It is inevitable that as the National Health Service (NHS) celebrates its 75th birthday this year, there is likely to be a spate of books on its history, future, critique, etc. Adding to this is a book releasing this week - Conversations about the NHS, which I have had the privilege to develop.
Bookended by a chapter on the past and present of the NHS and its future, published by Routledge, the book contains interviews with 14 stakeholders: four members of the House of Lords, the editor of the Lancet, the past President of the Royal College of Physicians of London, past Chair of National Institute for Health and Care Excellence (NICE), past Chair of British Medical Association (BMA) Council, past Chairs of BMA’s junior doctors committee and trainee psychiatrists, along with representatives from the Patients Association-an organisation which will receive all the royalties of the book.
As we celebrate one of the greatest achievements in this country, it is crucial that we not only look back at its lifetime and its successes but also look at where it has not succeeded and what are the lessons. This ought to help us ensure that it continues to deliver world-class service in the future. Like any 75-year-old individual when we look back at our lifetime, we recognise that there are moments of pride in our achievements, be they personal, social, economic, or political but also of regret of all the things we did not do or we could have done better.
NHS is unique in lots of ways, but it has had to cope with changes in societal demands and expectations coupled with the introduction of inordinate advances in investigations and therapeutic interventions. These in combination with a healthcare system-free at the point of need inevitably have contributed to increased longevity in general, although it has slowed down over the pandemic period. Bambra and Marmot in their evidence to the Covid inquiry chaired by Baroness Hallett noted that austerity imposed on the country since 2010, has had a disproportionate effect on ethnic minorities.
Over the past few decades, medicine has advanced in technology and therapeutic interventions from antibiotics to MRI scans, precision medicine and genomics, NHS has tried to keep pace, but has it always succeeded?
Society too has changed dramatically leading to changing patient and social expectations of healthcare. So if we were establishing NHS today, would we do it in the same way? Probably not. And if we were starting now, what would we do differently? If we look back at Beveridge's five giants: want, disease, ignorance, squalor, and idleness, none of these have been totally eliminated. Homelessness is increasing as is poverty and consequent squalor. Rates of childhood poverty have gone up. Another area that needs building up is social justice and equity of access. In addition, the capability to be healthy needs to be recognised and built up.
It involves individual, family, community, and national level interventions, with clear messages on education and information. Healthcare needs and demands rights but equally importantly these come with individual, family, and community responsibilities. There needs to be an open discussion and exploration of these ideas to make sure that the NHS is fit for purpose.
NHS has done wonders in increasing the longevity of the population but this brings with it certain challenges. It has helped people live longer who are likely to have multiple complex co-morbidities. This in turn raises issues of care whether it should be provided by generalists or specialists and other issues of demand and supply. Demand for healthcare has been increasing exponentially whereas resources have not caught up with it. However, resources are only one albeit an important factor.
For a considerable period of time, health has been seen in isolation whereas it should be linked with education, employment, housing, justice as well as social determinants. An awareness of and preparation to manage geopolitical determinants must be borne in mind. The lessons for the NHS must include interlinking from parental learning about child rearing and development to elimination of poverty, overcrowding, and unemployment will contribute to better health. Public health needs to be an integral part of the NHS. Between the capability to be healthy and inclusive nature of social justice and equity and inclusive public health, the NHS needs to think outside the box. It needs to engage with communities, community organisations, faith leaders, teachers, and others depending upon local needs.
Working with the possibility that there are likely changes in the workforce, the arrival of AI, newer grades such as specialist nurses and associate physicians, and pressure on generalists in primary care versus specialists in secondary and tertiary care, any future vision needs to take these into account. Rights versus responsibilities especially in the context of the capability to be healthy are important aspects of healthcare which require an open debate and discussion. In Conversations about the NHS, all the stakeholders see similar problems: lack of workforce planning, lack of integration of social care and healthcare, challenges faced by primary care, etc, however, there are some innovative solutions.
Lord Crisp highlights that by the time people get to the NHS, it may well be too late so he proposes health creation. This means that public health and health (physical and mental) need to be linked together. The past Chair of the BMA Council suggests that NHS should be run by an independent board on the lines of the Board of Bank of England. Two past chairs of Junior Doctors Committee (Rajiv Wijesuriya and Sarah Hallett) also suggest that integration between health and social care and workforce planning is crucial.
Lord Alderdice, a medical psychotherapist, suggests that integration of social and health care with a focus on responsibility to be shared across the community. Sir Ian Gilmore echoes that there needs to be community responsibilities as well. Sir David Haslam emphasises that medicine should be done with the patients and simply not to them. Richard Horton notes that model of primary care and secondary care set at the time of the establishment worked at that time but no longer does so. He proposes that we may need to consider community settings where generalists and specialists come together. A similar point is made by Baroness Meacher. Baroness Neuberger also emphasises that health needs to be integrated and not seen in silos.
Two trainee psychiatrists Max Pemberton (who is also a columnist for Daily Mail) recommends a merger of physical and mental health whereas Daniel Poulter (also a Conservative MP) proposes that education about health is a must from an early stage. Rachel Power from the Patients Association recommends joint decision-making with the patients. Lucy Watson (previous Chair of Patients Association) suggests using retired individuals to support information sharing and supporting the staff.
The book is out later this month and hopefully will generate interest and debate on individual, community, and governmental responsibilities on the one hand and healthcare workforce expectations and medicine’s social contract on the other.
Discount is available on the purchase of the book. If you go to this website and look at the discount code, it will give you 20% off - https://www.patients-association.org.uk/news/professor-dinesh-bhugra-gives-royalties-from-latest-book-to-the-patients-association