Italy celebrate winning the World Cup in Berlin, July 2006. Photo: Getty
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The last World Cup: after Brazil 2014, is the tournament finished?

Football is a supreme instrument of soft power and can unite people as little else can. But allegations of Fifa corruption have tarnished the image of the beautiful game. Can anything be done to save it?

The imagination is always at the end of an era.

Wallace Stevens

In the spring of 2006 I was working on the Observer when, one quiet afternoon, the editor, Roger Alton, called out to me across the newsroom: “Jase, d’you fancy going to the World Cup?” This was a question to which, if you liked football, the answer could not be “no”. Alton was an inspirational editor. He combined charm with just a hint of menace. He was menacing because capricious and unpredictable. But it was his very unpredictability that made him such a good editor – this and his high intelligence, which he tried to disguise by speaking in a kind of hectic demotic. The writer Geoff Dyer once described him to me, accurately enough, as being like a “cross between an Oxford don and a London cabbie”.

There was no budget for me to go to the World Cup in Germany but Alton sent me all the same for five thrilling weeks. I’m pretty sure, in retrospect, that the amiable sports editor, Brian Oliver, whom Alton affectionately called the Gaffer, had no idea what to do with me, yet he took my being crashed into his team of reporters with grace and good humour.

This was perhaps one of the last assignments of its kind there was to be on a British Sunday newspaper. I was not required to blog or tweet or write daily reports for the website. (Nowadays I’d be told to live-blog every England press conference, or something to that effect.) Rather, my only responsibility was to write a weekly essay, travel the country (all accredited journalists were provided with a complimentary first-class rail pass) and watch football matches. My sense of good fortune was heightened by the extraordinarily warm and settled weather in Germany during those weeks of the tournament.

I rented a small apartment in Berlin, in a building just off Pariser Platz and a short walk from the Brandenburg Gate. My apartment was directly opposite the Hotel Adlon, where Fifa’s blazered officials were holed up for the duration of the tournament in five-star luxury. This was also the hotel from a high window of which Michael Jackson, in an act of demented exhibitionism, precariously dangled one of his baby children, for the amusement of himself and the world’s media. From the window of my flat, I could see Peter Eisenman’s Holocaust Memorial, a forbidding grid of grey, coffin-like concrete slabs, or stelae, occupying a five-acre site, reminding all visitors to the city of the traumas of the German past.

Each morning, if I was not travelling, I bought a selection of newspapers and international magazines from the nearby Hauptbahnhof, the magnificent redevelopment of which had been completed to coincide with the start of the World Cup. Then I’d buy a coffee from the café of a local art gallery and sit on the pavement terrace and watch football fans of all nationalities idle and loiter – you could tell which team was in town that day by the colour of the replica football shirts being worn.

It was obvious that the World Cup was having a transformative effect on Germany. A large screen, on which matches were broadcast live, was positioned near the Brandenburg Gate, the main attraction of the Berlin Fan Fest. There were public viewing areas such as this in cities across the country and they proved to be enormously popular. By the end of the tournament hundreds of thousands were gathering at the Berlin Fan Fest for Germany matches.

Yet the mood inside the country at the outset of the tournament was one of anxious self-scrutiny. Franz “the Kaiser” Beckenbauer, Germany’s greatest player and the chair of the World Cup 2006 organising committee, had spoken of how football “makes a better world, it’s a game that brings tribes together. It is our historic opportunity here now in Germany to be good hosts, to show the world who we are.” He could have added, though the subtext was obvious, “and how we have changed”.

His optimism was not altogether widely shared. Germans are understandably unsettled by ostentatious displays of patriotism. When I arrived in Munich, just before the opening game between the hosts and Costa Rica at the Allianz Arena, I was struck by the absence of German flags on public display. By contrast, in England that World Cup summer, with expectations of success inflated by the promise of Sven’s so-called golden generation of players, the flag of St George was ubiquitous.

 

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There was also the small matter of Jürgen Klinsmann, the German national team coach, who was being caricatured as the “reviled reformer”. The son of a baker, Klinsmann is a Swabian, but rather than live in Germany he was stubbornly resident in California (he is married to an American). He had enjoyed a distinguished and itinerant playing career, in Stuttgart, Milan, Monaco, London and Munich, and spoke fluent English with a North Atlantic accent. He had the calm and good manners of an experienced airline pilot. The German press didn’t like or trust him: he was too cosmopolitan, too committed to a culture of change, too confident in his own certainties.

Klinsmann wanted Germany to play in an entirely new way: a much more expansive, high-energy, attacking game. He and his assistant Joachim Löw (who succeeded Klinsmann as coach in July 2006), had spent time together in London studying Arsène Wenger’s Arsenal, the fast-paced, highly technical multinational team of many talents, the team of Thierry Henry, Dennis Bergkamp, Robert Pirès and Patrick Vieira. They wanted to emulate the style of Wenger’s Arsenal, and would do so with a new generation of players, many drawn from immigrant families. “We need to question every single ritual and habit,” Klinsmann said on becoming national coach. “And we need to do it continuously – and not just in football . . . Reforms don’t happen in phases. They need to be part of an ongoing process, one that doesn’t stop when the World Cup is over.”

