So here we are at 70 (me and the NHS that is) and we have come to a crucial moment in recreating the contract between the English people and their NHS.
There seems to be clear evidence that the public want the Government to take more of their money in tax to pay for their NHS, and in the next few months it looks like they might well do just that. But never forget that this isn’t the Government ‘giving the NHS more money’ it’s the people themselves who will have to find some extra cash from their often very limited financial resources – and it seems they are willing to do this.
This is remarkable.
Given how unpopular tax is when taken from people’s wallets and bank accounts the fact that English people want to pay more of it to the NHS signals how strongly the majority of people feel about their health service. Their love for the NHS goes beyond its importance to them as a health care system that they can depend upon without recourse to their own resources; they love the NHS as a set of economic and social relationships that has all of us looking after each other through the endeavour that is bought and organised with those taxes. This 70 year contract has endured well and most people want it to thrive for another 70 years.
But for NHS health and local government social care to thrive, it doesn’t just need more public money (which it does), it needs a lot of public help as well.
Back in 1948 – when we were a war-ravaged nation with bomb sites at the end of many urban streets and with harsh rationing limiting the opportunities of the population, it was the people who found the money for the NHS. The war had just been won through a combination of state organisation and individual sacrifice and endeavour. The state organised things and the people carried them out, with great effect.
This looked like an unstoppable way of organising housing, education, welfare and health. By the early 1950s even a Conservative government were building 300,000 council houses a year, schools were being built and staffed to provide new educational opportunities and the NHS had nationalised the nation’s hospitals and developed and paid for a primary care system delivered by GPs running their own small businesses.
The contract was straightforward – the public pays and the state organises and delivers services.
For the NHS this organisational relationship – the public pays and the state organises – synchronised with the way in which medicine as a practice organised itself: the body of science that informed and developed medicine was owned and established by academic doctors and brought to the consulting room by doctors; the patients received that knowledge through the practice of the doctors.
As the post war decades rolled on this structure of people/state/public service relationships began to corrode. True, throughout the 50s, 60s and 70s the state could build lots of houses and flats, but it took people, active people, to turn those cold buildings into homes. Schools could be built and teachers trained and employed but if pupils and their parents did not become actively involved with education very little happened. The state could make an offer of educational opportunity, but since the 1967 Plowden Report it has been recognised that the more active the motivation from pupils and parents, then the more educational opportunity flowered.
State offers just don’t work as well without active, empowered people.
The problem with the state/people relationship in NHS health care has been longer in developing and has come to a head during the past decade. It is now clear that the average NHS patient is one of millions of people with more than one co-morbidities caused by their long term conditions. Very few of them will ever be ‘cured’.
When you work with younger people with complex needs, or with older people with co-morbidities, it’s pretty clear from the outset that the NHS and social care can’t really solve their health care needs. For these people the medical care provided by the NHS is a vital part of improving their lives, but it is not the total answer.
Intellectually everyone can agree that the background causes of the problems for those with complex needs or older people with co-morbidities goes beyond the issues that medicine alone can solve. Everyone – clinicians, health care managers, social care organisers, members of the public and their carers – knows this.
But the expectation of both clinicians and the public is that the NHS will make them better. Back in the much simpler days of 1948 this compact between public and health service looked possible.
I pay my taxes → the government organises NHS care → the NHS makes me better.
A lot has changed since then. The nature of ageing, illness and the complexity of need are now asking different and more complex questions of our health service. Much of the NHS tries to keep to the original contract and many of the public expects it to continue to work that way.
But practically we now know that this doesn’t work – and this is not simply saying ‘individuals should do more to look after their health’ – it’s saying that the whole of society needs to work with the NHS to do this. Conversely the NHS (and medicine) must learn how to work with the wider society to improve people’s lives.
It is this area of argument, policy and practice which has led me back to blogging. I have come across hundreds of real-life examples of how the NHS seeks out and works with diverse sectors of society to improve the health of the sick. I am hopeful that these can be woven into an argument for change – an argument also being developed by many others.