Happy 75th birthday NHS: What next?

Introduction

As the National Health Service (NHS) of the United Kingdom reaches its 75th birthday in July, perhaps the time has come to re-evaluate its strength and weaknesses. Dr Martin Deahl (in this issue) in the accompanying paper has illustrated his personal experiences over the last 40 years or so working in the NHS, here I provide a brief history, potential challenges and possible solutions. NHS has been described as the closest thing the country has to a religion and has been described as the best healthcare service in the world. Needless to say both are potential exaggerations but there is something about the NHS that gets people excited. In the middle of the Covid-19 pandemic the then Prime Minister kept repeating the slogan Save the NHS. And yet every single day in every single paper there are either reports of new discoveries or treatments which should be made available irrespective of the costs or various crises that face the NHS. Staff shortages have become routine which puts inordinate amount of pressures on those who are at work. Rates of burnout are totally unacceptable. The clapping and banging pots and pans every Thursday evening during the pandemic has given way to worries about long waiting lists. Population as a whole is cognisant of pressures on the service and staff and many sick people stayed away from seeking help during the pandemic. It can be argued that the NHS is a victim of its own success with people living longer and living with multiple complex conditions with increasing demands and no relative increases in investment.

Certainly like any 75th birthday, it is interesting to look back at life gone past. Of course, the circumstances under which the service was established are not the same and society is not the same either. The societal expectations of medicine and healthcare have changed with demands for equal partnerships in making any clinical decisions rather than old-fashioned paternalistic view and at the same time staff want a better work-life balance. Access to information from the internet right or wrong is starting to influence help-seeking.

I do not propose to provide an exhaustive history, which is available elsewhere.

Healthcare before the NHS

The NHS as a national service along with other welfare state provisions emerged in the aftermath of the Second World War. Until then, the government had limited or little role to play in healthcare of the population. The basic principle of the NHS was free to access at the point of need for the rich and the poor alike and providing treatment from hernia repairs to heart transplants and that remains so. So whether it is a peer of the realm or a bus driver they are treated the same. At the same time until the middle of 19th century the government had no role to play in medical education which was the prerogative of various medical Royal Colleges and guilds prior to that. In 1834 Poor Law was passed acknowledging that government had a responsibility to look after its population’s health. At that time Parish medical officers were made responsible for the care of the health of poor people in specific geographical areas which also had parish workhouses which had sick wards so that those who needed care could be treated (Levitt, 1976). Means test was necessary to access free treatment. In 1848, the Public Health Act established statutory powers to deliver population health by local medical officers. The General Medical Council was established in 1858 to self-regulate doctors and a register of qualified medical practitioners was set up. The reach, spread and access to medical services remained patchy.

The National Health Insurance Act was passed in 1911 which gave workers who fell ill a degree of protection. It meant that the employers, individuals and the state made compulsory contributions and in many ways was the actual precursor of the NHS. At that point in time, this was applicable only to general practitioner (GP) care and individuals from the working classes. It did not provide hospital care and not for the families either. Prior to the 1911 Act, very few working-class individuals could afford GP care through membership of friendly societies, and so on.

In 1938, the Emergency Medical Service (EMS) was set up in order to manage war casualties and divided England and Wales into 12 regions, and each hospital was categorised by its specific function. During this period, many existing voluntary hospitals became second-line (specialist) hospitals, and salaried specialists were introduced.

Jaques (1978) points out that in order to understand the setting up of the NHS, the following objectives must be taken into account while providing services:

Sir William Beveridge in 1942, saw five giants (want, disease, ignorance, squalor and idleness) as standing in the way of social progress in his report which became the blueprint of the NHS. Tragically none of the five giants have been slain in the last 80 years and they are still roaming.

Timmins (2017) emphasises that virtually every day since 1948, the NHS has been said to be in crisis but the morale within the NHS has never been lower. Of course, there was no golden age although we like to think that there was. Repeated so-called reforms have had major unintended consequences sometimes creating more chaos and dissatisfaction.

It was clear from the start that services would be available free of charge. These will also be comprehensive and promote good health rather than only the treatment of poor health. Funded by tax and bringing together hospitals and GPs, the health service was going to be comprehensive. One of the unintended consequences was when GPs were set up to be gatekeepers to the secondary care and hospitals a sense of possessiveness and tribalism was introduced leading to a fragmentation of services. These fragments had different management structures with some services being local, others regional and some national. Pharmacy, ophthalmic and dental services were run by different authorities from hospital or local authority. Along with the arrival of the NHS, social security benefits and welfare state had arrived too. Lettin (2005) offers an interesting oversight of first days of the NHS.

Although like any toddler, first steps were difficult but heart-warming for a lot of people because for the first time, they did not have to pay for their healthcare directly. As the NHS reaches 75th birthday it needs support in helping it deliver what is needed in the face of societal changes, increasing demand, expensive investigations and newer interventions to continual political interference often on ideological grounds have made this elderly being lurching from crisis to crisis.