Germany had hosted great international sporting events before – the World Cup in 1974, the Olympic Games twice – but never fully successfully. The tournament of 1974 was played in a country divided between a free west and a communist east. Indeed, the old German Democratic Republic surprisingly beat West Germany 1-0 after they were drawn together in the same group. It was the first and only occasion the two Germanys contested an international football match. The game itself was played in Hamburg in torrential rain and it was as if that night even the gods were weeping for the divided nation.

Two years earlier, Munich had been the host city of the 1972 Olympics. But these Games will be for ever remembered for the so-called Munich Massacre, the kidnap and subsequent murder of 11 members of the Israeli Olympic team after a raid on the athletes’ village by the Palestinian militants of Black September. Once again Jews were being terrorised and murdered on German soil as the world looked on and recoiled. Before that, in 1936, the Berlin Olympics were scarred by Nazi propaganda and the grotesque posturing of Hitler.

The mood was so different in 2006. During the weeks of the tournament, as Klinsmann’s attack-minded team progressed to the semi-finals, and as the sun continued to shine and people, bashfully at first but then with much more confidence and obvious joy, began to drape themselves in the German flag, and as more and more Germans and overseas visitors began to gather each day at the Fan Fests to drink beer and watch the games in a spirit of mutual celebration, and as a sceptical press stopped worrying and began to declare the tournament a resounding success, something changed inside Germany. It was as if a nation no longer felt ashamed and suddenly began to experience a kind of relaxed patriotism. The world was watching Germany and the world liked what it saw: a tolerant country, welcoming to outsiders, and one that had become a model of benign liberal democracy. And the trains still ran on time.

By the end of the tournament – Germany were beaten 2-0 in the semi-finals by Italy, the eventual winners, in an enthralling game at Borussia Dortmund’s 80,000-capacity Westfalenstadion that I attended – Angela Merkel was pleading publicly with Klinsmann to renew his contract as coach. She understood what the World Cup had done for her country and how it had brought people together and lifted their spirits. True to his restless nature, Klinsmann accepted the applause and his nation’s gratitude, and promptly returned to America. Job done.

The Netherlands manager gives his players a pep talk in Brazil ahead of this year's World Cup. Photo: Getty

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When Franz Beckenbauer spoke of football’s potential to unite and inspire and to bring tribes together he was surely right. Talk to any Nigerian, for instance, about Nigeria, an unstable post-colonial construct of multiple rivalrous ethnic groups and more than 500 languages, and you will be told that one of the few things that can unite Africa’s most populous nation – perhaps the only thing – is the national football team, the Super Eagles. Even in a more mature democracy such as England, where some of us mourn the passing of anything resembling a common culture, football can create a sense of unity and fellow feeling of a kind that has all but disappeared from daily life in an era of zero-hour contracts, virtual friendships, declining newspaper sales and multi-channel
television: something we can all share in and talk about. This sense of togetherness, of an enlarged and enraptured imaginary community, feels never more palpable than during a World Cup summer, when it can sometimes seem as if every second person you meet is preoccupied by the football. “The imagined community of millions seems more real as a team of 11 named people,” as Eric Hobsbawm wrote.

The game of football has become the lingua franca of our globalisation. It is one of the supreme instruments of soft power, hence the desire of nations to host World Cups and of oligarchs and plutocrats to own great football clubs, the “superbrands” of international sport, as we have been coerced into calling them.

The top European leagues, especially the English Premier League, operate a rapacious winner-takes-all capitalism: the richest are getting richer and the rest can merely dream of catching up or go to hell. The game’s greatest players – Ronaldo, Messi, Ibrahimovic – are some of the most photographed, idolised and imitated people on the planet, their talent remarkable, their wealth stupendous, their influence reaching even into the world’s remotest towns and villages.

Absurd it may sound, but some of the most intense and emotionally draining experiences of my life have come from watching football. Even today, nearly 24 years later, I cannot think of England’s loss to West Germany in the 1990 World Cup semi-final at the Stadio delle Alpi in Turin, following an anguished penalty shoot-out, without feeling a sense of deep regret. Partly, of course, I’m mourning the person I used to be, the lost time and the lived experience that can never be recovered. I was only a year out of university back then and giddy with hope at what the future might hold but also unsettled by what seemed to me to be the sheer strangeness and wonder of the world – its randomness, its infinite variety, its essential mystery. There I was that night, a long way from Italy, gathered with friends around a television set in a rented house in the north London suburbs, watching as England tried and failed, so gloriously, to reach what would have been only their second World Cup final.

Italia ’90 – Gazza’s tears, Pavarotti’s “Nes­­sun Dorma”, Roger Milla’s dance – was when many people in England, those who had been so repelled by the violence and the hooliganism and the stadium disasters of the1980s, succumbed and began to fall in love with football again. They dared to believe that the game, so undermined by racism and the brutality of terrace culture, could be beautiful once more – something that appealed to all classes, to men and women, boys and girls: indeed, just as it does today.

