Reflections on the future of the NHS

Dr Zoe Wyrko, Associate Medical Director and Consultant Physician at University Hospital Birmingham, reflects on the NHS reaching a healthy 100th birthday.

The room was divided. The clinicians, many of whom were familiar with the pressure points of the NHS such as intensive care, acute medicine and general practice were finding it hard to see any glimmer of hope for the future on the back of ‘winter,’ present for the last 18 months and which had seen corridor queues returning to levels last seen at the end of the 20th century.

Others, perhaps less battle-scarred and often a step or two removed from front-line practice were either more pragmatic, or possibly just optimistic, and had the opinion that things could still be ok in 30 years’ time. The question?  “What are the prospects of the NHS reaching a healthy 100th birthday?” The first lecture in a series arranged by the Centre for Health and Social Care Leadership at Birmingham University, and delivered by Dr Jennifer Dixon, Chief Executive of the Health Foundation.

In a time when it is increasingly easy to exist within an echo chamber of our own beliefs and values, the presentation of irrefutable facts together with alternative ways of looking at that evidence should be welcomed, and gives food for thought for some time afterwards.  Recent British Social Attitudes surveys have shown that there is continuing solid public support for the NHS, although it is somewhat worrying to see the ‘very or quite satisfied’ and ‘very or quite dissatisfied’ lines beginning to converge again after over a decade moving apart. Also of little surprise is the consistent opinion that health and education should be the top two priorities for government spending, and the top reasons for satisfaction with the NHS among the population are primarily the quality of NHS care closely followed by the fact that it is (on the whole) free at the point of use.

However, we get what we pay for, and while health has gained an increasing share of government spending over the past few generations, spending as a proportion of GDP is lower than in many other European countries. This middling spending is reflected by middling to poor performance. As a nation, our adults and children are obese and our life expectancy, particularly for women is poor when compared with 14 other European peers. Mortality from cardiovascular disease is high, as are the numbers of hospital admissions for diabetes. Is the real reason that our population is satisfied with the NHS simply that most people have no experience of any other system to compare it to?

And do we all see the NHS in the same way? The realistic answer is that we probably don’t. Jennifer Dixon went on to discuss the concept that the NHS can be considered through four different lenses – government, management, clinicians and science, and public and patients - each one with a slightly different timeline of key events. The government took a relatively hands-off approach for the first 25 years following the establishment of the NHS, but the subsequent cycles of introduction then abolition of varied management structures together with targets, regulation and performance management certainly seemed to make up for this. Health service management has followed the government’s whims, moving from administration, through consensus management in the 1970s into a structure more familiar to the modern NHS from the 1980s onwards. The substantial impact of the 2012 reforms are still being felt, she asserted, even as these reforms seem to be being gradually reversed.

Clinicians were drawn into management, and thus a degree of wider responsibility for the service, from the 1980s onwards. There had been GP fundholding, followed by primary care trusts, and then clinical commissioning groups. The past three decades have also seen health scandals including Shipman and Mid-Staffs with subsequent impacts on both legislation and practice, together with increasing sub-specialisation throughout primary and secondary care. The final lens of public and patients (which we should all remember to look through even when we also belong to one of the other groups) is still not a strong force, despite attempts to remedy this in recent years with bodies such as HealthWatch, and structures including Overview and Scrutiny committees.

Presented in this way, I could see why progress within the NHS can be bone-achingly slow, and repetitive cycles seem to accelerate. These lenses seem to cause divergence rather than convergence, and perhaps I can see why and how the ‘them and us’ culture that occurs between the different groups (as well as within them) has occurred. Add to this the principles recently published by Caroline Tuohy, stating that scale and pace of change is a matter of political strategy at the centre of government, and that policy change is held within the logic of the existing policy framework, it is almost surprising that developments ever happen.

So what of the future? Jennifer concluded by highlighting that ageing, multiple morbidity and inequality are all increasing and cannot be ignored. But there is real potential for the patient and public lens to sharpen and become stronger through technology and social media. And how is the medical profession going to change to accommodate advances related to artificial intelligence becoming incorporated into healthcare? The ground is moving fast, what of those people and structures who aren’t able to (or don’t wish to) keep up? Her final point was that up until now, the long-term has been consistently ignored in the NHS, but how much longer can this be continued for before problems occur? To conclude, the vote was repeated. And the room was more pessimistic than at the beginning, although undoubtedly better informed!

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