treating patients. There are shortages in key diagnostic roles. Moreover the big increase in use of agency staff is not only very expensive but also leads to people who don’t know the systems and processes of that particular hospital having to fill in gaps.

    There are several other hypotheses around staffing for which the data is not good enough to address properly. One is that an increase in recruitment from outside the EU – more than 50% of nurses and doctors recruited last year came via this route – is causing more churn. It certainly feels like a risk given higher salaries available in other countries, and we heard anecdotally this was causing problems. We are, in any case, going to be dependent on international recruitment for some time, even if the government adds more training places for UK staff, given the lag time.

    It was also hard to quantify the impact of falling morale on discretionary effort. That it is falling is clear enough from the NHS staff survey, with pay being the fastest growing cause of unhappiness. This is why we are seeing more people quit. Nuffield Trust analysis has shown that “in the last decade, the numbers pointing to work-life balance, promotion and health as reasons to leave have all roughly quadrupled.”

    What is less clear is whether the staff that have stayed are doing less than they did before. The NHS is hugely dependent on unpaid overtime, which is a problem in itself, but it’s not clear if this is falling as it’s not measured. It’s certainly the case that the doctors and nurses we spoke to remain committed to the job despite their frustrations.

    But given the high leaver rates, and falling morale, at a time of crisis, it remains utterly baffling to me that the government are continuing their industrial dispute with doctors (and the Royal College of Nursing). Against tough competition this has to be the most astonishingly myopic public spending decision I have ever seen. It is already costing us dearly.


    It is well known within health policy circles that the NHS is severely undermanaged compared to other systems. The UK spends less than half the OECD average on management and administration, which is why I bang my head against the nearest wall whenever I see a newspaper splash bemoaning fat cat managers, or yet another politician promising to get more resources to the “frontline”. It is, of course, the case that if frontline staff are not properly supported they end up becoming expensive admin staff themselves (see also policing). Meanwhile the number of managers per NHS employee has fallen by over 25% since 2010 due to deliberate policy decisions from the centre of government, particularly Andrew Lansley’s disastrous “reforms”.

    But simply adding more managers is unlikely to work. They also have to have the powers to make a difference, and the right incentives to follow from the centre. Over the past decade managers have become considerably more constrained. One obvious example is in the ability to invest in capital, which, as we have seen, is a big problem. More and more bureaucratic constraints have been put in place to allow the centre to manage limited resources, costing a huge amount of management time and limiting effectiveness.

    There has also been a big increase in the range of targets hospitals have been responsible for – including many “quality” targets which are essentially about process rather than outputs. This has led to hospital analysts spending a lot of time providing information to the centre rather than supporting the needs of management within their hospital. It is has also created confusion as to what trusts are supposed to be doing. Activity targets, which have remained, albeit heavily watered down, from the New Labour era, have been competing with quality targets, creating contradictory objectives and limiting autonomy. The Blairite targets, like the 4 hour one for A&E, were criticised for being too simplistic, but setting a minimum standard is all such targets can do. And they achieved that, a success that has now been completely undermined.

    Meanwhile the central bureaucracy has grown to manage all this complexity. There are fewer managers but more managers managing the managers. The latest approach – integrated care systems – designed to bring different parts of the health system into the same regional structures – makes some sense in theory but risk adding to this complexity. The lack of clarity as to what they are supposed to be achieving is concerning, and we’ve already seen the Secretary of State slash their funding, which can hardly help.

    It’s hard to untangle the reasons for the relative success of the NHS during, and just after, the New Labour years. How much was it due to large annual funding increases and how much was a simple focus on a handful of indicators backed up by strong financial incentives in the form of payment-by-results? It’s certainly the case that simultaneously keeping to very tight spending increases (as was true from 2010-2019) and significantly increasing the complexity of the system, while also reducing management capacity, was a very bad idea.

    The Death Spiral

    In my January post I asked if the NHS was now in a death spiral. Writing this report has in some ways made me more positive. There are some obvious things that could be done to alleviate the crisis, even if they would take some time to have an impact. While the NHS is a complex system many of the problems described above are plain to anyone paying attention, and have been well documented. Moreover, staff commitment is, despite the workload and the strikes, stronger, I think, than I gave it credit for.

    But, and it’s a big but, I remain extremely depressed at the refusal of the government to engage properly with these issues. There have been some small improvements, such as reducing the number of targets and re-focusing attention on activity; investment in some diagnostic centres; and growing use of virtual wards (where patients are treated at home), which might help with bed capacity, though there is not yet any evidence of their effectiveness.  

    Overall though we are drifting further into crisis due to a stubborn refusal to accept the obvious. Doctors need to be paid more. There needs to be significantly greater capital investment – in beds, equipment and IT. We need more managers, with greater autonomy. Yes this all costs money but at the moment we are wasting enormous sums on a low productivity system.

    Labour have been little better, desperate to avoid committing to more resources given their fear of being seen as big spenders. It is deeply frustrating hearing people talking about reform versus more funding as if they were opposites. Yes, the system needs reform but that can only be achieved with investment. In the long run it will save money (though let’s not kid ourselves that the NHS is ever going to get cheaper given demographic change) but not over the next few years.