The moneymen sensed the zeitgeist and seized their opportunity. Within two years the Premier League had been launched, after the leading clubs broke away from the old Football League. The new league would be bankrolled by Rupert Murdoch’s Sky Television and marketed as a “whole new ball game”. The fans were described as a “captive market”: it was correctly calculated that they would be willing to pay for satellite television subscriptions and, if the best players began playing in England, for high ticket prices, because they had no choice but to pay, prisoners of their own desires and fantasies.

There is something fundamentally irrational about fandom, about committing yourself so completely to something over which you have no control. The true fan makes that bond of allegiance to club and country in early childhood and it can never really be broken, no matter how helpless you feel or how unhappy or irritated being a supporter makes you. How to account for this? How to account for the hold sport has on the collective imagination?

An estimated 715 million people watched the 2006 World Cup final between Italy and France in Berlin, and South Africa 2010 was broadcast to 204 countries. Fifa has sold the worldwide television rights for Brazil 2014 for $1.7bn; the tournament is expected to generate $4bn in total revenue for football’s governing body. Does any other event have such global appeal?

 

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By the time you read this, the 20th World Cup in Brazil will have begun. But it takes place in the shadow of the corruption allegations over the decision to award the 2018 and 2022 World Cups to, respectively, Putin’s Russia (whose national football league is blighted by rumours of match-fixing) and the repressive pseudo-state of Qatar. Even before the Sunday Times reported the extent of the alleged bribes and bungs used to win the vote for Qatar – such an eminently sensible choice, when you think about it, with its 50° summer temperatures and its hatred of homosexuals, alcohol and liberated women – the stench of corruption hung over Fifa. We should not forget that David (Lord) Triesman was forced to resign as chairman of the Football Association and of the England 2018 World Cup bid team for stating the obvious: the right to host the World Cup can be bought.

The whole opaque process by which Fifa’s 24-man politburo selects the host nation is open to continuous abuse and manipulation, and the English FA has not been a blameless bystander. It was all too willing to play the game rather than attempt to rewrite the rules. It was unedifying to witness the elaborate dance of seduction with which the FA and its associates attempted to woo Jack Warner, the now-disgraced Trinidadian politician who was then vice-president of Fifa. David Beckham and Prince William (aka the Duke of Cambridge) were among the useful idiots the FA took to Trinidad in an attempt to secure the support of Warner who, as president of the Concacaf federation, controlled three votes. In the event, England received only two votes, from Japan and the representative of the English FA, and was eliminated in the first round of voting for 2018. It was as if Warner had accepted their hospitality and favours and then spat at them.

There is nothing wrong with wanting to bring the World Cup to the world’s emerging powers – 2010 was a dull tournament but the South Africans were deserving hosts, even if that country of poverty and mass illiteracy paid billions of pounds it could not afford for the “privilege”. Brazil, the self-mythologising samba nation, is reported so far to have spent £11bn on new stadiums and transport infrastructure. But the people are not yet in the mood to party: Brazil has been destabilised by riots, strikes and street protests and just this past week 10,000 marched on Arena Corinthians, the stadium in São Paulo that will be the venue for the opening game between Brazil and Croatia, to protest against World Cup excess and government indifference. Meanwhile, Qatar has said that it would spend more than £200bn on its World Cup project, and so the decadence and extravagance become more extreme with each tournament.

Yet the greater problem resides less with those wishing to act as hosts than with Fifa. Under the long rule of the megalomaniacal Sepp Blatter, football’s governing body has allowed the World Cup to become ever bigger and more bloated, which suits Fifa just fine. For Fifa, the World Cup is a well-oiled engine of cash generation. It brings prestige and the world’s attention to the hosts, for a transient period – but at what ultimate cost, especially when, as in the case of Qatar, the country has no football culture to speak of and impoverished migrant workers are dying needlessly there as they labour in the horrific heat to build Fifa’s air-conditioned stadiums in the desert?

“It’s a money machine, World Cup after World Cup. For them, that’s more important than serious and clean governance,” said Karl-Heinz Rummenigge, chairman of Bayern Munich and the European Club Association, long before the Sunday Times revelations appeared. “I will give them a chance [to clean up] but I’m ready for a revolution.”

Europe’s leading clubs – Bayern, Barcelona, Real Madrid, Manchester United, Juventus, AC Milan – resent having to lend their players to national associations for matches and tournaments, only to have them returned injured or fatigued. The clubs understand that history is moving in their direction; that club football, at the very highest level, is superior to the international game, with its round of meaningless friendlies and tedious, one-sided qualifying matches against the likes of San Marino and Moldova. The clubs naturally despise Blatter and also resent the machinations of Michel Platini, the former player-turned-head of Uefa, which from 2016, in another act of grandiose expansionism, will increase from 16 to 24 the number of countries playing in the finals of the European Championship (the tournament was at its best when the finals comprised just eight nations).

