I believe that we as people do in fact make our collective history, but we cannot choose the ideas, culture and institutions with which we start. My choice of title merges two aspects of our lives, agency – the fact we have the ability to make things happen; and constraint the structures around us that limit what we can do. Over time – together- we can change those constraints – but here and now they limit us.
For me it also describes where the NHS is now.
The fact that the NHS is at the centre of our lives in this coronavirus crisis is an intensification of the relationship that we have had for many years.
The deep affection that British people have for their NHS has always been one of the most important aspects that define who we are as a country. The very moving sight of millions of us clapping to show our support and love for the NHS on March 26 was the most recent manifestation of that affection.
This public feeling of deep affection will now be accompanied by an open public accountability which in the past has been lacking.
At the moment, and for the coming weeks the NHS will genuinely be making history. It will do so under the intense gaze of a society that is both very grateful and full of anxiety. Today and in the next few weeks high anxiety will lead us to watch the TV every night for news of what in the past have been internal and very boring structures and decisions. This public feeling of deep affection will now be accompanied by an open public accountability which in the past has been lacking.
In the past few weeks I have had tens of texts from friends outside the NHS asking me why this or that happens and why this doesn’t, and have had to explain to people what a CCG is, what a Community Trust is, and why – for decades – the relationship with social care has been so very poor. None of these people were particularly interested in NHS and its weird structures before, and the NHS has not been very interested in explaining very much about heath care to the public.
For the past 70 years the public and the NHS have settled into a relationship which might be characterised as – “You the NHS look after our health, and we the people will not only pay you for it but will also love you for it. At every election and referenda we will make you the most important issue and we will ask governments to give you more money than any other service.
Now get on with looking after our health”
This has generally been a good relationship.
In terms of people’s health care one side, the NHS, owns the issue and the other side the public, give money and respect to those that own it.
But over the last few years there has been a growing recognition of the problems this causes. Most NHS Integrated Care System plans start by saying that we need a different relationship with the public – that the NHS needs the public to be much more involved with their health and health care.
The NHS needs a different relationship with the public to reduce demand for NHS provided health care. The public increasingly grumble that clinicians need to let them understand a bit more of the ‘mystery’ about the conditions that they have so they can be more involved.
But by and large the day-to-day experience of the model has stayed the same.
So we enter this crisis in a relationship where the NHS owns our health care and the public pay for and love the NHS (who own their health care).
Within a few days of the crisis hitting that starts to change. Given the level of infections that we know are coming – the NHS cannot cope and needs the public to do something. The NHS needs the public – all of them and very frequently – to wash their hands. Not only to wash their hands but also to wash them with an intensity that they have not done before. We have to take some responsibility for our own health care by doing something several times a day.
If the public knew about more about health care and about how the foam from soap cuts through the fat around the virus and renders it harmless, more people would have understood why they were doing what they were doing. But that kind of medical knowledge has not been owned by the public but by clinicians.
A few days later we are told to stay 2 metres apart and, for some of us, not to go out at all. Like hand-washing that feels like common sense, but how many people who are now being told to do it understand very much about infection?
Just as with hand washing the media are carrying out an excellent education programme but it’s new and has not been happening for the 70 years before this crisis.
This crisis shows that the NHS needs the public – all of them – to play a much bigger role in taking care of their own health. The reality is that we (and not GPs) are our own primary health carers (in the sense of being our own first responders). The NHS needs most people to take on this responsibility.
Now – in the midst of a crisis when we need an informed public – how much easier it might be if the relationship between the NHS and public health care had been more interactive for the last 70 years?
Along with so many others it’s now very likely that relationship will change forever.
But as things stand today, one of the constraints within which the NHS is making history is that the public don’t feel they have much of a role in their own health care.
In this new age of infection, nations with a public that understands the science of infection will fare much better than those where only a few possess such knowledge.
 “Men make their own history but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already , given and transmitted from the past.” Karl Marx the 18th Brumaire of Louis Bonaparte Chapter 1.