    We wrote this report to satisfy our own curiosity but also in the hope it might help create a better conversation about the NHS during the election campaign. We don’t need a completely different model. This one can work. It did very recently. But we desperately need honesty about what it will take. I would say that what’s coming this winter should focus minds, even if nothing else does, but the last one doesn’t seem to have done so, and that was horrific enough.

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    © 2023 Sam Freedman
    548 Market Street PMB 72296, San Francisco, CA 94104

  • Peter Worman says:

    They’re clearly concerned that the coffers are running dry as all the other state departments have been rinsed. They’re also not too concerned about the 84% of people using state health care. All that will happen is the private medical schemes will tank, health care practitioners will emigrate, the connected cadres will access hospitals in Singapore etc and 99% of the population will be subjected to sub-standard health care.

  • Alain Leger says:

    At an advanced age, I am hoping to have gone upstairs before being left with no care or worse, after having paid much in medical aid contributions

  • Dominic Rooney says:

    Election clickbait – no funding = no progress.

    • Neil Parker says:

      The “Midas Touch” in reverse. Everything you put your finger on collapses! I think most – if not all – ANC politicians live in Wakanda if not Cloud 9. Only last night I heard a talk show host trying to convince us that it’s not incompetence/corruption which is destroying Eskom – it’s these clever people aided and abetted by Western nations who are driving a “renewables agenda” to make money. No doubt a similar line will emerge when skilled healthcare professionals flee the country and the health system collapses.

      Incidentally I think Bell Pottinger rhetoric fades into insignificance against Marvel Comics’ Wakanda myth swallowed hook , line and sinker by our increasingly misguided politicians.

  • Iam Fedup says:

    Just another opportunity for the thieving scoundrels to steal. Things are getting desperate for them now.

  • Jonathan Lang says:

    ” “South Africa cannot continue on a path where public healthcare is buckling due to under-resourcing, unfilled posts and long queues, whilst the private healthcare sector charges exorbitant rates and caters for the few who can afford it,” said Cosatu parliamentary liaison, Matthew Parks.”

    This sentence sums up the total ignorance and idiocy of the scheme and the people supporting it. To provide the same standard of care to the entire population as is provided by the private sector will cost approximately 24% of GDP. Where will that money come from? If the public sector is currently under funded, how will the NHI provide a better service? It’s madness.

    As the government will become the only “client” of the healthcare system, we know what will happen. Hospitals and doctors will not be paid on time or at all. I would expect a large proportion of doctors to leave the country immediately and many of the other (good) ones to leave after the hospitals fall apart and their salaries are not paid.

  • Klaus Muller says:

    Please tell me, anybody (except government “workers”) who pay for medical aid via their company must now cover additional costs to pay for NHI.

  • Theresa Avenant says:

    I can’t believe there are so many right winged wingers on DM at one time. Even the Tories are in on it. Have they not noticed that Britain’s NHS is in a bad way because the Tories have been in power for quite some time. South Africa has one of the most deplorable levels of inequality in the world. The great wisdom mongers will have it that it is okay that a small minority of our population can afford expensive medical aid and health care whilst the rest die in waiting rooms and hospital corridors because of the lack of State Medical Resources. Adequate State health care is possible in South Africa and is actually a Constitutional Right. We have good health care systems in the Western Cape e.g. Groote Schuur Hospital, Red Cross Hospital and the new state of the art dispensary clinic in District Six. I am fortunate enough to live in Cape Town and make use of public health because I cannot, at my age, afford medical aid and private health. I have had two successful surgical procedures at Groote Schoor Hospital where I also received life saving emergency treatment not long ago. My chronic medication is provided by the State via District Six Clinic where the service works very well. If it can be done in the Western Cape (who also need additional assistance) it can be done in other provinces. All it takes is a little bit of patience and sacrifice from a few people who hold the vast majority of the wealth.

  • joseph.jazz.bolton says:

    ANC couldn’t organise a piss-up in a brewery

  • Miles Japhet says:

    The naivety of the ANC is beyond comprehension.
    They have no understanding of the implications when you remove choice from individuals. This will see a further wave of emigration and loss of vital skills across the economy including the health sector.
    Other countries will benefit hugely as they currently are.
    This means lower GDP, lower taxes and an even more unaffordable NHI.
    Next up is the private education sector and then the Revolution has succeeded and the poor of South Africa will descend further into poverty.
    Nice own goal ANC – just stop and think a little.

  • Miles Japhet says:

    The blind following of a failed ideology defies the imagination. More flight of skills, lower taxes, further descent into a failed State. And the poor get poorer.
    Stop and look around you and work out which system has delivered the highest standard of living in the world to people – certainly not communism.
    Proper own goal as an MP, when you use private healthcare and education and do not use public institutions!!

    Nice one ANC!!!

  • Annalene Sadie says:

    South Africa moved from multiple departments of education to a single department. How has that improved the level of education in the country? Why would the NHI fare any better?

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