Posted on Friday 15th June 2018
The NHS is 70 and I reached 60 this year.
When you reach a ‘milestone birthday’ you’re encouraged to look back as well as celebrate. In my case every birthday card seemed to remind me that I am lucky to be alive at the grand old age of 60! And of course when the NHS was launched in 1948 the life expectancy of males was around 66, so I would have been getting a bit worried back then!
So as I look back on the things that matter in my life I thought it good to see what events the NHS and I have seen together. The impact of history makers and landmark episodes such as Kennedy’s assassination, Martin Luther King’s ‘I have a dream’ and his assassination, Churchill’s death, Mandela’s imprisonment, release and death. The first black US president in Obama, the impeachment hearings for Nixon and Clinton, the first UK woman prime minister in Thatcher, the Blair transformation of Labour. Events such as the Great Train Robbery, Vietnam, Iraq, Syrian and Afghanistan conflicts; The First Moon Landings, Royal Family news around the Queen at 90, Charles and Diana, William and Kate, Harry and Meghan. The Harry Potter phenomenon, scientific breakthroughs in DNA and Genome technology, social media, the internet, mobile telecommunication, artificial intelligence. We’ve seen human tragedies such as the Boxing Day tsunami in the Indian Ocean, the rise of ISIS, Grenfell, London and Manchester bombings. We’ve seen the first test tube baby, climate change, rock star deaths such as Bowie and Elvis, Hendrix and Lennon, Prince or Jim Morrison. The first heart transplant or England winning the 1966 football world cup and 2003 rugby world cup. We joined the common market and now of course we have Brexit. Everyone has their own memories often linked with the belief that ‘things were better when…’
So many events, so many memories and if looked at carefully, intercut with so many factors that have shaped our NHS. We should also add societal references around the impact of diet, alcohol, recreational drugs, obesity, transgender challenges, risky activities, ageing, social care restrictions and perceived funding pressures to that list and ask how different our NHS is 70 years on from its inception.
The vision of course began with Aneurin Bevan’s ambition to provide a health service available to all, free at the point of use and financed entirely from taxation. Through the years since 1948 we have seen prescription charges introduced, DNA structure ‘discovered’, smoking and cancer link established, children being allowed to visit their hospitalised parents on a daily basis, polio and diphtheria vaccination programmes introduced leading to better management of childhood diseases, the Mental Health Acts bringing compassion in care , and the rise of the independent sector. We’ve seen robotic operations, computerised diagnostics, investigative and diagnostic procedures, computerised reporting and the effective management of previously life threatening illnesses along with new procedures such as coronary artery bypasses, better awareness of dementia and associated diseases of getting older, fertility, neurosurgical and cancer treatments bringing change to every facet of the service. All allowing massive improvements to our health service and the physical facilities . Our NHS is wonderful and we now are capable of delivering care in ways we never envisaged would be possible 70 years ago.
However whilst the aims of eliminating want, disease, squalor, ignorance and idleness at the heart of the Beveridge post war reconstruction were epitomised by the NHS, those noble ambitions have been challenged ever since by advances in medical science, increasing costs of medicines and technology, financial restrictions and central control.
Successive reorganisations look likely to have taken us on a journey from centralised to devolved management and back again to central controls all the time influenced by management dogma, reinvention of wheels and political whims. We’re moved from recognising that the 1948 services were a mess to be sorted out in a time of post war financial challenge to a time of well…financial challenge and an NHS and social care system that needs to be sorted out!
The cataclysmic effects of the Second World War showed that tinkering with systems or modifying existing ways of working no longer felt good enough. Instead a massive change of system was needed and the tensions felt in 1948 have been challenges to governments ever since. In 1952 Bevan himself said “we shall never have all we need” and “expectation will always exceed capacity”. There was even a 1956 Guillebaud report into NHS efficiency only eight years into the life of the NHS when we were told that no opportunity existed to increase income through non-governmental routes or to substantially reduce costs. It recognised capital expenditure was too low so we saw the explosion of the 1960s and 70s building programme and the new facilities delivered through PFI, PPP and third party independent funding from the 1980s onwards.
