Principles Under Pressure as NHS celebrates its 73rd Birthday

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By Professor Martin Powell, Health and Social Policy
Health Services Management Centre, University of Birmingham.

NHS birthdays have always had a different character. While the 10th birthday in 1958 was largely optimistic and celebratory, the 30th (1978) and 70th (2018) were pessimistic, amid talk of crisis.

The 73rd birthday of the NHS on 5th July is different again, being both optimistic and pessimistic. There are reasons to be cheerful. The NHS was not overwhelmed by Covid-19, as some feared. Battered but not bowed, it stood firm against its biggest challenge since its formation. Moreover, ‘necessity was the mother of invention’. Like global vaccine development, the NHS worked at pace to change the ways in which it worked.

However, there is no doubting that, as on its previous birthday, the NHS is feeling exhausted. After some 15 months battling the Pandemic, NHS staff are clearly burnt out. The NHS seems to be like Narnia: always winter (how trivial in comparison the old ‘winter crises’ appeared to be) and never Christmas (1% pay increase, and paying again for car parking). Even when we ‘learn to live with Covid’ with low numbers of Covid patients in hospital, staff will need to rally themselves to face the enormous backlog of cases, with hugely increased waiting lists.

There has been discussion about whether the NHS has been faithful to its principles throughout its 73 years. However, these principles have never been clearly and unambiguously set out, resulting in very different interpretations of them. Nevertheless, in simple terms, the main principles can be seen in terms of:

  • being free at the point of care
  • universal (covering everybody)
  • comprehensive (covering every treatment)
  • being equitable or fair.

The first three have been largely achieved. While there are charges for some in the NHS, such as for prescriptions, dental and optical treatment that were introduced many years ago, high cost elements such as hospital stays remain free. The NHS covers the vast majority of the population, regardless of any taxation or insurance payments. It covers most treatments, but some drugs are not covered by the NHS, as they are deemed not to be cost-effective. Moreover, some go private as they are unable to find NHS dentists.

It can perhaps be argued that the equity and fairness principle has been most problematic. This is because it covers so many dimensions (such as geography, age, gender, class, race or ethnicity etc). Moreover, the roots of health inequality come from an unequal society, and the NHS has to deal with the health consequences of issues such as poverty, unemployment and pollution. So, while the NHS cannot be held responsible for the unequal health of the nation, it still asks itself whether it does all it can to achieve more equitable outcomes. For example, in addition to age, there also seemed to be clear morality gradients in terms of class and race. The most shocking face of this was the disproportionate numbers of NHS BAME staff who died from Covid. Away from the Pandemic, BAME women face five times the risk of maternal death during pregnancy.

The best birthday presents the NHS could wish for from the government may include more funding and reform of social care. However, the best gift it could give itself is to ensure that it does everything possible to live up to its proud principles. In particular, it is clear that fairness has been stretched and is likely to be stretched further in light of the pandemic. However, this equity or fairness principle is vital if the NHS is to further add to, in the words of its founder, Aneurin Bevan, the ‘massive contribution [it] makes to the equipment of a civilized society’

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