75 years on

I never knew my grandmother. She died from cervical cancer, 13 years before I was born. She died in agony, because the family could not afford medicine or dressings to relieve her pain.

Her daughter, my aunt, had to leave her job and her husband to care for her, because the family could not afford nursing care, or the cost of a hospital admission.

She died in 1942, 6 years before the NHS was born. Her story was commonplace then.

I wasn’t born in the NHS. I was born in Canada. But my parents were among the first doctors to be trained within the new NHS. They emigrated because the incoming Tory government tried to close down the NHS, strangling the outrageous costs of the new service – the burden on the hard-pressed tax-payer. How things have changed……

I don’t like to think of myself as ancient, but my first job in the NHS was in 1973, when the NHS was just 25 years old. In a hospital that had been a Merchant Seamans’ Orphan Asylum. So many of the hospitals nationalised then were repurposed from those set up by a host of charities and, even today, many of them retain those links, despite more recent additions. It tells you something that those buildings are still serving a purpose, when more recent constructions are held up by screw-jacks or draining the financial life-blood from their hospital trusts.

So many people say that the NHS is dead. It is not dead. It is wounded. It is not performing as well as it should, but it is a testament to the vision of Aneurin Bevan and those who supported him, particularly Charles Wilson, Lord Moran, the powerful and professionally influential President of the Royal College of Physicians, that the founding principles laid out 75 years ago are still recognisable and still command the support of the great majority of the British people. A recent Ipsos Mori survey found that only 8% of people in England think that the government has the right policies for the NHS. 90% want care free at the point of delivery; 80% want that care to be comprehensive; 84% want funding through taxation; and 82% want a greater level of funding for the NHS – and that includes two-thirds of Tory voters.

Working as a consultant through the ‘90s, I remember the years when government ideological obsession with the power of ‘the market’ starved the NHS of investment in people, buildings and equipment. I remember being told by Tony Blair, “Voters have 24 hours to save the NHS” on the eve of the 1997 election. I remember waiting times for treatment that stretched into years. These were turned around, not overnight, but over a decade. Not as a result of the private sector coming to the aid of the NHS, but through imposing targets to cut waiting times on health systems, together with the funding to achieve those targets, by paying over-time to NHS doctors, nurses and support staff and paying for the drugs and equipment to carry out those treatments. By 2010, we had a service that delivered for our patients and which they trusted. Public satisfaction had never been higher. Demand for private healthcare had never been lower.

We turned things around then. We can turn them around again. But it isn’t going to be quick and it isn’t going to be easy.

Bevan’s founding principles have stood the test of time.

  1. The NHS should be comprehensive – it should meet the needs of everyone
  2. The NHS should be universal – it should be free to all, at the point of delivery, to access GP consultations or hospital treatment
  3. It should be based on clinical need: not on the ability to pay

That is why we still have an NHS 75 years on. That is why it still commands such loyalty. And that is why there are still people who are willing to turn out and fight for it to continue to deliver for our children and grand-children.

Just like lack of interest in climate change and the natural environment, we are faced with a government that is, at best, ambivalent about the concept of a national health service.

We hear criticism that the NHS focuses on treating illness rather than preventing it. As does every private healthcare company in this country. As a former head of the NHS said : health is made at home: hospitals are for repairs. Health is dependent on the income of your household; your education; a warm, dry uncrowded home; a fulfilling job in a safe environment; clean air to breathe, good affordable food to eat and uncontaminated water to drink. And above all, security – a secure home, income, future. These are not within the power of the NHS to deliver – they are within government’s power to a very large extent.

To care for people, staff need to feel cared for themselves. Treated with dignity.

How can you concentrate on caring for people if you are worrying whether you can keep a roof over your family’s head, put food in their bellies, and pay your debts, many of which can come from paying for your training, sitting exams and other expenses linked to being able to do your job?

As we were repeatedly told, during the pandemic, NHS workers, like teachers, refuse collectors, bus drivers and many others, are key workers. Public servants.

Public servants. Not public slaves.

And it isn’t all about your pay packet. When I started as a junior doctor, I had no debt – my university fees were paid by the state. I was expected to apply for jobs every 6 to 12 months, and to move around the country to build my experience, but hospitals had staff accommodation, at least until you had found your feet in the new town that you had landed in – and some were much better than others. And you could get a hot meal, freshly prepared, if you were working through the night. These all disappeared in the cuts to public services through the 80s and 90s. How little would it take to explore ways to make staff feel cared for: valued? On-site childcare; access to fresh food during working hours, no matter what those hours might be; help with travel to and from work; covering the cost of education and training. There are so many aspects of terms and conditions that could improve daily life.