In its 75 years there have been dozens of reforms which have often taken the role of applying sticking plasters rather than a proper diagnostic and treatment review. I do not propose to list all the reforms either but suffice it to say that in spite of pressures NHS has been a victim of its own success as along with other social changes it has contributed to increased longevity of the population which has also led to population living with multiple complex co-morbid conditions. However, the existence and indeed in some ways strengthening of silos between physical and mental health, public health and physical and mental health and health and social care has been damaging to the institution of the NHS. This has also created difficulties for patients and their carers to navigate.

Where next?

Nobody can predict the future although like weather forecast short-term predictions can be made. One of the major lessons from the last 75 years is that health cannot and should not be seen in isolation and has to be seen linked with education, employment, housing, justice and other subjects. So at governmental level policies should take all these into account. Health and wellbeing are a result of biological, cultural, social, commercial, economic and political factors which occur at international, national, community or local, familial and individual levels so for healthcare to survive and thrive a much broader overview is needed.

It can be argued that NHS is an institution with memory. Institutions are not buildings but structures, processes and people. Their skills, experiences, interactions and processes and strictures they function under make an institution work. The first thing for any institution to survive and thrive is that its functions should be clear. Secondly it should be funded appropriately and staff be supported and trained and helped to develop.

There needs to be a clear debate and discussion about the roles of various healthcare professionals, skill-mix, whether we need more generalists or specialists, role of primary care, community services, integration of physical and mental health, integration of social and healthcare, integration of health and public health and how partnerships are to be created. Managerialism and bureaucracy needs to be decreased. The time is right to look at the use of e-health, tele-health and AI for which suitable training must be offered especially focusing on digital impoverishment and ethics related to privacy and confidentiality.

One way forward is for the social covenant/compact/contract between healthcare professionals, patients, their carers and families and the government needs to be revitalised. There is an urgent need for a long-term plan looking at the future 10 to 20 years on with cross-party consensus and delivery of the plan to be handed over to an independent Board.

Professions must assume responsibility for ensuring autonomy and self-regulation but it has to be done in an open and transparent manner. Health services must be equitable, accessible and accountable. A key advantage of working in a healthcare system like the NHS is its non-competitive nature even though politicians have often attempted to introduce an element of competition. Profession’s leaders must think outside the box, use allocated resources appropriately and ensure that these provide value for money. Learning from examples of good practice from other parts of the world and sharing these within the system is important. Leaders also have a clear obligation to provide joined-up leadership and address potential threats and changing healthcare needs of the society in the face of changing societal expectations. What is needed, however, is prominent voice of the patients, their informal carers and public at large. This is about the common good not narrow interests. Social contract needs to be comprehensive and coherent and needs a clear strategic direction. Furthermore, a long-term plan for healthcare is needed for which all political parties are signed up to. There is no doubt that politicians on behalf of the society determine the social contract and patients, public and healthcare professionals have to follow this but engaging key stakeholders at an early stage will enable stability and acceptance. This has to be conducted in the context of transparency. The professional leadership is important but occasionally missing in dialogues with stakeholders. No healthcare system can function without healthcare professionals and leaders of professions have a clear moral obligation to ensure that any health reforms are linked to the professional values of different disciplines. Tele-health and other technological advances need to be used appropriately including proper training and ethical concerns being addressed. In recent times, other professionals and cadres such as nurse specialists, physician associates and paramedics who are trained individuals with specific tasks and specialised skills have emerged. Their roles and responsibilities within the multi-disciplinary teams must be clarified as a matter of urgency.

The role of geopolitical and social determinants in the causation of ill-health needs to be understood. All policies must have a health impact assessment. This requires inter-ministerial liaison between housing, social benefits, education, employment, justice and so on. The services must be equitable taking into account specific needs of people with vulnerabilities whether these are related to age, disability, gender, sexual orientation, religion and so on. Patients must have a major role in policy making. They must be supported in expressing their voice. Closer liaison with community organisations and communities and primary care must be developed further.

Recruitment and retention is critical in delivering proper healthcare. High rates of vacancies and poor retention must be addressed urgently. Regulatory systems must be facilitatory rather than simply punitive. Simply looking after needs of the staff will help and make the staff feel valued. Periods of joint learning across specialties and disciplines can help teams working better together. Resources must be available to prevent burnout among staff, eliminate bullying and discrimination to improve staff morale and openness in discussing errors without apportioning blame.

Health is everyone’s basic right. Models of good clinical practice created and working elsewhere in the UK or elsewhere in the world must be widely shared and applied if possible.

Lifetime’s learning of and from the NHS will make sure that next 75 years of the NHS are successful and that we have learnt from the past. Happy Birthday NHS.