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In a new series of articles to mark the 75th anniversary of the founding of the NHS in 1948, 20/20 Consultant Michael Ilsemann investigates the public’s role in the management of the NHS, discusses the impact public opinion may have on healthcare, and asks, is the public’s emotional attachment to the NHS helping to holdback effective reform for the 21st century?

It may seem like a rather strange topic for a public health thinktank to discuss; of course, it can be safely assumed that a thinktank would argue that public perception of a national health service can only be a good thing. It is, after all, our NHS.

However, does there reach a point in which we can become too emotionally attached to the institution? Has the public expectation (as perceived by policy makers and expressed by the media) of the service become too great? Is this forcing the NHS to fall down a never-ending spiral of perceived failures when the actual experience of patients is a lot more positive than is reported?

Are we, as a society, over-burdening NHS professionals with an unreasonable expectation, causing a stifling of reform and negatively impacting upon healthcare? In short, at a time when the future of the NHS is being hotly debated, is it time for the public perception of what the NHS can provide to also change?

These are just some of the questions which I shall be answering over the next six months. In this first article, I shall address the changes in society’s attitudes since 1945, concluding with an assessment on the reaction to the 2023 Spring Budget as an example of how public opinion and the role of the media can be too interconnected in the national debate.

It is easy for everyone except for historians to forget the circumstances in which the NHS was founded. When the Attlee government first proposed the formation of the NHS in 1946, Britain was bankrupt and ravaged by the destruction caused by the Second World War.

Attlee’s government came to power in 1945 promising to create a land fit for heroes, with the NHS being one part of the welfare package that it was to be introduced. Tuberculosis and polio had not yet been irradicated; measles, mumps and rubella were killers and seasonal flu had a greater mortality rate than it does today. The medical priorities of the early NHS were substantially different than they are today.

Society in 1945 was different. Death, if not accepted, was at least seen as an inevitability of living. Men died in war and industrial accidents, women died in childbirth, infants were susceptible to diseases such as polio and Rickets.

There was more of an acceptance that as we live, so we must die.

21st century medicines and treatments are better and more efficient than 75 years ago, resulting in an increased life expectancy. As such, society today has never been further away from death, its inevitability shielded away from advancements in medical science. Developments in health and safety, and medicine have rightly reduced the mortality rates.

Paradoxically, an ageing population becomes more exposed to a greater number of illnesses, such as neurological conditions which were traditionally considered part of the ageing process as a patient grew older.

However, this has now contributed towards one of the major challenges facing the NHS; the public perception of the service the NHS can provide.

The NHS, quite rightly, has a place in public affection; it has created, delivered, saved and treated hundreds of millions of lives. Indeed, most (if not all) of the UK’s population since 1948 have relied on the NHS at some point, even those with private medical insurance.

But it is now required to treat an ever-expanding range of illnesses and diseases which would have been beyond the imagination of policymakers in the 1940s. Nowadays, the medical priorities are cancer, heart disease and obesity; different illnesses which require different treatment methods than in 1948. Some illnesses, such as AIDS and HIV, have only recently been identified.

As the pressure on the NHS has increased, so too has its role, focus and size; leaving it cumbersome when flexibility to meet these challenges is required.

No commercial entity or any other public service provider would be required to change its priorities or service provision without long-term strategic planning. Yet the focus of policymakers remains short-term, stuck in a cycle of 10-year plans constrained by an obsession with public opinion as impending elections loom over the metaphorical horizon.

Of course, it is more than appropriate for the public to have a say on healthcare. It is important not just for the health of the individual; but a healthy society creates a successful nation. Furthermore, it is often only through public opinion that any large organisation will sometimes know when something is wrong.

The NHS is no different.

But the issue is when public opinion is driven by the media editors with a story to sell or a politician with an election to win. The Conservatives are often reluctant to discuss widespread reform, out of fear that Labour would label such reforms as “privatisation.” The Conservatives fear that Labour would cause widespread panic amongst the electorate causing an obliteration of Conservative support at the polls. Both positions (Conservative nervousness and Labour political opportunism) are extremely unhelpful.

On the other hand, the Labour Party has for too long worshipped the institution of the NHS, as if it is the golden calf of modern progressive politics. The obsession of Labour to use the term “our NHS” is merely a political reminder of the perceived debt the Party considers Britain owes Attlee and Bevan. Even that, or the Labour Party believes that it has the sole monopoly of ownership.

The failures of generations of politicians to bravely address the problems facing the NHS whilst maintaining the principle of “free at the point of use” has stifled reform, a needed part of the development of any large organisation, to the point in which the default position for any aspiring politician is ever greater investment.

The result is a bidding war between the two major parties, to the stage where it becomes almost impossible to comprehend the massive amount of promised spending by any future government (how can anyone fully understand billions of pounds of extra funding?).

It is time for both major parties to act more maturely and less politically for the sake of the nation’s health.

The issue of investment shall be dealt with in a later article, although it is worth mentioning now that greater investment does not always result in better service provision.

The changes in society’s attitude towards the level of service is demonstrated by the rise of medical negligence claims in the last forty years. This is a direct influence from the US, a nation with the most basic of national services but with one of the highest demands of patient satisfaction. There has been a long-standing belief in the US that if a patient has not been cured, then there is blame and if there is blame, then there is a right to compensation.

The UK has seen a huge upsurge in medical negligence claims; there were 12,629 claims for the period 2020/21 compared to only 5,426 in 2006/07, an increase of 133%. This rise in claims is indicative of a change in public attitude towards medical treatment within public healthcare; perhaps the sad inevitably of a society now used to the cushion of free healthcare and a welfare state incomprehensible to its forebears.