Instead, what do we see? Berating ‘key workers’ for seeking to relieve the impact of inflation, so that they can at least care for their families with dignity. Government refusal to negotiate because ‘That is the role of the ‘independent’ pay review bodies’ – while setting the boundaries that those ‘independent’ bodies can operate within. And then refusing to commit to the outcome of those reviews, or applying the moral blackmail that recommended pay restoration will result in less money available for care for patients.

There has to be a better way! We have to find a better way.

So the big birthday present from the government is to publish the Long Term Workforce Plan for the NHS ( in England) at long last. Finally we have confirmation that things are really as dire as many of us have been saying, and it will require a herculean effort to turn them around. We have some actual figures on the gap between the staff that we have, and the staff we need now and for the next 15 years. We have a plan, cunning or otherwise, and £2.4 bn apparently allocated for the first 5 years of that plan.

But a cynic might say that this plan is setting out a commitment that will fall to the next government or three to fulfil. Depending on whether they decide to review the whole thing in the light of “now we have seen the books, we need to determine our own priorities.” A commitment that might fall into the same category as “fixing social care once and for all” or “we are building 48 new hospitals”, of which none have reached the planning stage. Good for pre-election sound bites, but changing very little in the real world. And I speak from experience – the plans for hospital restructuring across Halifax and Huddersfield, have been under discussion for 10 years, most of that time being taken up by negotiations with the Treasury. And that scheme was allocated funding years before the ’48 new hospitals’ pledge.

For too long, we have been trying to harvest talent and numbers from the poorest nations on earth. Other richer economies are doing this now, and there aren’t enough trained clinical staff in the world to go round. The penny has finally dropped – we have to train our own!

At last there are firm figures placed on the deficit of main groups of staff, with estimates of numbers of training places required, including not only lifting the cap on domestic entrants to existing medical schools, but an intention to establish additional schools in areas such as in Cumbria, in the hope that this will encourage more graduates to join the local workforce. The plan importantly commits to adequate numbers of foundation placements and specialty training places, particularly GP specialty training places, without which this expansion would be pointless.

Just one little difficulty. The whole NHS will need to gear up, once again, to become a training organisation – something that has been neglected, particularly since the 2012 madness of Andrew Lansley, with budgets for Health Education England being robbed to keep hospitals just about afloat ever since then and NHS organisations looking to recruit and poach ready-trained staff, rather than go through the expense and inconvenience of training them themselves.

But exactly how is that clinical training capacity is going to be expanded without further reducing capacity for treating today’s patients? It is the right thing to do in the medium to long term, but poses a difficulty right now. A recent Doctors Association of the UK (DAUK) survey results showed 9 in 10 medical students being turned away from placements, because there was no one to treat them; three-quarters of students finding doctors have no time to teach them on placement; half of medical students reporting 5 or more students per ward and a third reporting 5 or more students per GP practice.

For the plan to be delivered, the whole NHS will need to become focused on training the next generation of staff, but the time (and space) to do this needs to be recognised. The proposed increases in desperately needed District Nurses comes up against the reality of hugely depleted numbers of District Nurses able or willing to supervise practice placements.

If this plan is to deliver, every NHS organisation and almost every member of staff, clinical and non-clinical, will need to become a trainer, on top of delivering their current day job. As we used to do.

Anniversaries are an opportunity to look back over past years, as well as thinking about what the future holds.

It is clear that Aneurin Bevan and his advisers, including Charles Wilson, came up with a robust structure that has continued, by and large, to serve the people of this country well and retain their trust. It isn’t perfect. No organisation in which millions of person to person interactions take place every day could ever ensure that each conversation, examination, operation will meet everybody’s hopes and expectations.

But it is also clear that every attempt to hand over the service to market forces and competition has been a backward step. There may have been opportunities to powerful commercial organisations to get their hands on tax-payer funding for low-risk elements of healthcare. There may have been opportunities for IT companies to peddle their snake-oil in constructing a Tower of Babel. There may have been opportunities for doctorpreneurs to exploit gaps in service delivery that they themselves might have contributed to. But there is no evidence of any benefit to the people of this country to compensate for the extra costs, bureaucracy and complex reorganisations that have taken place over the past 35 years.

We need to take another clear look at the simple and fair system that Bevan set up three-quarters of a century ago and accept that the nation’s health is a service, not a commercial commodity to be bought and sold.

I’d like to leave you with with two figures I want you to remember, particularly when the government tells you how much they are putting into the NHS. The original 14 members of the European Union have spent, on average, £3665 a year, on healthcare, per head of population between 2010 and 2019. 18% less, year on year. The UK has spent £3005 per head of population. Capital investment, in buildings, equipment and IT in the UK has been just over half as much as in those countries, that we like to compare ourselves with. You get what you pay for.

Happy birthday NHS!

Dr Colin Hutchinson, Chair of Doctors for the NHS

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