Perhaps only the clubs and the corporate sponsors have the power and the will to blow Fifa apart and effect the necessary change. Led by Sony, five of the six main Fifa sponsors have expressed public concern so far about the Qatar corruption allegations.

On 14 June, England play their opening group game of the World Cup against Italy in Manaus, capital city of the state of Amazonas in northern Brazil. Many millions of us in this country will be watching on television, despite the match kicking off at 11pm BST. For a while at least, we shall forget, or try to forget, all about how football is administered and sold around the world and allow ourselves to become absorbed by what is happening on the field of play, by the drama or otherwise of the game itself.

But this time, for me at least, it feels different. It fells like the end of something. It feels like the end of an era. After Brazil 2014, unless there is urgent and fundamental reform of a kind that would seem unlikely, the tournament is finished. In Vladimir Putin and the secretive autocrats of Qatar, Fifa has the partners it deserves – and the world should turn away in disgust.

Jason Cowley, editor of the New Statesman, is the author of a memoir, “The Last Game: Love, Death and Football” (Simon & Schuster, £7.99)

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Now listen to Jason Cowley discussing this article on the New Statesman podcast:

Jason Cowley is editor of the New Statesman. He has been the editor of Granta, a senior editor at the Observer and a staff writer at the Times.

This article first appeared in the 11 June 2014 issue of the New Statesman, The last World Cup

IMAGE: BENJAMIN HARTE/ IKON IMAGES
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Towards an eternal winter – can the NHS survive?

Longer but not healthier lives, rising hospital admissions, expensive new treatments and underfunding – is it over for the National Health Service as we have known it?

When George Farrelly finally made up his mind to study medicine, he did not so much make a choice as follow a calling. An intense, preoccupied young man who grew up in Cambridge and Rome, Farrelly had majored in history at Harvard and imagined a future as a writer. His epiphany came when he cloistered himself in a Benedictine monastery on Lake Geneva to answer no less a question than: “Does God exist?”

The kindness of a monk who nursed him through a bout of winter pneumonia made a literary life seem suddenly empty of meaning. Farrelly burned the novel he had been working on and resolved instead to devote himself to what he liked to call “street medicine”: a sincere but as then vague aspiration to minister to the broken-spirited, the out-of-luck and the poor. It was the late 1970s, and when Farrelly enrolled as a mature medical student at St Bartholomew’s Hospital in London, the path to prestige lay through such exalted fields as neurosurgery and cardiology – not the comparatively parochial world of the GP. Farrelly and his wife, Isabel Hodkinson, also a physician, seized their chance to live their grittier – if more romantic – vision when they took over a practice housed in a former council flat in the East End borough of Tower Hamlets. The switchboard was so rudimentary that when somebody called to book an appointment the phones in the rooms all trilled at once.

Twenty-seven years later, the husband-and-wife team are still treating patients in the area from the much smarter premises of the Tredegar Practice, a modern surgery sandwiched between terraced streets and newer estates near the Bow end of Roman Road. On a recent Wednesday morning, Farrelly grabbed his black medical bag from his consulting room and set off at a brisk clip. An energetic 64-year-old with wispy grey hair, Farrelly could easily pass for a compassionate but streetwise inner-city priest. He was visiting patients on the “integrated care list” – typically older people with multiple, chronic conditions who are too unwell to make it to a surgery and who are presenting in ever greater numbers to Britain’s GPs.

First up was Steve Blum, a former lorry driver who blamed his problems on a 60-a-day cigarette habit he had only managed to kick after it very nearly killed him. Blum had suffered his first stroke in 2006, while at the wheel of a 26-tonne truck hurtling through the Dartford tunnel. A second stroke several years later left him barely able to walk. Farrelly reached Blum’s second-floor flat, installed himself on the sofa  and produced a checklist and pen. It was time for the patient’s annual review, and the pair had much to discuss.

A heavyset man with a neatly trimmed beard, Blum had the worn-out look of a permanent patient who cannot remember being pain-free. His family had produced a laminated handout detailing all of his complications  – and the 16 types of medication they required – to serve as a handy cheat sheet to thrust into the hands of staff whenever he had to go to hospital.

Gradually, the pair worked their way down the list: memory loss; type 2 diabetes; arthritis in his hands, feet, knee and right hip; damaged nerve endings; depression (which had triggered two overdose attempts); anxiety; degenerative disease in the back; sleep apnoea; asthma; high blood pressure; high cholesterol and an enlarged prostate. Finally, they broached the question of Blum’s weight – which hovered stubbornly near 20 stone – before concluding with a goal-setting exercise. “What are your wishes – your dreams – over the coming year?” Farrelly asked. “To win the lottery,” joked Blum, who was born and bred in Tower Hamlets and found some solace in gallows humour. More gruffly, he added: “To go back 11 years and not have had my stroke.” The pair settled on a plan that included Blum using his mobility scooter to accompany his son and nephew to see his beloved Tottenham Hotspur play at Wembley. After all, Blum would soon have cause to celebrate. In two weeks he would mark his 56th birthday.

