The NHS at 72: we’ve renewed our vows

Sunday 5^th July, the 72^nd anniversary of the creation of the NHS, will see the last planned clap for carers at 5pm. Like the rainbows in windows across the UK, the clap is a tangible sign of the almost religious sanctity of the NHS in the public psyche. When all else fails, the NHS represents unqualified and free social protection writ large, and it arguably has never mattered more than in the last three months. In a world full of services having small print exclusions, dodging obligations, offering qualified support or lapsing in quality, doing whatever it takes for those in need is the NHS’s enduring appeal.

“Whatever it takes” was also the message from the Chancellor Rishi Sunak in mid-March, referring to emergency government financial support for the economy and the NHS. The bill is forecast to be close to £300bn in 2020/21, according to the Office for Budget Responsibility. Despite assurances that there will be no return to austerity, cutting future public spending remains a possibility. Polling consistently shows the public wants more spent on the NHS over other areas. But with a tax-funded budget of £125bn and 1.4m staff, the NHS in England is the largest organisation in Europe.

Governments have a penchant for administration-defining reforms. Given Covid-19 and Brexit, you’d be forgiven for thinking the current crop’s agenda was already well defined. But think again. The whole civil service is due a downpour of “hard rain,” according to the PM’s chief adviser Dominic Cummings, with the aim of modernising “the blob.” With health steadily increasing as a share of total public spending (now standing at nearly 20 per cent), the NHS may soon be in the crosshairs for reform again too. We’ve collectively renewed our vows to the NHS, so what’s next?

First, anyone worried about future costs of health care must tackle the sheer burden of illness the NHS faces. Gains in life expectancy have stalled in England over the past decade, there is a growing gap between rich and poor, and in some groups (eg women living in deprived communities in the north of England) life expectancy has reversed. People living in the poorest areas start getting chronic diseases at 51—a full 19 years before those in the wealthiest. We are also among the most obese nations in Europe.

Contrary to public belief, the risk of ill health is not just about the actions individuals take but the wider context in which they live. This context is powerful, shaped by “social determinants” such as employment, education, housing, access to green spaces, early life experience and parenting. Then there’s the “commercial determinants” of health, for example marketing and supply of fast food, alcohol and gambling. An administration serious about health (and its future costs) would develop cross-government strategies to stem avoidable harm, shape people's ability to live a healthy life and contribute to the economy, as well as measure progress transparently.

Second, key to the NHS’s ability to manage in future will be a lasting solution for social care, long ducked by successive governments, and resulting in huge avoidable demand on the health service. Third, if NHS reform is on the cards, a very big lesson from the pandemic is that rapid progress is made possible through technocratic (managerial and clinical) competence rather than democratic (political) central direction. For sure, not everything has been rosy, including key areas largely not the direct responsibility of the NHS—supply of PPE, testing and support in care homes are stark examples. But the service has shown how fast it can move in a crisis. From putting up Nightingale Hospitals from scratch, reconfiguring services across whole cities, rapid sharing of best practice among clinicians, supporting rapidly discharged patients quickly, and delivering most outpatient and general practice services virtually, the speed and organisation has been impressive. Changes have taken days and weeks, not years.

What enabled that? Not new technology and data, usually heralded as the salvation in future. But the threat of the virus, which focused minds, forced people to overcome innate cautiousness towards risk, and allowed more room for collaborative leadership, devolved decision-making and rapid consensus to be built in the face of uncertainty. This was all coupled with a temporary holiday from some performance and regulatory targets. In short, we freed up human agency and trust supported by kit, not the other way around. Can this pace of improvement be replicated once the emergency has waned? That’s the central question we must find answers to for the NHS to face the future successfully and live within its means. But it is a million miles away from the showy structural reforms politicians favour.

Given the fiscal squeeze ahead, we may only have a brief window now to learn and act in each of these three areas. But that would be the best 72^nd birthday present for the nation’s favourite institution.