Monday, September 25, 2023

The NHS at 75: An unhappy birthday

The National Health Service was where Dr Chris Luke cut his teeth

He still has very strong positive feelings about it on its 75th birthday, and its aim to be a model for good patient care, if not for producing a Model-T.

I know I’m ‘a bit late for the party’ but – aside from the fact that there was no party – I really couldn’t let the UK’s National Health Service’s recent 75th birthday go by without at least wishing it a hearty congratulations. In my defence, what ‘celebrations’ there were were subdued, to say the least and – aside from a dignified service in Westminster Abbey – balloons and bunting were scarce.

It’s not hard to see why, with tens of thousands of posts lying vacant throughout the system, 7.5 million people waiting to start routine hospital treatment in May 2023, and hardly a week passing without nigh-unique industrial action by staff at every level and in every corner of the service. And the NHS’s present parlous state is certainly a threat to the sort of ‘cradle-to-grave’ care envisaged by its original visionaries, like the social economist, William Beveridge, the Scottish physician-novelist, A. J. Cronin, and the Labour Party Minister of Health, Aneurin Bevan, who respectively outlined the needs, described the challenges, and delivered a suitable system of care, funded from general taxation and ‘free at the point of use’.

William Beveridge, who worked in Whitehall during the war, published his historically catalytic report in 1942, ‘Social Insurance and Allied Services’.

Famously, Beveridge’s view was that the country had to do battle against what he called ‘the Five Giants: Idleness, Ignorance, Disease, Squalor and Want’, and his report offered a blueprint for social policy in post-war Britain, that was to be delivered by Clement Attlee’s Labour government, which benefited from a widespread and enduring (albeit inaccurate) perception that the Conservatives (under Churchill) were against the plans for a national health and welfare programme.

Dr Archibald J (AJ) Cronin is perhaps the least well-known of the trio, now, but he is arguably as important to the creation of the NHS as anyone, insofar as his world-famous 1937 novel, The Citadel, described in heart-breaking detail the appalling consequences of disease when medical care was unavailable or (often in the pre-war years in Britain and Ireland) unaffordable.

The Citadel is ostensibly about an idealistic young doctor who cares passionately for the working-class people of South Wales, among whom he initially lives, but then drifts away from his youthful principles and is ‘led astray’ into a more mercenary, self-serving existence, punctuated by marital breakdown, charges of professional misconduct, and personal tragedy.

The novel was informed by Cronin’s own work among coal-miners, including with the celebrated Tredegar Medical Aid Society, which is said to have been the actual template for the NHS. In fact, the book contains a devastating critique of the medical profession, ‘its injustices, its hide-bound unscientific stubbornness, its humbug’ (sic), even if the author subsequently explained that ‘I have personally witnessed…the horrors and inequities detailed in the story’ and ‘this is not an attack against individuals, but against a system’.

Sadly, as a medic who spent nearly four decades in this same system, I still recognise much that incensed Cronin. I also recall that Bevan – like so many readers in the USA, Western Europe and the Soviet Union – was greatly affected by The Citadel, and it seems to have inspired his legendary animosity towards the BMA (who vigorously opposed the establishment of the NHS).

Sadly, the best-known explanation as to how the medics were ‘won over’ in 1948 and the NHS birthed, remains Bevan’s most-quoted quip: “I stuffed their mouths with gold” (in short, he let them continue their private practice in so-called ‘pay beds’ in the NHS). Nonetheless, setting aside these remarks, it seems to me – a lifelong devotee of and former hospital consultant in the NHS – that the origins of its current failure were already discernible in the months following July 5, 1948, when Bevan visited Park Hospital in Manchester (now Trafford General Hospital), which later became known as ‘the birthplace of the NHS’ (around 2,500 UK hospitals were nationalised that day).

Bevan has been described as more of a prophet than a politician, and compromise in any conflict seems to have been anathema to him. He was adamant, to the point of fanaticism, perhaps, that all NHS care must always be free, even though, within months of its (difficult) birth, it had become clear to the mandarins in Whitehall that the costs of the new public healthcare were soaring alarmingly.

