NHS 80 – National consistency or local autonomy

The NHS is 70 years old this month. With a long-term funding settlement now in place, in a short series of blogs from the RSA’s Public Services & Communities team, we are highlighting different approaches that NHS policy makers and senior leaders should consider in making the NHS fit for its 80th birthday.

It was 170 years ago that the 1848 Public Health Act gave councils the powers to take measures to prevent the spread of disease within their growing populations. This was a major catalyst for a period of "municipal enterprise and development, influenced by the pioneering work in the late nineteenth century of Joseph Chamberlain who, as leader of Birmingham, the largest authority in Britain, oversaw a massive growth in local services and proudly boasted that the lives of all citizens of the city had been ‘improved’ by the council’s achievements".  Indeed, a hundred years later during the creation of the NHS it was "originally anticipated that universal healthcare would be a function of local authorities, which already administered a large number of hospitals". The NHS was launched on the assumption that access to health care for all would reduce sickness levels and so demand for, and expenditure on, health services would gradually fall. Evidence tells us that this has not been the case.

In the 1920s in Peckham, two doctors had an idea – rather than continually treating symptoms and ill-health, what if they focussed their energy on preventing symptoms and ill-health. The health centre operated upon a cooperative subscription model – the residents in the community paid a small fee in exchange to access for things that would promote a good healthy life – a swimming pool, workout centre, lots of natural light, a theatre, cork floors for barefoot manoeuvring, a game room, and of course, two physicians. There were around 128 families subscribed to the centre and benefitted from its holistic approach.

Yet 28 years after it was established, a national initiative, with a philosophy of free at the point of access and dedicated to treatment and consistency of service, would put the Peckham centre out of business. That initiative was the NHS. As a case study of the centre remarked ‘the NHS insisted on consistency, the Peckham centre wanted autonomy’. The NHS was established with an incredibly noble goal, and its profound impact on the lives of people across the UK is undisputed… if we are talking about the treatment of urgent and serious illness.

What can be disputed is its impact on holistic health in the UK – rates of obesity have skyrocketed, prevalence of poor mental health is higher than it has ever been, and one in four children still start school with some form of tooth decay. These are the sort of health issues that the Peckham centre sought to prevent and explore holistically – and if successful, would drastically reduce the follow-on costs and poor health outcomes that come with a deterioration in these areas. 

Here we are, nearly 100 years after the Peckham initiative was established, and the debate remains the same: what is the appropriate balance between preventing ill health and fixing it?

Public Health England’s (PHE) Chief Executive Duncan Selbie recently spelled out his view that this is a balance in need of recalibrating: "the NHS’s upcoming 10-year plan will only succeed if it has local government’s expertise and a golden thread of preventing poor health running through it. We must of course treat illness but even smarter would be to prevent it. With 40% of all poor health being preventable and 60% of 60-year olds experiencing at least one long term condition this has to be a no brainer."

The reality of the system does not match this ambition according to research this published week from the Health Foundation, which highlights a significant funding departure from prevention-based healthcare. Funding is set to fall by almost a quarter on prevention programmes focussed on alcohol abuse, smoking, and poor diet. The budgets for sexual health services and substance use prevention are also reportedly subject to significant cuts - around 25% for the former on a local authority level, while as high as 40% across numerous local authorities for child and adolescent drug and alcohol services.

We suggest that as long as we conflate prevention and treatment the NHS as it is currently organised will always struggle against rising demand and downward pressure on budgets. As Charles Leadbeater noted, “a health system based on hospitals is working efficiently when the beds are full as much of the time as possible. Yet a healthy society is one in which people do not need to go to hospital.”

This is the holy grail we want to reach. We contend that one way of doing this is to be much clearer than we currently are about this distinction, to split the two apart.

The N in the NHS is about National. People want to know that when they fall ill or are passing through key life stages there is specialist support for them and an easy route through which to access them - 'the patient pathway'. Aside from those ideologically supportive of a universal and free health service, this is why we love the NHS so much: we encounter it when we or our loved ones, are at our most vulnerable and mortal. To support this we need clear national standards, concentrations of expertise, world class surgeons, practice, equipment. This is the national treatment service – fixing ill health.

