It is relatively uncontroversial to argue that the past decade has been the NHS’ toughest. Looking back, the NHS had emerged from the 2000s in comparatively good shape, having converted significant investment into radically shorter waits for routine care – at the time the public’s biggest bugbear.

But by the early 2010s, the ‘problem set’ facing the NHS was rather different, and the policy mix of the prior decade was now misaligned with those challenges. The underlying epidemiological challenge was to improve outcomes for an ageing population with multiple long-term health problems. The resulting system challenge was in part to move closer towards what I labelled the ‘triple integration’ of physical and mental health, primary and specialist services, and health and social care. And the economic challenge was to try and do so at a time of deeply constrained revenue and capital funding. Because when the British economy sneezes, the NHS catches a cold, as Anita Charlesworth and colleagues show in Chapter 3 of this volume. The international comparisons are even starker. In the decade to 2019 it has been calculated that the UK spent on average £40 billion less each year than if we had matched average per-person health funding across the EU14. Indeed, the UK would have had to spend nearly a fifth more to match French per-person health spending, and nearly two-fifths more to match that of Germany (Health Foundation, 2022).

Yet despite these pressures, by the 70th anniversary of the NHS in 2018 there were some grounds for optimism. The NHS had just secured a more workable medium-term financial settlement, backed by broad consensus on its own long-term improvement plan. The government had agreed to replace the 2012 Health Act with a legal framework better aligned to population health and integrated care.

However, five years, three prime ministers and one pandemic later, the NHS turns 75 in a more uncertain position. So it is unsurprising that the debate on the NHS’ future is again intensifying. Some argue that the chickens are coming home to roost from chronic political short termism that has repeatedly deferred long-term workforce decisions, underinvested in capital infrastructure and technology (even during a period of negative real borrowing costs), done little on prevention and stalled on social care reform.