Seeing and hearing: reflections on how the NHS has changed

Our Senior Fellow Helen Buckingham looks back at the lessons learnt from 25 years working in the NHS.

Blog post

Published: 04/05/2017

“What you see and hear depends a good deal on where you are standing; it also depends on what sort of a person you are.”

C S Lewis

What does a career NHS manager such as myself see and hear from where I stand in April 2017? And what sort of a person am I? Interesting questions on which to reflect as I start a year’s secondment to the Nuffield Trust, marking my 25th year in the NHS.

A career including 15 jobs and seven reorganisations (the number of jobs not unrelated to the number of reorganisations) mean that I have stood in quite a few different places over the years. I’ve worked in health authorities, NHS trusts, PCTs, an SHA, national bodies and now a think tank. I’ve held almost every executive portfolio on the board not requiring a clinical qualification – finance director, strategy director, Deputy CEO and CEO. I’ve led estates, information and IT; HR, OD and communications teams; and worked alongside colleagues in local government, in Whitehall, and in the independent and voluntary sectors.  

What have I seen and heard?

For a start, quite a shift in resources. 25 years ago in 1992, the NHS budget was roughly half of what it is now. But expectations have risen with the funding. I remember my first ‘purchasing plan’ round (the catchphrases and acronyms have changed over the years too) when I was negotiating contracts with trusts in the context of a maximum two-year wait for inpatient treatment – and that came after the maximum six-month wait to be seen in outpatients. Even the current ‘easing’ of focus on the constitutional standards for elective care is unlikely to take us back to those days.

Over the last couple of years in particular, we’ve seen a real shift in focus on mental health alongside physical health. Having stood on various platforms to describe a vision for a time when it would be just as OK to talk about mental ill health as it is now to talk about cancer (another disease which used to carry a stigma), it’s heartening to think that although we may not be quite there yet, that day is definitely coming.

There’s been a shift, although it’s not yet sufficient, in how the NHS works with patients and the wider public – and indeed with our own staff – on making decisions about the way in which services are run, and how they can develop and change. Current structures give us huge potential to be able to do this well and better: for example with local Healthwatch bodies; with FT governors; with local authority partnerships; with patient directors.

Yet too often NHS culture and practice still seems to regard ‘consultation’ as a hurdle to be jumped. The system overall is yet to truly see organisations and systems embracing the views of their communities as assets able to help to drive the changes we all want to see. We need our communities’ participation to help us think about how to make best use of the resources which, despite the huge growth, continue to feel all too limited.   

Tribalism remains too prevalent. We use words like ‘system leadership’, ‘partnership’ and ‘integration’, but all too often we use those words on our own terms. Whichever part of the system we define as ‘us’, we talk differently about ‘them’ when ‘they’ aren’t in the room. That applies at lots of different levels – between organisations in a local system; between the NHS and non-NHS organisations; between local and national bodies; between different professional groups.

This is of course completely normal human behaviour. But unless we call it out, and work on it, it will continue to get in the way.

On the positive side, there hasn’t been a single day when I haven’t seen individuals in the NHS, whatever their clinical or non-clinical roles, completely committed to making things better for patients, and showing that in a million small and not-so-small ways.

Despite some undoubted failings in care over the last 25 years, the values of the NHS are alive and well: they will keep us going through the tough times.

What sort of a person am I now, 25 years on?

A bit more experienced than as a new graduate trainee coming straight from university into the service. Like most people, the service has knocked me around and bruised me a bit over the years.

Yet I’ve been able to take advantage of some amazing opportunities, and learn from some of the best leaders in the world. I’ve been through the very scary moment when I realised that people were looking to learn from me, as well.

If anything, my passion for the NHS, and what it represents, has grown over the years.

The Constitution sums it up: “The NHS belongs to the people. It is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most.”

Despite all the challenges, I can’t think of a place I’d rather be.

A version of this article was first published in the Health Service Journal on the 28 April 2017.

Suggested citation

Buckingham H (2017) 'Seeing and hearing: reflections on how the NHS has changed'. Nuffield Trust comment. 4 May 2017.