Last week I was discussing the way in which the structure of the NHS now removes its long-term plan from politics and politicians. The wider social and political narratives of the role of the NHS in society are now, in some way, missing from the meaning of the plan.
I closed that sequence of posts by talking a bit about how the NHS has a role to play in bringing ‘left behind’ elements of society back into contact.
Last week I asked a psychiatrist friend how he viewed the nation’s current fractured state brought about by Brexit. He, like many others, argues that the fixation on Brexit is caused by a desire not to have to think about the basic causes of the schisms and splits in our society. We fixate on this thing that appears to be that which that divides us because we don’t don’t to spend any time having to deal with the real causes of our disagreement and dislike of each other
(None of this is saying that leaving the EU is not of historical importance in its own right, but it’s now clear that regardless of whether we stay or go our society is in a fractured and dangerous state. In or out we will have to spend a lot of time and resource in getting back together as a society).
He is not alone in thinking that many of the 17.4 million who voted to leave were very angry at being left behind the rest of us. With the referendum, they had an opportunity to say something about that – and they used it. (This is not to say that those people didn’t passionately want to leave, but to recognise that many of them have not shared the opportunities that others of us have had).
I think that healing this division has a lot to do with the possibilities and responsibilities of the NHS long-term plan. It’s true that some rural well-off areas voted to leave the EU. But it’s also the case that the poorest northern (and many midland and southern) towns and cities voted to leave and by any measure of inequality have been ‘left behind’.
Statistics about health and healthcare inequality form part of these wider inequalities. The NHS has had trouble reaching out to some parts of the country and has failed to have the same impact on healthcare outcomes in these locations as it has in others.
And one of the many good things about the plan is that it recognises the importance of these inequalities.
To take an example. Given the inequalities that exist between cancer survival rates in different areas we will not be able to achieve the improvement in national rates unless there is dramatic improvement in those areas that are left behind.
This is true of nearly all the broad long-term plan targets. In the next 10 years the NHS needs to do MUCH better in many of the left behind areas than it has in the past.
So, isn’t that enough for these left behind areas?
No not really, because the problem for those who experience being left behind is that the state – in all its many and varied relationships with them – has usually done things to them rather than with them.
And this is the issue in all public service relationships with people who have been left behind – they are done to rather than worked with.
For the NHS long-term plan the crux of the matter is that if it continues to do to people who have been suffering inequalities of health, it will fail. Let me remind you of the example I gave last year of improving cancer survival outcomes in the poorer areas of our society. Outcomes are worse here because of late presentation and late diagnosis. The NHS might, by doing things to people, on its own be able to do a bit about late diagnosis but it will not be able to do anything about late presentation without fully involving a population that feels (because it has been) left behind.
This is a point that I and others have raised for the last 6 months. But here I want to frame this not just in terms of inequalities but in the terms of the significant parts of our society that have been left behind.
I think the NHS has a responsibility to do something about it.
I think the NHS long-term plan, being the only example of large long-term increases in public expenditure for the next few years, has even more of a responsibility to do something about it.
Let me give you an opening paragraph of what a frame with this approach might have said in any introduction of the long-term plan.
Many people refer to the NHS using the possessive pronoun ‘our’. We talk of OUR NHS. And indeed across the country much of the population feel ownership of this national institution. Given that so many in our society now feel separated from the opportunities that others have and given that the statistics of inequalities in health outcomes are now so stark, the long-term plan will work with the sense of belonging that the NHS provides to ensure that those who, at present, feel left behind feel more included. The NHS will not only work hard to reduce health inequalities but will work hard to involve people in making progress to better health. We will do this in their communities and with them as individuals. We will reinforce their sense of ownership of the NHS by making sure that within the next 10 years it really does become theirs.
And in doing so make more of society theirs too.