We’ve seen the impact of the constant tussle between demand and finance ever since despite establishing audits and performance indicators, community care and new GP and consultant contracts, the internal market and the separation of commissioning from delivery, Foundation Trusts and payment by results, the NHS plan and Five Year Forward View. However we still don’t feel we’ve got it right so we have lots of people looking at what lots of other people do and calling it management.
To achieve what?
Undoubtedly we have an incredible social institution that we all take for granted and often abuse. We’ve forgotten why we set up the NHS and now see it as a consumer ‘right’. We criticise and moan then look other countries and count our lucky stars. We’ve seen health spending rise from £12.9bn in 1948 to £149.2bn today in real terms. It consumes 12 times what we originally spent achieved through annual rises on average on top of inflation of 3.7% a year. It squeezes other public sector spending departments and takes 30% of all public services spending (David Smith. Sunday Times, June, 10 2018). And still we believe the system is ‘underfunded’ and ‘close to collapse’ when dealing with both an ageing and growing population. The NHS activity measures are variable but factors including drug therapies, lower lengths of stay following procedures and greater support enabling people to live with long term conditions mean productivity has broadly risen by 1.2% on average over the long term.
So observers and participants, consumers and staff recognise the need for change but surprisingly in the last eight years when NHS real terms spending has been at its lowest (1-1.5%) we have seen greater efficiency and productivity. However doing more operations or seeing more outpatients in their current form is ‘obsolete’ according to Simon Stevens at the 2018 NHS Confederation and he demands a transformation of care and a complete redesign of services in return for a 4% annual uplift. Add to that the need, obvious to most, of aligning health and social care responsibility, minimising health inequalities and the need for us all as consumers of care to adopt a lifestyle change and we might see an NHS fit for another 70 years…or will we?
So what needs to change?
We have examples of excellence – my own experiences of the NHS recently have been marvellous. Well-coordinated, timely, good humoured and informative – with good outcomes. Others in my circle however have seen delays, multi date appointments, poor coordination or support and certainly not focussed on the patient.
This variation in standards, increasing reliance as a society on charities and acceptance of service restrictions leads to increasing length of stay for the elderly and infirm together with our misuse of A&E. The variable management of the vulnerable and those with long term conditions, lack of joined up services and inability to cope with an ageing and demanding population says to me that maybe the radical explosive change of 1948 needs somehow to be revived and relaunched.
Back then we didn’t know what we didn’t know. Now we know more and hence we do more. Doctors used to tell me when I ran hospitals that they ‘buried their mistakes’ now we rightly face higher expectations, litigation claims and the need of the patient is paramount. All this has a cost and impact on the service.
So, returning to the David Smith article, he said; “anyone thinking a 4% settlement would convince everybody the NHS was…properly resourced is being naïve. In the 2000s when NHS spending was rising at double that rate, public satisfaction was lower than now. One thing we have learnt over 70 years is that there is no amount of money that will provide sufficient resources for a service with growing, and in the end, unlimited demands”.
How far away therefore are we from asking ‘what services do we want?’, ‘what do we need?’, ‘what can we afford?’, and ‘what does it look like?’
If we believe the futurologists we’ll see events which will mirror the changes we’ve seen over the last 70 years and arguably impact heavily on a creaking system. There will be wearable computers recording and transmitting health data, artificial eyes and brain transplants, baby sex selection and mind wipes to rid us of bad memories, invisibility cloaks and robotic child care, hydrogen based fuel stations and human settlements on the moon…where will this leave our health systems and who will be brave enough to be a Bevan of the 21st Century? Bevan offered many memorable quotes including “no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”. I doubt however he meant the NHS to be the catch all solution to societal behaviours and individual lifestyle choices it now has become.
Instead let’s challenge politicians to embrace change and challenge ourselves, the public, to determine what service we want and can afford with another quote from the architect of the NHS:
“We know what happens to people who stay in the middle of the road. They get run down”.