Happy birthday, NHS! Seventy seven years old today! And this year, to celebrate, we’ve decided to give you… an ultimatum! In the words of Fit for the Future (the Government’s 10 Year Plan for NHS England): it’s change or bust; reform or die!
Thirteen years ago, when you were still only 64 (just a kid with a crazy dream) we put on a real show for you. In the eyes of the world that stunning segment on the NHS was the dazzling centrepiece of the 2012 London Olympics opening ceremony. Oscar-winner Danny Boyle’s skilled direction offered us all a moving homage to Nye Bevan’s dream of universal care, free at the point of delivery, based on need and funded through general taxation.
But this year. Well. What can I say? Times have changed. Brexit. Covid. Crumbling infrastructure from years of underfunding. A massive crisis of public confidence. And a devastating loss of staff morale. Something clearly has to be done. And this Government is committed to doing it.
No more dragging down the nation’s productivity with a rising health budget. No more paying off the yearly health sector deficits. ‘By 2029 to 2030,’ says the 10 Year Plan, ‘most providers will be expected to generate a surplus, transforming the NHS into a driver of growth rather than a burden on public finances.’
The tenor of this economic background score is dark and unsettling. It’s not just a passing remark on the way to expressing the Treasury’s obvious displeasure with rising health spending. It’s embedded systematically across almost every proposal in the document. It’s fundamental to the entire framing of the Plan. It has the sinuous presence of Lord Voldemort rising ominously above a young girl’s hospital bed in that Olympic homage, thirteen years ago, before she’s rescued by a host of Mary Poppins’s descending from the sky under umbrellas.
‘This Plan will transform the NHS into an engine for economic growth rather than simply a beneficiary of it,’ proclaims the Executive Summary. The bidders for a slew of new Global Institutes aimed at driving ‘genuine global leadership on [health] research’ will be required to show ‘how they will help bring economic growth to areas most in need.’ Integrated Care Boards will be expected to establish Health and Growth Accelerators – because the NHS has ‘a unique responsibility to catalyse growth and economic prosperity in the communities it serves,’ we’re told. ‘Health will stop being solely a driver of higher government debt,’ the Plan insists, ‘and start being considered an asset to drive growth’.
Don’t get me wrong. There’s much to be said for the three ‘fundamental shifts’ in the direction of the health service set out in Fit for the Future:
- From hospital to community
- From analogue to digital
- From sickness to prevention.
They all make sense. In fact they’re not even new. Fit for the Future didn’t come up with the idea that prevention is always much better than cure. And the call to move care into the community has been present in almost every health plan over the last four decades. Even if achieving it is not the same as proposing it. But the obsession with growth introduces a frightening mission creep into these obvious proposals.
It’s not rocket science to figure out that any sensible health plan must address the rising burden of utterly preventable chronic disease. And it’s scarcely contestable that prevention here means radical change to the dysfunctional food system which burdens our diet with ultra-processed food, seduces us with sugar and saturated fats and systematically robs us of dietary fibre and nutrients.
But Fit for the Future offers slim pickings when it comes to serious change in this department. It launches a ‘moonshot’ to end what it calls ‘the obesity epidemic’. (Can we please stop calling what’s happening an obesity epidemic? It’s a metabolic disaster of gargantuan proportions. It affects around 90% of the population. And the False Economy of Big Food is costing us £268 billion every year.)
The moonshot will bring in mandatory reporting on the balance between healthy and unhealthy foods in the sales portfolios of big food companies. It will ban the sale of high-caffeine drinks to young people, restrict junk food advertising, give a minimal uplift to Healthy Start payments, strengthen the Soft Drinks Industry Levy and expand free school meals. But that’s about it. And it’s nothing like enough.
‘Government can only go so far on its own,’ the report insists. ‘To achieve such a significant ambition,’ says the Plan, ‘we will need to harness scientific innovation, including recent breakthroughs in weight loss medication.’
Ah. And now we’re back on familiar ground. Pharmaceutical responses to chronic diseases are massively profitable – precisely because in the long-term (ideally as long as possible) they don’t actually cure disease. At best they manage symptoms. At worst they create life-long dependencies on pharmaceutical toxins. And in the process they make someone somewhere a shit tonne of money. The projected growth in sales of semaglutide (a weight-loss drug) over the next ten years is exponential, offering compound annual growth rates (CAGRs) in their double digits.
Profits (for someone) are also to be found elsewhere in what the government calls secondary prevention – to distinguish it from the rigours of actual or ‘primary’ prevention. ‘We have identified 5 transformative technologies – data, AI, genomics, wearables and robotics – that will personalise care, improve outcomes, increase productivity and boost economic growth,’ the Plan declares.
Again, not all of these proposals are bad. We can all think of ways in which digital technologies could massively enhance the management of our health, particularly if they did something to update the seriously clunky architecture of the current NHS app and offered patients everywhere, as the Plan promises, ‘a doctor in their pocket’. But as anyone who’s tried it can attest, coming up with a successful app that’s both reliable and useable by those who need it most is a lot harder than it seems to be.
The trouble is the architects of Fit for the Future are so intent on identifying the wonderful opportunities for growth that no space at all is allocated to the obvious downsides of the technologies they believe will deliver it.
Genomic sequencing at birth; the replacement of human care and attention with the instant availability (and inaccuracy) of generative AI; the gamification of our psychological wellbeing; all of these could turn out to be seriously problematic for health in a system geared towards profitability and growth. Meanwhile, the avenues of real prevention are rejected, neglected or over-ruled.
Ask not what we can do for our health. Ask only what our healthcare can do for growth. I picture Nye Bevan turning in his grave. ‘No society can legitimately call itself civilised,’ he declared in 1948, ‘if a sick person is denied medical aid because of lack of means’. But the spectre that haunts this new and wonderful vision for the NHS is precisely of a return to that uncivilised land. And where is Mary Poppins when you need her?
What’s missing above all from Fit for the Future is the fundamental insight that health is primarily about balance rather than about profit. And that the economy, in consequence, should concern itself primarily with care in all its forms, rather than with growth at all costs. The principles of The Care Economy are already known to us. But they’re disturbingly absent from this 10 year vision.
Image: Nick Webb / wiki commons (CC-BY-NC 2.0); modified
