The NHS: feeling well and thriving at 75

It is a thrill and an honour to welcome you to the 75th anniversary celebration of the NHS. Time flies. It seems only moments ago that many of us here were assembled in 1998 for the glorious 50th anniversary celebration. That meeting, at the close of the last millenium, marked, as you know, a turning point for the NHS. We recognised and celebrated the achievements of the last half of the 20th century, but we also set the stage for the enormous leaps that we have made in the 25 years since.

A lot has changed since 1998. Who could then have anticipated that durable peace would finally settle not only on Ireland but also on the Middle East and the Balkan states? We could not then have known for sure that measles would now be eradicated, river blindness brought under control, and the worldwide epidemic of multidrug resistant tuberculosis stopped through unprecedented international public health collaboration. In the United States, where health care costs reached 22% of the gross domestic product in 2015, real reform finally took hold, beginning with President Whoopie Goldberg’s famous call, paraphrasing Ian Morrison, that the United States become, “At last a nation where health care is a right and carrying a semiautomatic machine gun is a privilege, instead of the other way round.” Today American health care is administered under a single, government sponsored insurance scheme, with public accountability not at all dissimilar to the NHS. For the first time in nearly a century, American healthcare costs are falling (they are now only 50% higher than Britain’s), the population’s health is improving, and all Americans can get the care they need, regardless of wealth or race. Laser surgery has been performed remotely at the European Union’s colony on the moon under the control of a world class surgeon in Manchester; cystic fibrosis has been conquered by gene therapy; and the NHS has thrived. As Lord (Anthony) Blair said, recovering from his recent cataract surgery, “The care was so good, and the service so prompt, I can hardly wait for my next operation.”

Of course, you already had a lot to be proud of in 1998. The NHS had its flaws, but its cost, clinical excellence, and universality proved that a nationally organised, publicly funded, total system of guaranteed health care was one of the best public policy options for a developed nation. Nevertheless, in typical British fashion, your leaders self critically pointed out problems where they existed, such as long waiting times, poor service, technical variation, and rationing of effective care.

Summary points

• A look back from a possible future shows not-impossible developments in health systems

• The turning point for the NHS came shortly after the 50th anniversary celebrations in 1998, when eight principles for progress guided crucial adjustments in NHS strategy

• The cost, clinical excellence, and universality of the NHS prove that a nationally organised, publicly funded, total system of guaranteed health care is an excellent policy option for a developed nation

You remain self critical, but even the harshest among you must take note today of the enormous progress you have made. Today, unlike in 1998, the NHS is almost wait-free. At a cost that has been held for 20 years at 7% of gross domestic product, your citizens can get the help they need, day or night, when they need it. Whether by phone or internet, in hospitals or in community health centres, NHS patients and their families can expect dignified, customised, and even cheerful responses from any NHS employee they encounter. Wasteful and hazardous geographical variations in care are nearly gone: doctors, hospitals, and community health services have moved steadily toward scientifically supported, evidence based best practices as their norm, and they engage in steady and respectful dialogue to reveal differences in practice as they emerge and to help them to reduce those differences methodically, reporting their progress to the public as they go.

Progress like this in part characterised the NHS from its inception. But you and I know that, shortly after the 50th anniversary celebration in 1998, the NHS reached a historic turning point as the secretary of state, the NHS Executive, and the royal colleges (including the Royal College of Nursing) settled wholeheartedly on a new set of eight principles for progress, to undergird and, in a few cases, to revise and replace the principles and vision set out in the 1998 white paper.¹ These eight principles—sometimes called the Langlands Eight—guided some crucial adjustments in NHS strategy and have remained more or less intact for over two decades. Every school child can recite the Langlands Eight but let me recite them again, with brief explanations for their rationale.

1: Improvement comes from knowledge

Since it began, the NHS has invested in transferring knowledge about how to organise care. For example, the NHS developed standardised models for community based primary care, public health, and specialty care in hospitals. By 1998, however, you had begun to understand how much you could gain from finding and spreading your own best practices—the best you could find within the NHS—in clinical care and management. As one NHS executive stated, “If the NHS fails to use our own internal best practices as our standard, we lose perhaps the only significant advantage of being large.” Or, to quote another, “If we only knew what we knew, we would be geniuses.”

Before 1998, systems in the NHS defaulted to the status quo—that is, without enormous efforts to introduce changes, time honoured approaches were taken as the standard. In the first few years of the 21st century, you decided that thenceforth the status quo would not be the standard; instead, the best known practice, adapted to local use, would be the standard—whether in clinical care, such as the best approach to treating depression, or in managerial practices, such as the best system for scheduling doctors’ time or the smoothest use of operating theatres.