Moreover, GPs reported that they were being called out to people’s homes in the middle of the night, much more often than in the bad old days, frequently for minor ailments, and regularly found umpteen NHS dentures, spectacles and cough bottles in the house, because there was now no charge for the service or such items.

So, despite his subsequent political beatification, it seems to me that Bevan was being disastrously unreasonable when he resigned in protest at his own government’s proposals to introduce prescription charges for dental and visual care, and its decision to transfer money from the National Insurance Fund to pay for rearmament, after the financially ruinous 1939-1945 war.

Even in its infancy, then, while the NHS was seen as a profoundly welcome alternative to unaffordable medical care, it was politically divisive, the notion that all care and equipment should be provided free at the (ill-defined and arbitrary) point of need was self-evidently economically unsustainable, but politically unarguable, and it gloassed over the sometimes-unhelpful aspects of human nature on both the receiving and providing ends.

And, over the subsequent 75 years, the NHS has had to accommodate car factory ‘management science’, massive demographic and cultural change, countless political and educational experiments, soaring lifestyle illness rates, turbocharged technological developments, endless ‘re-disorganisation’, crumbling buildings, horrible scandals surrounding obstetric and adolescent psychiatric care, a remarkable failure to procure reliable information technology for its employees, Russian hacking, and worsening staff attrition rates, caused by a systemic disregard for their human primal needs. And, equally worryingly, Beveridge’s ‘Five Giants’ are becoming as socially destructive as they were before the welfare state was established, with housing shortages, millions ‘out of the labour market’ and food banks dominating the headlines.

I continue to monitor the well-being of the British health service for several reasons: a nostalgic fondness for a system where I was so passionately ambitious as a young trainee and consultant, admiration for a public service originally predicated on the same values of fairness, compassion and decency that I absorbed as a boy in Dublin in the (truly) ‘rare auld times’, and – most importantly – the knowledge that, while young medics routinely flee these shores for the Antipodes, the template for our public service is still largely the NHS.

But for decades, now, I’ve fretted that the politics, economics and management of healthcare are flawed at a profound level, on both sides of the Irish Sea.

Most egregiously, there often seems to be a perception that hospitals are essentially like car factories, places where efficiencies can always be made, metrics are all-important (‘what you don’t measure’, etc) and where the machines need to be kept running ‘24/7’. And while the currency of healthcare used to be the relationships of care, comradeship and common humanity between people, nowadays, the currency of healthcare seems to be just that: currency (cash, coinage, moolah).

In truth, hospitals and GP surgeries are places where distressed people need other – kindly – people to take the time to find them a seat and a glass of water, to hold their hands, look them in the eyes, and speak warmly and reassuringly.

This takes time, space, water and seats. And it requires an actual understanding of humanity and human needs, which are so very different from the manufacture of cars.

Tragically, I don’t expect the NHS (and even our own public health system) to reach its centenary in good health unless those who run it grasp what the word ‘humane’ really means. But for those who do seek a total reboot of healthcare, here is a wonderful reminder of the primordial guiding tenets of the NHS, provided by the Dean of Westminster, the Very Reverend Dr David Hoyle, who celebrated the 75th anniversary of the National Health Service at Westminster Abbey, on July 5, 2023:

‘We gather in thanksgiving for… the grace and glory that is the NHS. We celebrate 75 years of public witness to the common good. Born of the radical conviction that we must care for one another, the National Health Service sets before us all the better angels of our nature. Here is high principle translated into best practice. Here is the steady dedication of those who, for us, face pain and fear, know life and death, tragedy and near miracle, and return another day to do that again. Here is a courage tested to its limits. Here is a virtuoso capacity for innovation; a dedicated and lively expertise. Here is love made manifest.’

Some may snort at the religious rhetoric. I say, ‘whatevs’; but that’s a manifesto for great healthcare management if ever I heard one.

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