The antecedents of the NHS are to be found in Tredegar and in the Beveridge report, which preceded it. Disease was one of Beveridge’s five great evils. Infectious diseases such as polio, diphtheria and tuberculosis caused people to die in their early and mid-50s on average. The need for a sufficient and healthy labour force to rebuild the economy necessitated combating those diseases, which also caused a high rate of infant mortality. The need for a better, longer-living workforce drove much of what Beveridge looked at.
There was in fact a good deal of state funding provision before 1948 to cope with the devastation of disease, but what Bevan did, against tremendous opposition within the service and politically, was to centralise the system, nationalise hospital provision, create standards across the country and, crucially, give people the assurance that they would always be seen and treated, based on their need, not their ability to pay.
The health service was built on a tripartite structure of hospital, GP and community services. In return for good terms and conditions, clinical freedom and autonomy in the system, the doctors finally agreed and the NHS was born. It was a wonderful achievement, but it was also a wonderful compromise. Over the past 70 years, the tensions in that compromise—the local versus the national, the role of clinical autonomy, priorities and the quality of the service—have regularly surfaced. There are always crises—astonishingly, every year there is a winter.
We now treat 1 million people every 36 hours, and employ nearly 2 million people. We are very grateful for everything they do, and we celebrate them today on this 70th year. However, the challenges are different today, and the service should therefore be different in the next 70 years. This anniversary is an opportunity to celebrate the achievement, revisit the compromise and set a course that is as resilient for the next 70 years. The diseases that are with us today—cancer, and cardiovascular, respiratory and liver disease—are very different. Depending on a person’s social class, dietary risks, tobacco and obesity are the biggest contributors to early death and disability. Alcohol and drug misuse, and lack of physical activity, are also key. We are finally starting to appreciate the impact of mental health and social isolation on physical health.
Life expectancy has increased, but the prevalence of people living with one or more limiting long-term illnesses has changed the picture of healthcare demand, and that requires the system to change. In Bristol, women live an average of 64 years in good health, but a further 19 years in poor health. For men, the figures are 63 and 15 years, but that average masks a huge range in social class. Several areas of my Bristol South constituency are in the bottom 5% in England for male life expectancy. In 2010 the Marmot review told us that such health inequalities cost us approximately £36 billion to £40 billion in lost taxes and costs in welfare and to the NHS—that is a huge amount of money. We must prevent and manage life-limiting diseases and address the silent misery of families who support and cope with people living with them.
Accountability is a major issue for the service in the next 70 years. We need to start treating patients and the public as assets to the health service, not as nuisances. We need somehow to introduce democratic accountability into decision making. The complex fragmentation of the health service makes it wholly unclear where responsibility, and hence accountability, lies. From the bottom up, hundreds of bodies are involved. The 200-odd clinical commissioning groups are members’ clubs with no element of either direct or representative democracy, and they are plagued with conflicts of interest. At the top, there is not just the Department and Ministers, but a raft of arm’s length bodies, which Members of Parliament find it impossible to navigate. I worked in the system for a CCG, and I still find it really difficult—it is an absolute mess.
One reason for the mess is the disaster of the Health and Social Care Act 2012, but the NHS has been poor on accountability since the early centralisation. It has always been fragmented in a way that makes accountability harder, and it has always seen itself as separate from the rest of the local system, which has democratic accountability. That is a problem. It has always been riven by powerful vested interests that distort the general accountability. That is a key part of Bevan’s compromise, and I think we need to revisit it.
Presented with a well-made case that is supported by, dare I say it, experts or informed leaders, the public will make difficult decisions. I know local politics can make things difficult when tough issues such as service changes are necessary, but excluding people does not make that any easier. Making a hard case to local people and their MPs is challenging work, but if that does not happen decisions gain no legitimacy. We can keep the “N” in the NHS, but we need to give local people far more control to make it more resilient for the next 70 years.
It looks like we are going that way. We have heard about the experience in Scotland, and this is also a devolved matter in Wales. Very interesting things are happening in Manchester, but we need a much better debate about what local looks like. We must recognise that the key issues for now are the money and the workforce. Technology gives us huge opportunities, including on some of the workforce issues.
I want to finish by talking about leadership. I joined the health service as a manager in the late 1980s, and I am very proud of the role that managers play in the services. General management, which was introduced in the 1980s, has few friends, partly because it was associated with the Thatcher era of reforms, and partly because it threatens clinical autonomy and freedom, which were fundamental to Bevan’s compromise. We should use this anniversary to celebrate managers and leadership in the NHS. We need good clinical and non-clinical managers to make the changes we want to see, deliver the efficiencies we need and keep making the system safer. I hope that they can also help leaders make the NHS more open and accountable. We need that for the next 70 years.