NHS @ 65: tender, fragile, fragmented, strained, vulnerable

Blog post

Published: 04/07/2013

Tender, fragile, fragmented, strained, vulnerable. In disarray. At a cross-roads. These are just some of the words used by key contributors to the Nuffield Trust’s latest publication: The wisdom of the crowd: 65 views of the NHS at 65.

The service has never been particularly good at celebrating its big anniversaries. The tenth, in 1958, was pretty much all sweetness and light. But most of the others – from the 20th through to the 50th – were overshadowed by one crisis or another, by a sense of foreboding, or by both.

By contrast, the 60th, back in 2008, when the Trust published: Rejuvenate or retire? felt pretty good. Sure, all the questions about long-term sustainability – an issue over which the service has repeatedly seen off the sceptics and indeed has outlived many of them – were still knocking around. Hence the publication’s title.

But waiting times were tumbling and satisfaction with the service was rising towards record levels. Clinical outcomes in some areas were still not good by international standards. But overall the service felt better than it had done in decades.

The $64,000 question that emerges from this publication is can the NHS achieve in a period of prolonged austerity what it failed to do enough of in times of plenty?

The big question was whether it had achieved enough with all the extra money that had been pouring in since the start of the decade. The general view, even then, was ‘not enough’. Too much, for example, had gone into higher pay, and not enough had been used to reconfigure for the 21st century, the way the NHS works.

That view, this time round, and with the benefit of hindsight, is much stronger.

‘We missed the best opportunity in the history of the NHS to actually reform it…we just threw money at it,’ as Lord Darzi, the former Labour health minister, puts it in this publication.

Or as Sir David Nicholson, chief executive of NHS England concedes, the extra money ‘allowed us to subsidise poor care when we shouldn’t have done.’

Or as Mike Farrar, chief executive of the NHS Confederation puts it: ‘did we do enough? … I don’t think we did … so now we are having to do it without the money.’

There is, however, a remarkable consensus in the views expressed in The wisdom of the crowd about what the ‘it’ is.

A formula emerges that what the NHS needs is: more specialised care in fewer specialist centres; a smaller hospital base; more surgical ‘factories’ for elective operations on lower risk patients; much more care at home or closer to home; patients more empowered to take control of their own care; much closer integration of health and social care; and far greater transparency on clinical outcomes and patient satisfaction to help drive all that.

This is now so much the conventional wisdom that one almost wonders whether it should be questioned. The key issue, however, seems to be how to get there – and how can the policy and operational communities persuade the political class, the public, the staff, and dissenting clinicians that this is indeed the correct vision for the future.

Given that most of the contributions to this were being put together as the terrible beauty of Andrew Lansley’s reforms were lurching into life, all that is compounded by a huge sense of uncertainty about precisely how the new dispensation is going to work in practice – as opposed to the theory of the perfectly incentivised clockwork universe that the former health secretary devised.

Which helps explain all those adjectives about tender, fragile, at a cross roads, vulnerable and challenged which litter these contributions.

That, and, of course, the money. As Liam Byrne, Labour’s most recent chief secretary to the Treasury, famously put it: ‘there is no money.’ And no likely prospect of significant real terms for growth for some years to come.

So the $64,000 question that emerges from this publication is can the NHS achieve in a period of prolonged austerity what it failed to do enough of in times of plenty? Can it use the massive sums it currently spends – some £120 billion on health and social care combined – in a much better way? Views on whether it can, as you will discover if you read this report, are deeply divided.

But the answer to that question is likely to decide how happily, if at all, the NHS celebrates its 70th and 75th anniversaries – and how far it manages to cling yet again to its founding principles of a pretty comprehensive, pretty equitable, tax funded service, delivered largely free at the point of use, with treatment and access dependent on need, not on ability to pay.

Intriguingly, Scotland has also done a 65@65. Sixty five views from patients whose lives, in the words of the Scottish Government’s press release ‘have been transformed by the NHS.’

It is an almost undiluted paean of praise, not just to the service, but to – and I quote – ‘the dedicated and selfless staff that nursed them back to health.’ You would think that health care north of the border has no problems.

Somewhere between the official Scots view and the English tendency for self-flagellation over any and every failure must lie a realistic medium. A sensible one – if not one that will always be happy.

Nicholas Timmins is a Senior Associate at the Nuffield Trust. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.

This is an extract from Nicholas Timmins overview to the Nuffield Trust publication: The wisdom of the crowd: 65 views of the NHS at 65, which he edited. The collection of essays, supported by PwC and media partner the Health Service Journal was published on Thursday 4 July 2013.

Suggested citation

Timmins N (2013) ‘NHS @ 65: tender, fragile, fragmented, strained, vulnerable’. Nuffield Trust comment, 4 July 2013. https://www.nuffieldtrust.org.uk/news-item/nhs-at-65-tender-fragile-fragmented-strained-vulnerable