Until then, you had been sitting on a gold mine, but not mining it. Here are the words of the then incumbent president of the Royal College of Physicians in her inaugural speech in the year 2001: “If we know that someone—anyone—in the NHS has achieved a level of care or outcome that outdistances the rest of us, we have not just an opportunity, but a sacred duty, to put that example to use everywhere as our new standard of practice, or go it one better. Let physicians never confuse professionalism with insularity. The NHS is our close and welcome partner in finding, documenting, and helping us to learn from the best among us.” The other royal colleges followed.

To accomplish this transfer of technical knowledge as a core activity—that is, to make the best practice the NHS standard—required major changes in the structure and capacity of the NHS itself. You began with the formation of the National Institute for Clinical Excellence and the Commission for Health Improvement, but over the next few years you learned more about effective technology transfer. The most successful model eventually came from, of all places, the United States, from its Agricultural Extension Service, which throughout the 20th century developed, refined, and operated one of the best technical exchange systems ever seen. The Agricultural Extension Service continually bridged the gap between innovators, universities, and developers, on the one hand—sources of great, new ideas for better farming—and the field. It placed in the hands of farmers, in usable forms, innovations that might otherwise have taken decades to diffuse into practice.²

Today, the NHS Extension Service, managed in cooperation with the royal colleges and other professional groups, has three key measures of success: the speed with which sound advances in care and service spread throughout the single NHS; the speed with which information about the best sites for specific areas of clinical and service performance become known to all NHS caregivers; and ratings of helpfulness given to the NHS Extension Service by its main customers: doctors, nurses, and managers in delivery sites.

The usefulness of today’s technology transfer activities in the NHS could not develop fully, of course, until the second of the Langlands Principles was adopted.

2: Measurement for improvement is not measurement for judgment

In 1998, with well meaning naivety, you were perhaps a bit taken in by a common but incorrect belief—namely, that the principal use of measurement of performance in the NHS was to increase accountability, to make judgments. You thought that measurement would facilitate improvement by supporting market selection, rewards, punishments, and selective accreditation. You were only partially right.

The problem, of course, is that measurement alone does not hold the key to improvement, any more than measuring my daughter’s errors in playing the Minute Waltz improves her piano playing. It is not possible to learn without measuring, but it is possible—and very wasteful—to measure without learning.

For a while, the NHS got it wrong. You overemphasised accountability and you underemphasised learning. You invested heavily in onerous processes of inspection and accreditation, and you developed snazzy, nearly useless “report cards” for public consumption, copying wasteful practices from the United States. We Americans could have warned you about the price you would pay for fostering a psychology of conflict around measurement in the NHS, inducing the measured parties to fight back with defensive criticism of the measurements themselves. We could have told you about healthcare organisations that, faced with an accreditation survey, bury the evidence on their own errors and flaws, instead of revealing and studying it in the service of improvement.

Gradually, you came to realise how costly this negative “name and shame” approach really was. Leaders came to recognise that measuring could be an asset in improvement if and only if it were connected to curiosity—were part of a culture primarily of learning and inquiry, not primarily of judgment and contingency. Today, reports on performance on important dimensions of care are eagerly awaited by many in the NHS, so that best practices can be found and the learning can begin.

3: Make control over care as local as possible

As the century turned you experimented briefly with rather large primary care groups as the most promising level of aggregation for improvement of care. Nice try, but you aimed a little too high. You found that you needed a slightly more sophisticated view of the problem of scale: to assign to large aggregates, like the primary care group, only those aims and tasks that could not be accomplished within smaller units, such as arranging for highly technical specialty services. The solution, you learned, was to focus control over resources and encourage innovations in care at a level of aggregation large enough to transfer resources rationally from, say, one care programme to another, but small enough to recognise and involve patients and their families as individuals.

For some aims in public health and population based care, the primary care groups created new opportunities for rational, effective programmes of care. But for many other aims the best unit of control and accountability is smaller, and you therefore returned in part to the idea of the fundholding general practice as an ideal unit of organisation.³ By studying the most successful fundholders, like Dr John Oldham in Glossup, you learned, for example, about how groups of five to 20 doctors entrusted with the care of communities of 10 000 to 20 000 could sensibly manage the associated resources while avoiding both anonymity for patients and bureaucracy for themselves. Primary care groups as originally conceived were just a shade too big to accomplish many of the needed improvements in personal health care.

To make list management work, however, you had to make a major shift in training the doctors and nurses who were to care for those lists. With the full support of both your academic centres and the royal colleges, you defined a new set of skills that had to be mastered as a condition of medical and nursing qualification These skills equip today’s NHS doctors, nurses, pharmacists, physiotherapists, and other clinicians much better to manage limited resources and, even more important, to be constructive in improving the systems of care in which they work. Among these skills are knowledge of systems, mastery of cooperation and negotiation, understanding finance at the organisational level, skills in local measurement and tracking of outcomes of care and satisfaction of patients, and the ability to conduct and learn from local, small scale trials of change in the search for improvement.⁴

Equally important, NHS managers and authorities realised quickly after 1998 that they needed new skills and more training just as badly as others did.