The National Health Service, which turns 70 this summer, is not that much older than Blum. But its litany of problems – like those of so many of its patients – can seem almost too much to bear. Midway through the worst financial squeeze in its history, saddled with the legacy of interminable reorganisations and ruinously expensive private finance initiatives, and grappling with the twin pressures of staffing crises and ever-increasing demand, the organisation’s future has never looked so uncertain.

At the start of this year, strains building below the surface burst spectacularly into view as the NHS suffered its worst winter crisis since the 1990s. With ambulances backed up in hospital car parks, A&E departments overflowing and elderly patients left languishing on trolleys, NHS England was forced to postpone more than 50,000 non-urgent operations to free up more beds. As standards of care began to unravel, staff expressed their shock and anger on social media: one A&E doctor apologised for “third-world” conditions.

“The big danger is that this is all going to collapse,” Farrelly had told me last summer, during a lunch break at a cafe near the Tredegar Practice. Wearing sombre colours and sandals, which enhanced his ecclesiastical aura, he spoke with the combination
of finality and resignation that has become a default setting among hard-pressed medics. “If you have increasing flow of work, decreasing people to do the work, and decreasing resources, it’s going to crumble  – you won’t be able to do the job.”

Dr Jackie Applebee, who works with Farrelly, is equally forthright. A vocal official in the British Medical Association, the doctors’ union, Swansea native Applebee is also an outsider who has learned to call Tower Hamlets home. Having worked in the borough for 17 years, she spends much of her spare time campaigning on behalf of the NHS, her stethoscope swapped for a megaphone. One rain-spattered Saturday afternoon, she stepped on to a stage at Chrisp Street Market, a drab precinct a couple of miles from the surgery, and delivered her prognosis.

“It’s going in the same way as the American health service where people die on the streets because they haven’t got insurance,” she said. “We have to fight to keep the NHS free at the point of delivery.” Applebee then began to hand out flyers, telling one passer-by: “People don’t notice until it goes off a cliff – which it will if something wonderful doesn’t happen very soon.” The leaflets posed the question: “Can #ourNHS survive the next five years?”

t’s not the first time that NHS campaigners have foretold the apocalypse, and newspapers have been predicting the organisation’s imminent demise almost since Aneurin Bevan, then Labour health minister, oversaw its creation. With politicians and the media lost in a maze of questions posed by Brexit, the weary familiarity of reports of staff shortages, growing waiting lists and increased rationing of care can seem perversely comforting by comparison.

This time is different. In the winter of 2016-17, the British Red Cross warned that the NHS was facing a “humanitarian crisis” after two patients died following long waits on trolleys. Though the use of a term usually reserved for famines or war zones had a ring of hyperbole, even the most sober voices have begun to sound the alarm. In October the Care Quality Commission, the health and social care regulator, warned that although standards had generally held up in the past year, the future looked “precarious”. Front-line staff are less diplomatic. “We feel that we are kind of working on a ship that is sinking and on fire at the same time,” one hospital doctor tells me during a busy evening shift. “There’s definitely a feeling of impending doom.”

Much of the public discourse on the NHS has traditionally revolved around the question of money – whether it is getting enough, and how to find more if it isn’t. Yet the dilemmas confronting the health service cannot be reduced to the one-dimensional question of resources alone. Many factors have shaped the contours of the current crisis, from the consequences of successive waves of market-based reforms stretching back to the 1990s, chronic staffing shortages, steadily declining bed numbers and the increasingly arms-length approach to the health service taken by the Conservative government. Looming over all these issues is the fact that the NHS and its 1.5 million staff now face a challenge it was never designed to meet: caring for a fast-growing, increasingly elderly cohort of patients living with multiple, chronic conditions. Patients like Steve Blum.

Seventy years ago, people tended to live “square-shaped lives” – staying in relatively good health before falling ill and passing away conveniently promptly. Half the population never reached the age of 65. The NHS was built on the assumption that one patient would see one doctor for one problem, and if they were really ill they would go to hospital where they would either get better or die. Childhood diseases such as polio or rickets were far more pressing problems than the later-life scourges of type 2 diabetes or dementia.

Now, every part of that picture is different, driven by a combination of medical advances and social changes. There are already more than 11 million people over 65 in the UK today, and a quarter of the population will fall into this age range by 2040. Survival rates for heart disease have increased dramatically in the past 15 years, and prognoses tend to be more optimistic for illnesses such as breast or childhood cancers. Life expectancy for men in Britain has risen to 79; for women it’s 83. But the problem is that longer lives do not necessarily mean healthier ones, and the number of patients suffering from chronic illness is rising fast. Dementia cases will top one million within the next three years according to one forecast, while millions more people will be living with preventable diseases fuelled by the self-destructive ways in which we eat, live and work. Obesity has almost doubled since the early 1990s and the UK now has the worst weight crisis in western Europe, according to the OECD.

