It is time for a new consensus on the future of the NHS and for academics to lead the debate, argues Dame Joan Higgins.
On a recent visit to Greece I was interested to learn more about the so-called ‘Golden Age’ of Athens in the 5th century BC. It made me think about the factors which lead people to argue that a particular period was a Golden Age and to ask whether we could ever say there had been a golden age in the NHS – or in health policy more broadly.
The Golden Age of Athens involved strong leadership and a clear vision of the future; a commitment to civil society and the rule of law; public support for major building schemes like the Parthenon; subsidy of theatre, the arts, literature and philosophy; and the teaching of logic and aesthetics.
Intellectuals and writers such as Sophocles, Aristophanes, Euripedes, Pythagoras, Socrates and Hippocrates played a dominant role, with the latter in particular changing views on the causes of ill health and its treatment.
Whole greater than parts
One of the essential features of this Golden Age, and of others, was the relationship between different societal parts – science, technology, engineering, the arts and culture, public policy, governance and civil society and ideas, values and ethics. The whole was much greater than the sum of the parts and no aspect of society was seen, or developed, in isolation.
If we apply this analysis to UK health policy, could we say that there has ever been a Golden Age in which all these features coalesced? And what would we be looking for?
I would suggest a broad consensus on priorities and on ends and means. A holistic approach involving integration of public policy with wider societal goals. And a paradigm shift in ways of thinking and respect for (and inclusion of) experts, professionals and intellectuals.
There are, perhaps, two periods in which some of these qualities were present. Firstly, there was the great period of Victorian reform between around 1830 and 1870 which resulted in public health legislation and improvements in housing and social welfare. This saw a radical shift in our understanding of the causes and spread of disease and a commitment to tackling them.
Then a century later, in 1951, the Festival of Britain boosted industrial design, technology and engineering at the same time as highlighting the unprecedented investment and progress in post-war housing, health care and social benefits.
We might instead talk of golden periods rather than ages and I would point to two. In the early 1960s the ‘Hospital Plan’ promised a huge building programme for new hospitals and the modernisation of others, not just for district general hospitals, but also for community hospitals and improvements in primary care. Then in the early years of the Blair government we saw the ‘NHS Plan’ which was the result of widespread consultation and commanded broad support.
These two periods were not all embracing and we did not build a Parthenon, but they did reflect a shift in thinking and a new consensus.
However the problem in both the 1960s and 1990s was that the NHS, far from being part of an integrated drive for broader societal improvement, was seen as a thing apart. It was regarded as a special institution that must be protected at all costs, including through hypothecated funding.
The danger is that such a status can stop innovation in its tracks as well as preserving in aspic those features which need to be challenged, in order to improve health and wellbeing.
Some of the current debates about integration of services and adequacy of funding have become so inward looking and sterile that they have blinded us to fundamental questions about the purpose of health policy and the NHS in a prosperous society.
For instance, how do we know how much money is enough money if we are not agreed about what it is for?
Governments have shrunk from this question for many years, but it is becoming increasingly urgent. We cannot avoid the issue by saying that all would be well in the NHS if there was simply more of the same.
It isn’t just about the money. It’s about attitude of mind. It’s about confidence and imagination as well as breadth of vision. It’s about an openness to new ideas and innovation, and a willingness to take risks.
In the Golden Age of Athens, intellectuals had a leading role in framing and debating questions and we need to draw on a wide range of perspectives to inform the discussion. I would point to demography and geography, in particular, as well as law and ethics as disciplines which can, and should, be considered.
Just as the practice of health care in the UK has become parochial, inward looking and detached from wider world issues, so its analysis is in danger of becoming so.
In my view, intellectuals and policy analysts have a social obligation to use their skills and knowledge for the public good. They bring expertise, independent mindedness and objectivity. They can interpret evidence for different audiences and disseminate information.
There are challenges, of course, when these experts are funded by government. They must conspicuously maintain their integrity and distance (which can be easier said than done). There is often the opportunity for ‘hands on’ practice, interpreting government policy and facilitating implementation, but I think there is a duty to go beyond that. University departments still have the freedom to test out ideas, to challenge the status quo and to formulate new paradigms.
This may not feel like a ‘Golden Age’ but intellectuals have always been central figures in creating the knowledge and conditions for reform. They are sometimes at their best and most influential in periods of crisis. This is the moment to walk towards those challenges and not away from them.
Professor Dame Joan Higgins is a former director of the Manchester Centre for Healthcare Management at Alliance Manchester Business School.