Narratives of the NHS tend to swing from extreme to extreme. It is the jewel in the crown of our public services, symbol of all that is best in our nation. And it is an unsustainable behemoth in need of total transformation. It is stuck in 1948 and obsessed with change. It is staffed by angels and managed by bullies. It has saved countless lives and destroyed untold others through carelessness, abuse and neglect. It is “our” NHS, paid for through our taxes, and it is unaccountable, answering only to Whitehall. It is highly equitable and presides over shaming mortality gaps between rich and poor. It “puts patients at the heart” of all it does and ignores people’s voices and rights. It is underfunded and we can no longer afford it. It is impossible to do business with and it is being privatised.
What do these contradictory narratives tell us? That the NHS is not a thing, but a vast, complex and highly variable system. That there is a great plurality of views about it, some ideologically driven, and a tendency for people to overstate their case. That the NHS both reflects, and must straddle, the many divisions and imperfections in our society, politics and public discourse.
All of which makes it hard to strike the right tone in marking its 70th birthday. Some of the celebration, to my personal taste, veers into the self-congratulatory and mawkish.
The NHS fundamentals
I want to celebrate the endurance of the NHS fundamentals: comprehensive healthcare, to all who need it, and free at the point of use. These principles – the legacy of Bevan – while battered and thinning in places, have broadly held up in practice, in public opinion and in cross party consensus. 40 years after the neo-liberal order over-turned the post-war welfarist consensus, and 10 years after the 2008 financial meltdown ushered in austerity, that is quite an accomplishment.
I want to celebrate the dedication, skill and compassion demonstrated day after day by hard working NHS staff (and yes, also social care staff). In a world dominated by the values of the market place, it is testament to the human spirit that hundreds of thousands of people continue to devote themselves to caring, healing and public service.
I want to celebrate the huge difference the NHS has made for so many of us. I would have died at the age of 23 were it not for the NHS. Most of us can tell similar stories about ourselves or our loved ones or people we have known.
How will the NHS survive for another 70 years?
And I want the NHS to survive another 70 years, which means avoiding misty-eyed British exceptionalism. Our funding model may be unique but other countries achieve equitable access to care in different ways. Other countries spend more on health and other countries achieve better outcomes. Other countries have not tolerated the erosion of social care and public health. We may feel good comparing ourselves with the US system, but so can many other countries. As recent think tank analysis has shown, the UK spends a bit less than average on healthcare and achieves slightly worse outcomes than average. We’re not that special and we could be so much better.
So, I want to see the NHS change but not by being locked into an endless spiral of “major transformation”. That never seems to work. What we need is a steady focus on improvement, in the direction urged over many years by us in the voluntary and community sector, and now set out in countless policy commitments.
Let the NHS learn from and build on the best of what it does. Let it work in collaboration and nurture empathetic and collaborative leaders. Let it embed person centred approaches. Let it embrace innovation and technology while retaining and valuing humanity. Let it synthesise “what’s the matter with you?” with “what matters to you?” Let it have quality not cost as its organising principle. Let it get serious about inequality. And let it be sharply accountable to all of us, not just the ministers, for improving health outcomes.
Can we pull that off? Now that would really be worth celebrating.