Doctors fear bulging waistlines alone could break the NHS by fuelling a surge in type 2 diabetes, osteoarthritis and some cancers. “There’s a real risk that people will live for longer, but they will have spent longer dying,” says Sarah Jarvis, a GP and clinical director of patient.info, a website that offers information provided by doctors. “We are fighting against a rising tide of lifestyle factors that are threatening to overwhelm us.”

Unless the health system learns to focus on prevention as well as treatment, then its inexorably rising costs will strengthen the voices of those who see the NHS not as Britain’s proudest postwar achievement, but as a terminal patient beyond hope of a cure.

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Though the NHS can make a good claim to be the world’s most iconic health-care system, its founders were by no means the first to conclude that governments should get involved in financing medicine. In the early 1880s, Otto von Bismarck, the German chancellor, pioneered a form of employer-funded social insurance that forms the basis of the system in various European countries that now provide near-universal coverage. Nevertheless, the sheer sweep and boldness of the NHS vision represented an entirely new way of thinking about the relationship between health care and the state. Ever since the first physicians began concocting herbal remedies and performing rudimentary surgery on our ancestors, the horror of falling sick and not being able to afford the right care has been passed down through generations like an unwanted heirloom, burrowing its way deep into the collective psyche. The inauguration of the NHS on 5 July 1948 lifted this ancient curse at a stroke. Health care would be brought under a single umbrella organisation, paid for from general taxation and offered free at the point of use – regardless of the contents of a patient’s wallet. Buoyed by postwar ideals of solidarity and egalitarianism, the organisation was more than just a giant patient-processing machine: it seemed to offer a more optimistic reading of the human future.

“It was an extraordinary act of leadership to have established the National Health Service,” says Don Berwick, emeritus president of the US-based Institute for Healthcare Improvement. “The whole world looks to the NHS as a learning system – a way to explore what can happen in government sponsorship of health care.”

Although the health service enjoyed a period of relative plenty in the early 2000s under New Labour, that largesse would not survive the 2008 financial crisis and the austerity agenda adopted by the Conservative-led coalition two years later. The NHS is now experiencing the leanest decade since it was founded, according to the King’s Fund think tank. While Theresa May is technically correct to say that her government is spending record amounts on the NHS, the more pertinent question is whether it is spending enough.

History suggests not: the King’s Fund has forecast that spending on the NHS will increase by an average of 0.7 per cent a year in real terms in the five years to 2020-21 – compared to a long-term average of about 4 per cent a year. The contrast between the virtually flat graph for spending and the steadily upward curves for hospital admissions, ill health among the elderly, the cost of new treatments and rising patient expectations suggests that something will have to give. Chancellor Philip Hammond succumbed to intense pressure to allocate additional funds in his last Budget, but the amount fell well short of the extra £4bn a year the NHS wanted.

With frozen welfare benefits and stagnant wage growth dragging hundreds of thousands more into poverty, and social care badly impacted by savage cuts to council budgets, the impact of years of austerity on Britain’s physical and mental health is increasingly being felt by GPs, paramedics, nurses and the managers battling to hold the line. “I have been a chief executive in London for 17 years and I don’t recall seeing the NHS under so much pressure,” says David Sloman, who runs a group of three hospitals including the Royal Free in Hampstead. “Staff are working incredibly hard in challenging circumstances and we need to think differently about how we deliver NHS services in the future.”

The NHS remains Britain’s biggest bastion of collectivism to have survived the neoliberal age. Yet many staff believe that the chronic underfunding is serving an ideologically driven agenda to place ever-larger segments of the health service under corporate control. Though the value of clinical services commissioned from private providers represents less than 8 per cent of the NHS budget, the firms’ roles have grown markedly in the past decade and this trend is accelerating. The value of NHS contracts won by private providers rose to £3.1bn in 2016-17, up from £2.4bn the previous year, according to the NHS Support Federation campaign group. Richard Branson’s Virgin Care led the charge, winning a record £1bn of NHS business last year. Even if such companies only control a small proportion of overall spending, the fear among NHS staff is that outsourcing the most profitable procedures – such as cataract surgery, hip replacements or diagnostics – is corroding the system slowly from within. Cherry-picking such activities is like removing blocks from a Jenga tower: take too many and the whole structure starts to wobble. “This is when we have to say enough is enough,” says Ben White, a doctor who has campaigned on behalf of the NHS. “Before we know it we’re sleepwalking into a completely different health service.”

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When George Farrelly pursued his vision of “street medicine” in the early 1990s, Britain’s GPs had their share of struggles, but their workloads tended to be more manageable and on-the-job burnout was a relative rarity. Now, many feel more like storm-battered emergency workers fighting to prevent a dyke from bursting its banks.  Although GPs play a vital role in saving the NHS money by keeping patients out of expensive hospital beds, the organisation has gradually reduced the proportion of resources devoted to primary care – and surgeries are feeling the impact.