The H in the NHS is about Health. This is problematic: others have called the NHS, in effect, an ill-health service; we are keen to frame this more positively, picking up the prevention angle and the notion of a healthy society. The Peckham initiative emerged as a local preventative solution supporting local needs of community. We argue that this is the heart of prevention: what we might call a Local Health Service. What might this look like? We’ve recently concluded a three-year NHS-funded programme about how to catalyse the role of community in health, yet as far back as 1920 in Peckham this was well known. We've explored the notion of community (social) capital, highlighting the importance of human connections on health and wellbeing. This is a concept that has been well known since Robert Putnam’s work and is gaining new traction in conversations around loneliness.

The S in the NHS is about services. We call for a broader definition, one that recognises our lives exist within complex social systems. The contribution of housing, the design of our local environment, the provision of public transport, the work we do and so on, all have a greater impact on our health than anything the NHS can do alone. We need means of mobilising the contributions from across these wider systems to support the development of healthy communities and to support people to live healthier lives. This is work that the NHS is not best placed to co-ordinate but local government, with its focus on people and communities, and a local democratic mandate, is.

By the time the NHS is 80, we want to see an established local health service – preventative, community services that are responsive to local need, that leverage local knowledge, expertise and capacity. A good local health service, properly supported, will start to stem the flow of people towards national treatment services. We've already noted that this is nothing new, as civic entrepreneurs were driving improvements to health and sanitation through local government 200 years ago. Investing in prevention has been recognised long before Benjamin Franklin talked about an ounce of prevention being worth a pound of a cure¹. We recognise that investment in prevention is not attractive to economic models that can’t account for the nominal (counterfactual) saving, either by quantity or by budget line. But this doesn't mean we shouldn't look for ways of doing this.

A local health service would enable a commitment to localised approaches that systemically understand the specific health issue they are trying to solve. The causes of obesity in Motherwell might be entirely different from those in Milton Keynes, the forces driving depression in Cardiff might bear no resemblance to those in Carlisle. These changes do not have to undermine the underlying principles of the NHS which many in the country hold dearly, but questions remain. How can we move beyond the current, unsustainable set of incentives and power dynamics that play out across the current governance and structural systems? How can we prioritise the need to prevent ill health by addressing the factors that promote healthy lives?

₁ This quote appeared in the February 4, 1735 edition of the Pennsylvania Gazette. Benjamin Franklin, writing anonymously as an “old citizen,” wrote: "In the first Place, as an Ounce of Prevention is worth a Pound of Cure, I would advise 'em to take care..."

References:

Alcock, P., and May, M. (2014). Social policy in Britain. [Kindle Edition] Palgrave MacMillan. Available at: https://www.amazon.co.uk/Social-Policy-Britain-Pete-Alcock-ebook/dp/B00L1GEMM4/

Campbell, D. (2018) Fears of future strain on NHS as councils slash health programmes. The Observer, [online] 8 July. Available at: https://www.theguardian.com/society/2018/jul/08/fears-of-future-strain-on-nhs-as-councils-slash-health-programmes

Dobson, J. (2018) New seeds beneath the snow? [online] Bog Local. Available at: https://localtrust.atavist.com/new-seeds

Hunter, D.J. (2018) Looking forward to the next 70 years: from a National Ill-Health Service to a National Health System. Health Economics, Policy, and Law, [online]. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29547371

Leadbeater, C (2007) "The DIY State" Prospect Magazine,14^th January [online] Available at http://www.prospectmagazine.co.uk/magazine/thediystate

Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community. New York: Simon & Schuster.

Stevens, A. (2003) Politico's Guide to Local Government. Politicos

The Open University (2001) Peckham Health Centre. [online] Available at: http://www.open.edu/openlearn/history-the-arts/history/heritage/peckham-health-centre