Whereas in 1948 the public perception of healthcare was that patients shall be treated for their illness, there is now, in 2023, an expectation that patients shall be cured. Unfortunately for many patients, this is just impossible. However, with the almost weekly update of developments of “live-saving” drugs, promises of near limitless funding, unrealistic television shows depicting miracle-like treatment and a healthier population since 1948, this is perhaps understandable.

We have taken away an appreciation of the fragility of the human body, replacing it with an expectation that all of us will reach our eighties in the best of health. This results in a lack of any meaningful reform of the NHS, except for occasional lip service and ever-increasing level of investment.

A good example can be raising waiting times in A&E Departments throughout England and Wales. It is beyond doubt that waiting times are increasing and are in some areas unacceptable. There are multiple reasons for this, including changes in clinical practice, fewer hospital beds, raising emergency admissions, staffing problems and pressures on other services, such as GP surgeries.

It would be wrong to proportion any blame onto the public, but a reason for the increase in waiting times can be explained by the public perception of what A&E is believed to provide.

The media regularly publishes articles (as is their role) highlighting the increasing waiting times. These are seen, heard and read by millions, and is accepted by the public to point where even a two-hour waiting time for non-life-threatening treatment appears to be unreasonable. Medical unions comment on the growing public anger, once again reported by the media, which forces the government to act by promising an increase in spending.

It has become increasingly difficult to book an appointment at GP surgeries, with some patients reporting that it can take weeks to book an appointment. For many patients, this delay in receiving medical assistance is too long, forcing them to seek assistance from the only other outlet they know; hospitals. As they cannot see a consultant without GP referral, the public understandably seeks assistance from A&E.

The government’s message is to seek medical assistance from the non-emergency number 111, but following the Covid pandemic, many people only trusts diagnosis made in person. Remembering the message to seek medical assistance, the patient will then travel to A&E.

But there is an under-utilised resource ready for the NHS; pharmacies.

Pharmacies have the knowledge, expertise and the capabilities to assist GPs in the initial patient consultation and for treating minor conditions. They can certainly be of greater use than the local A&E department. However, the role pharmacies can play are not universally known by the public; there is still the perception that when you are ill, you must seek the medical advice of a doctor.

The perception of a pharmacy is still largely as a dispenser of prescriptions, over-the-counter medicines and as a retailer of toiletries. With better education and more awareness, the public can be encouraged to seek treatment for minor ailments away from GP surgeries and, certainly, away from A&E.

This will free up GP appointments for those who need them, in turn leading to fewer patients going to A&E, helping to lower waiting times.

However, this does not solve the root cause of the issue, including the perception amongst the public that after a GP surgery, A&E is the primary place to deal with their complaint.

The heart of this lies in education; educating the public as to the most appropriate cause of action.

Education of the public is key, an issue which shall be addressed in the next article.

Perhaps a good example of the relationship between media and public perception is the commentary on the 2023 Spring Budget. From a health perspective, there were many benefits to take from it; the £3bn increase in spending, tax incentives for companies investing in R&D, investment in mental health, improvements to employees’ childcare and pensions, and councils to be allowed a greater say over regional budgets.

However, the public would be forgiven if it thought that the Budget was a disaster for public health. Many commentators complained that the NHS needed at least double the extra funding, conveniently ignoring that the £3bn increase would take annual funding of the NHS from £157bn to £160bn. Journalists questioned the absence of any proposals to end the long-running pay disputes. And let us not forget to mention that Jeremy Hunt failed to mention how he would get mental health sufferers back to work and prevent medical staff from leaving the profession.

But let us look at the Budget objectively, and with as little emotion as we can manage when talking about our NHS.

The Budget is an hour-long speech outlining the government’s spending priorities across all government departments whilst detailing the government’s fiscal and economic plans for the year ahead. It is delivered in the most combative political theatre in the world; just look at how our European neighbours conduct their parliaments.

Do political and health commentators seriously expect the Chancellor of the Exchequer to announce detailed healthcare policies in an already busy speech? For that matter, do the public, whose opinions commentators are supposed to reflect and influence, expect that either?

Understandably, the government of the day wants the good news stories of their Budgets to gain maximum publicity; they do not want the focus of the news coverage to be narrowed down to a single item, as would undoubtedly have happened had the Chancellor announced sweeping healthcare proposals.

Of course, those who complained that the Chancellor missed an opportunity to resolve problems within the NHS failed to consider that it is not the role of the Budget to outline health policies; that is the job of the Health Secretary. Furthermore, for the Chancellor to announce settlement proposals would have ridden roughshod over the negotiation process, would have undermined government colleagues and would have ignored the government’s own policy-announcing timetable.

The unions and their supporters in the media, pressure groups and thinktanks fail to acknowledge that their public commentaries are part of a strategy to strengthen their positions during these negotiations. Unfortunately, these stories are read and accepted as truth by the public, which then adds to the growing anger that the NHS is a failing organisation, stifling needed debate on NHS reform.

Obviously, these commentators lack (perfectly reasonably) the skills of a clairvoyant, as within a fortnight of the Budget (on 28th March), the government announced its latest round of pay proposals which union members are currently voting on.

There is one key word in this article that we have not yet discussed. That word is “emotion.” Perhaps it is time for the public to take the emotion out of the NHS, for journalists, unions, medical professionals and politicians to work together dispassionately towards drafting a future strategy. Discussing the future of healthcare should not be so emotive, nor should it be so political, but should be approached with the same level of maturity displayed by its founders.

Next time, we shall look at education, in particular the awareness the public has of the different roles each part of the NHS can play and how the government can make people aware of the best cause of action for their health. Perhaps greater awareness will lead to greater patient satisfaction.

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