A record 92 practices closed in 2016 – a five-fold increase on 2013 – according to figures obtained by Pulse magazine. Although 34 of these closures were due to practices merging to pool resources, the BMA said a lack of funding was responsible for the bulk of the losses, which forced 265,000 patients to switch surgeries – more than in any previous year.

GPs were similarly aghast at the humiliating spectacle of one practice being forced to auction its equipment online to settle debts. “It was unheard of before; now we’re hearing stories every few weeks of practices having to close because they can’t afford to run any more,” says Mark Hamilton of campaign group GP Survival. “The goodwill that kept the NHS afloat for so many years is basically evaporating.”

With surgeries across the country struggling to fill vacancies, Farrelly was shocked to learn that up to half of a six-strong group of medical students visiting the Tredegar Practice on a placement were studying for qualifications needed to work overseas. “I’ve never heard people speak about this option,” he says. “Then hey presto: here I am with a group of people – they’re in their first year of medical school – and they’re already planning their exit.”

So many UK-trained medics have been emigrating to Australia, Canada or New Zealand that the Health Secretary, Jeremy Hunt, floated the idea of imposing fines to force them to stay. With unpaid overtime, roster gaps and stagnant wages taking their toll on hospital staff, there have been a slew of reports of nurses being forced to use food banks, or quitting to work in supermarkets. Brexit may make matters worse. NHS England employs 55,000 EU citizens, but applications from nurses wishing to move to the UK from Continental Europe fell by 96 per cent after the referendum. Even high-flying British specialists wonder what the future holds. “I believe in the NHS, it’s where my heart is,” says one cardiac surgeon in his mid-thirties. “But if they push me too hard, I will leave.”

The closest Farrelly came to quitting was midway through his career – when he seriously considered leaving Tower Hamlets to become a monk. Years later, there remains something of a spiritual seeker’s single-mindedness in his devotion to tightening procedures at his practice.

An evangelist for the “lean” school of hyper-efficient management pioneered in Toyota car factories in the 1980s, Farrelly encourages his staff to hold a weekly meeting where they brainstorm time-saving ideas with the help of a formidable-looking flow chart peppered with Post-it notes. Though he reserves particular scorn for politicians – whose top-down tinkering he blames for many of the NHS’s problems – Farrelly is equally adamant that the institution could do a lot more to reduce waste. “There’s a line between when you are coping and when you are not coping, and that’s not a very big space,” Farrelly says. “A lot of the system is at that tipping point.”

***

If Simon Stevens, the chief executive of NHS England, is daunted by the multi-pronged assault hammering at the walls of his kingdom, he doesn’t let it show. From his headquarters at Skipton House, a nondescript glass-fronted office block in Elephant and Castle, south London, Stevens is leading the most ambitious overhaul of the way clinical services are delivered since the NHS was founded. There is no question that the service needs to evolve. Yet there is still great scepticism over whether Stevens can reconcile two seemingly contradictory goals: providing better care, while simultaneously saving more money, more quickly, than ever before.

An imposing, cerebral figure with a reputation for knowing more about the NHS than just about anybody else alive, Stevens joined the organisation as a graduate trainee, going on to serve as an influential health policy adviser to Tony Blair. Having played a key role in the Blair government’s successful campaign to tackle waiting times and boost treatment outcomes, Stevens went on to spend a decade in senior positions at UnitedHealth Group, one of the largest health-care corporations in the US, before being headhunted to run NHS England in October 2013. His mission: to deliver an improbable-sounding £22bn of annual savings by 2020 (the day-to-day running costs of the NHS this year are about £110 billion).

Stevens set out his plan in a 39-page document called the Five Year Forward View. Despite its anodyne title, the dossier heralds far-reaching change. One of the main goals is to break down barriers between the many different organisations involved in care to provide better support to patients with complex needs, and with the hope of keeping more of them out of hospital.

That might sound like a straightforward idea, but in practice Stevens’s reforms herald a profound shift in the way the health service is run. After decades in which both Labour and Conservative governments sought to hold down costs by promoting internal competition in the NHS, Stevens has begun pushing the organisation in the opposite direction, believing closer co-operation is paramount.

With this guiding principle in place, Stevens set officials across England’s ecosystem of semi-autonomous hospitals, GP practices and local councils to work, sketching out proposals for how they could operate together more effectively. Dividing England into 44 areas with an average population of 1.2 million, the resulting proposals added a new entrant to the lexicon of NHS jargon: STPs (sustainability and transformation plans). In “vanguard” sites such as Blackpool and the Fylde Coast, South Yorkshire, Dorset and Berkshire, once-fragmented providers are starting to co-operate more.

“The heart of the idea is that there’s a lot that’s good. What needs to change is that there needs to be a better join-up between the components of care,” Stevens told me at Skipton House last summer. “Part of what we’ve been trying to do is to create those safe spaces, or those permissive environments, for those evolutionary developments to take hold.”

