As the NHS turns 70, it’s time to get serious about transformation

Source: NHE July/August 2018

Matthew Macnair-Smith, membership and policy manager at NHS Confederation, takes a look back at the last 70 years of the NHS and argues that it’s now time we get serious about transformation.

Famously, Lord Lawson described the NHS as “the closest thing the English have to a religion.” And in its 70th year, all the opinion polls suggest that it consistently tops the pile for things that Britons are most proud of. 

Today’s NHS bears little resemblance to what it looked like on 5 July 1948. As well as the vast array of new treatments and the scale of its activities, the gender ratio and ethnic diversity of its workforce is also hugely different. But what has remained intact is its founding principle – that the NHS should be available to all, free at the point of use.

To understand how important this principle is, it’s useful to look back at what healthcare looked like before 1948. 

At Confed18, our annual conference – which took place in Manchester, the birthplace of the NHS – a retired nurse told us that people today didn’t realise how lucky they were. She lamented the way in which affording medical care had previously been a source of real worry to many families and patients. Thankfully, out of the devastation of the Second World War came an agreement that something had to be done. 

The answer came in the form of a state-funded National Health Service – a key strand of the 1945 Attlee government’s post-war reconstruction. It wasn’t without controversy, with many arguing against it, but it was eventually pushed through.

In the early days the NHS expanded rapidly, with new hospitals springing up across the country. However, it wasn’t until 1974 that the NHS got its first full-scale reorganisation, with the intention of bringing about population-based funding and bringing together hospital and community services and the public health function. 

Then, in the 1990s, the system we see today started to really take shape, with the internal market being created, which meant authorities managed budgets and bought healthcare. The first NHS trusts were also established. In 2012 we saw a further reorganisation which brought in clinical commissioning, NHS England, and an array of new system architecture. 

Fast-forward to 2018 and we are now in the midst of attempting another reorganisation. But this time, it’s one that is quite different from its predecessors. This time, there is no legislation to mandate a particular form of change or achieve consistency and uniformity. This new reorganisation demands different ways of working for many clinical and project staff, and a different mindset from leaders. 

It requires the sacrifice of organisational identity for the interest of building services around patients. It challenges the current transactional basis of the split between purchaser and provider. It envisages not only changes in organisational form, but new ways of organising care and treatment. Its ambition is to eliminate, or at least significantly reduce, divisions – many of which have blighted the system since its founding.

These changes are being attempted at a time when the challenges facing the NHS are enormous. This last winter highlighted this all too well. Stats which showed the worst performance against a range of targets since records began, overwhelming workforce challenges, and the uncertainties of Brexit also continue to dog the NHS.

The report we commissioned from the Institute of Fiscal Studies and the Health Foundation concluded that, without major changes, meeting the needs of a growing and ageing population would require hospital activity to increase by around 40% over the next 15 years. 

With news of a 3.4% annual funding boost for NHS England, attention is turning to how this money should be spent. Some leaders see this as a chance to pay off deficits accrued over a particularly challenging two years, which remains a priority. However, without a properly funded reorganisation of the system, it will continue staggering from one crisis to the next. 

Public understanding of transformation has been limited, with concerns over local service closures and privatisation dominating the headlines. The opportunity to create a truly integrated system with clear pathways for patients should be the top priority, and gaining public support for this will be essential in the coming years. 

Now that we have the money, it’s time to get serious about transformation.

Top image c. University of Liverpool


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