As the NHS turns 70 there are many triumphs to celebrate. In the fight against the UK’s biggest killer, cardiovascular disease, drugs and technology along with the logistical expertise to deliver them have brought big gains in life expectancy. Survival for most cancers has improved remarkably. Access to anti-retroviral drugs mean that people diagnosed with HIV today can expect an almost normal life expectancy. Comprehensive vaccination spares almost all infants the infectious diseases of Bevan’s day while with the NHS has widened access to compassionate and effective care at the end of life that is world-leading.
Orthodoxy has it that the NHS is peculiarly troubled because it was made for a ‘different time’. Some legacies are admittedly idiosyncratic, notably the chasm between health and social care. Many other problems like inflating costs, the huge amounts of spending wasted on ineffective treatments and disturbingly high rates of patient harm are features of every modern healthcare system. In fact the NHS’s infrastructure of evidence-based guidance, cost control and regulation has meant it has remained safer and much more efficient than most. The feat of almost keeping pace with lavish systems is testament both to the resilience of this model of healthcare and the deep motivation staff draw from the NHS ethos.
Sadly the survival of the NHS to its centenary is by no means a given. Right now, the staffing crisis is probably the biggest single problem, while the potential public health catastrophe threatened by Brexit dwarfs Theresa May’s welcome but already inadequate promise of an additional £20bn in funding. Meanwhile the cliché of ‘unsustainability’ has become so widespread that scepticism about the feasibility of universal coverage is now commonplace. Our sometimes sentimental fondness for the health service tends to obscure the hardnosed economic case that remains for comprehensive healthcare funded through tax.
As critics of the NHS rightly point out we have huge problems in health. Our record on cancer survival and childhood mortality is mediocre by Western European standards but probably reflects profound social inequalities which a healthcare system alone cannot reverse. In fact, for all the successes of modern healthcare, the contribution of medicine to longevity has only ever been modest, compared to improvements in public health. Indisputably, the NHS (along with every other healthcare system) must be improved but more importantly we desperately need a health policy that is much more ambitious than simply providing healthcare.
The necessity of ‘prevention’ gets a lot of lip service but policy makers almost always call for relatively ineffective individual level interventions or overpromise on technology. GPs recommending weight loss or prescribing more tablets for blood pressure and controlling diabetes will help a few, but these are expensive and inadequate measures that cannot undo the damage caused by our toxic and obesogenic environment. Heart disease, stroke, diabetes and cancer are diseases with political as well as medical solutions. Infirmity and loneliness are not actually inevitable consequences of ageing so we need to build a society that allows people to remain healthy and independent into old age instead of hand-wringing about a ‘demographic time bomb’ that has already gone off.
When Labour comes to office, our health perspective needs to broaden to reflect the scale of these challenges. A commitment to narrowing inequalities in health should become explicit across diverse briefs like housing, transport, local government, education and the treasury. Investment in health is not a sunk cost and there are vital positive reasons to face up to the task. These include the synergies to be struck with environmental policy, for example through promoting clean air and active transport and the self-evident economic case for adding countless productive years of life to our society.
In managing the NHS itself, history demonstrates that ambitious top-down reforms, from both Labour and Conservative governments, are disruptive, costly and do not produce the desired improvements. Healthcare is the most complex system that there is and improving performance depends on constantly enhancing the multitude of small inter-relating parts that make up the entire service. Secretaries of state can be most effective when they provide long-term planning and align with staff to promote priorities in clinical quality and patient safety.
The space to institute that long term organisation depends on levelling with the public about the costs of healthcare and leading the debate on how much we are prepared to spend. While this might not sound radical, evasion about NHS financing has become so entrenched that dishonesty about both NHS funding and its deficit has become routine. Honesty about tough spending choices will take courage but the misery brought by endless fudges is now so clear that the public are ready to back forthright leadership.
Our NHS is a miracle of compassion and ingenuity that we should rightly celebrate and protect. We owe it to everyone who will depend on the NHS to be honest about how much quality healthcare costs and to fight for the long-term stability the system needs. But the next Labour government must also recognise that healthcare is no substitute for health and deliver a truly radical, population-based health policy.
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