After years of watching management consultants approach NHS cost-cutting as a kind of extreme sport – axing frills as lowly as free tea bags for nurses – it was perhaps inevitable that some have nicknamed the STP exercise “slash, trash and plunder”. While many health providers have welcomed the idea of closer integration, others fear that plans to merge different hospitals and A&E departments will leave patients worse off and create new avenues for the private sector to snap up even bigger contracts.

Much of the controversy centres on plans to create so-called “accountable care organisations” (ACOs) – a model widely used in private health-care systems in the US and Europe – where a single organisation takes responsibility for providing a full spectrum of services to a given population. Although the margins for much of what the NHS does are too low to offer easy profits, campaigners cannot shake the suspicion that ACOs will serve as convenient bridgeheads for corporations seeking new in-roads into England’s health market. The concerns were widespread enough to prompt Bruce Keogh, NHS England’s medical director, to write in the Guardian earlier this month that the model was not a “Trojan horse” for greater privatisation.

Stevens, who has repeatedly braved the ire of ministers to make a public case for more NHS funds, has similarly little truck with concerns about the growing role of private health providers. “When you look back at points in the past at moments where we stared in the mirror and said, are we going to ‘re-up’ with the NHS, or are we going to do something different, we’ve decided as a country – on balance – that we’re going to persist,” he tells me. “There’s no great sense that there’s an alternative that people would prefer. The question is, how do we future-proof the NHS for this next phase?”

Stevens’s thinking already appears to be delivering closer co-operation in some of the “vanguard” areas, but the biggest question remains unanswered: can such a fundamental rethink succeed without more money? Colin Leys, an honorary professor at Goldsmiths, University of London and co-founder of the Centre for Health and the Public Interest, has analysed plans to transform care in north-east London, which includes Tower Hamlets. His conclusion was unambiguous: without significantly more investment, the plans would imply a decline in quality, staffing levels and access for patients. “That doesn’t mean they’re not good ideas in themselves,” Leys tells me. “The question in my mind is, if they are good ideas, where’s the evidence? And secondly, will these good ideas work in conditions of underfunding?”

***

One of the great paradoxes of the NHS is that for all the routine use of the term “crisis,” it is still possible to walk into one of London’s top hospitals and marvel. On a recent Friday at Guy’s Hospital near London Bridge, a consultant called Ben Challacombe donned his surgeon’s cap – decorated with pictures of a cartoon Merlin. Challacombe’s specialism rests on wizardry of the electronic kind: a praying mantis-like machine with four robotic arms that enables his team to perform operations with the kind of hair’s-breadth precision that surpasses the steadiest of human hands.

Bathed in the glare of theatre lights, the device – known as “da Vinci” – twitched into life, its limbs gyrating obediently under the control of an operator intent on tunnelling ever deeper towards a thumb-tip sized tumour on a patient’s kidney. “We’ve got no time pressure,” Challacombe told his team, as pop music played softly to help them maintain focus. “Just do it beautifully.”

Medicine is on the cusp of a tectonic shift that could deliver a very different future to the bleakest projections for the NHS. From advances in big data and artificial intelligence to the development of treatments tailored to an individual’s unique genetic make-up, breakthroughs in “med-tech” will soon make it easier to spot, prevent or quickly cure once unconquerable diseases – provided a way can be found to pay for it all. “I think in two to three hundred years’ time we might think of this as another Renaissance, in the way connectivity and technology advancements went off the curve,” says Nazneen Rahman, head of genomics at the Institute of Cancer Research. “We’re moving from the traditional way in which health systems were about making ill people better, to being about keeping well people well.”

If there is one clear lesson to be drawn from the NHS’s plight, it is that this Renaissance will go one of two ways. Blockbuster new treatments could enable more people to live longer lives in ruder health than ever before. Or the sheer weight of demand and the ever-multiplying cost of care could conspire to deliver a more dystopian future; in which the privileged enjoy extraordinary lifespans thanks to bespoke, privately funded medicine, while the have-nots are condemned to live shorter, more disease-ridden lives than their parents.

As Steve Blum learned when he was finally forced to quit smoking, a life-threatening diagnosis can be a great spur to change. It can just as easily lead to apathy and denial. Blueprints exist to evolve a system that genuinely serves to help people from all backgrounds to stay healthy – rather than accepting the growing burden of chronic, preventable illness as somehow inevitable or normal. But that won’t happen unless Britain – as the custodian of a singular experiment in health care – makes an unequivocal choice to rescue the NHS from its glide towards eternal winter.

It took a case of pneumonia to nudge George Farrelly into the realisation that a lifetime of serving others would ultimately yield richer rewards than the pursuit of success for its own sake.

For all the trials he has faced during more than a quarter of a century of “street medicine”, it is not yet a decision he has come to regret. “I had thoughts today that I can’t go on like this. But then later I’ll think, ‘We have a method to try to make this work,’” Farrelly said one afternoon at the Tredegar Practice. “If we have a meltdown of the whole system, we will just somehow or other put something together.” Then, he went back to his desk. 

This article first appeared in the 11 June 2014 issue of the New Statesman, The last World Cup