The National Health Service (NHS) was established in 1948 under the post-war Labour Party. Before 1948, medical treatment in the UK depended largely on the ability to pay, insurance schemes, or charity hospitals. The NHS aimed to address social inequality by providing free healthcare for all British citizens, funded through taxation. Henry Marsh’s career unfolds within the NHS’s inpatient care crisis. An accumulation of reforms and underfunding from both Conservative and Labour governments, dating back to the 1990s, resulted in overcrowded wards, bed shortages, long waiting times, delayed discharges, and staff/resource shortages—challenges that continue to affect the NHS’s quality of care.

A key factor in the NHS’s decline was the 1990 National Health Service and Community Care Act. Through this reform, Margaret Thatcher’s Conservative government established an “internal market” within the NHS, expanding the use of private providers and financing. Consequently, hospitals had to operate more like businesses, forcing them to sometimes prioritize efficiency targets over quality of care. This trend toward expanding competition and the private funding of public services continued under the Labour government of 1997-2010, which introduced Private Finance Initiatives (PFI), foundation trusts, and practice-based commissioning. The subsequent Coalition and Conservative governments introduced further change to the NHS through the Health and Social Care Act of 2012. In the British Medical Journal, Hugh Alderwick describes this Act as “a mammoth restructure that tried to strengthen competition in the NHS” but resulted in “disruption and fragmentation” (Alderwick, H. “Conservative Party’s Legacy on the NHS.” BMJ, 5 July 2024). The reform was followed by a decade of limited funding growth (austerity), which failed to keep pace with population growth in Britain.

To manage budget constraints, hospital trusts were under intense pressure to reduce costs, often resulting in ward closures and bed shortages. Between 1987 and 2017, the number of hospital beds in England was deliberately reduced by more than half, from approximately 299,000 to 142,000, according to research by The King’s Fund (Ewbank, L. et al. “NHS hospital bed numbers.” The King’s Fund, 5 Nov 2021). This policy created a system running permanently “hot,” with high occupancy rates that left little room for emergencies or scheduling flexibility. The NHS’s increasing managerialism, which applied business principles and performance targets to clinical care, negatively affected its service. Initiatives like the Private Finance Initiative (PFI), analyzed in a 2011 National Audit Office report (The Comptroller and Auditor General. “Lessons from PFI and other projects.” National Audit Office, 28 April 2011), locked hospitals into costly, inflexible contracts that prioritized financial metrics over clinical needs. 

Marsh depicts the consequences of these pressures on the NHS throughout Do No Harm. In Chapter 11, the frantic search for a bed for the dying patient, Helen, illustrates the real-world impact of bed shortages. His frustration with the rollout of a new IT system, iCLIP, which delays a critical brain tumor operation, similarly captures his “fatalistic despair” (39) in the face of a top-down, target-driven bureaucracy. Marsh’s professional struggles are symptoms of a healthcare system where administrative and financial pressures constantly threaten to derail the fundamental work of patient care.