4: Improvement requires cooperation among disciplines

In the NHS you had long spoken of cooperation, but your deeds did not always match your words. Until the end of the 20th century, doctors and nurses, for example, rarely trained together, and “cooperated” mainly by avoiding each other’s territory. It was even worse between clinicians and managers, the former often judging the latter harshly, and the latter, perhaps in defence, usually failing to confront doctors with the needed changes in their behaviour.

You would never have achieved the success you have today if you had perpetuated this tribalism and fragmentation. As the presidents of the Royal Colleges of Physicians and Nursing stated in their joint address at the 20th annual meeting of the Academy of Health Care Professionals Royal Colleges last year, “It is hard to recall, and even harder to justify, the irrational conviction of separateness that for so long kept us from the fullest possible cooperation in continually refashioning care in the service of our patients.”

The NHS of today is so much more the jointly led endeavour of the many professional groups who work together—not separately—to provide care and protection to the people of Britain. Today, young doctors, nurses, and managers train together as they will work together, and their former disrespectful images of each other are now seen as unprofessional.

5: Waste is poor quality; removing waste is improvement

Perhaps because of the tribal separation of clinical from managerial leadership, many NHS leaders attending the 50th anniversary celebration in 1998 would still have distinguished between “quality”—by which they would have meant the technical and interpersonal properties of care given to patients—and “efficiency”—by which they would have meant decreasing the level of resources invested to produce that care.

Today, you have unified those ideas. Today, you see “cost” as a “quality” of a system of care—a variable to be improved just as you can improve levels of morbidity, mortality, dignity, or pain control. In the unification of professional perspectives around the core aims of the NHS—in teamwork—you have also found that every discipline has an opportunity to contribute toward every aim. You now regard it as the duty of lay managers to understand and help improve clinical outcomes. Equally, doctors and nurses, along with their professional societies, now understand their key role and responsibility in helping to achieve continual reductions in the cost of care, not by withholding services but by discovering and eliminating waste in all its forms. Formerly, clinicians would have seen the pursuit of wise cost reduction as “management’s job.” Now, they share in that pursuit willingly and as a matter of professional pride.

6: Waiting costs more than it saves

In 1998, the most significant defect in the NHS from the public’s point of view was its waiting times. Queues were everywhere—for appointments, for elective surgery, in clinics and offices, on the telephone. The “New NHS” white paper made efforts to change this by proposing, for example, a 24 hour telephone advice line. But concessions to waits were still apparent. Take the 1998 proposal of guaranteed access to specialist consultation within two weeks for women with suspected breast cancer—two weeks of anguished delay as a woman who has been told she may have cancer waits to find out if she does, while, in technical terms, the answer could be known in a few hours. And you called that “service.”

This turned out to be an error. You assumed that delays were inevitable in a system of constrained resources—that delays helped you cope with those constraints. In fact, as you now know, delays often reveal inefficiencies; they point out mismatches between supply and demand. By reallocating the supply of services to better match demand, by shaping demand cooperatively with patients and families, and with innovation in the design of the care itself, you learned to reduce delays substantially with the same or fewer resources.⁵ You found out rapidly in 1998 that simply calling for reductions in waits was far from sufficient; in fact, it just made hard working caregivers angry. To reduce waits required not exhortation but redesigning the processes of care themselves.

You found clues about how to do this within the NHS, back in 1998. Looking carefully for best practices, you identified clinics and specialists whose waiting times were substantially lower than the norm even though they relied on the same or fewer resources against the same or larger demand. You helped others throughout the NHS to learn from these leaders.

You learned, as well, from industries outside health care. By 1998, innovators in other industries had developed approaches—sometimes referred to as “lean production” or “just-in-time” methods—that smoothed flow and reduced both costs and delays.⁶ The relevant science bases are in queuing theory, operations research, and statistics, and by using these sciences to design care, you now achieve substantial reductions in delays even while you conserve resources. You mastered the theory and practice of lean production, adapted the methods to health care, and produced better results for both patients and caregivers.

In the NHS of today, a women with suspected breast cancer gets a firm diagnosis if she wants it within four hours of the first suspicion, day or night, so you can begin planning treatment if she has cancer and limit the psychological pain if she does not.

7: Service is at the core of our work

Before 1998, you underestimated the importance of service in your own health care. The problem lay in mentally separating “care” (the technical procedures used by healthcare professionals) from “service” (the experiences of patients and their loved ones). In the late 20th century, all healthcare systems tended to treat the former as their core work and the latter as an amenity. That framing was incorrect.

In 2023, we now fully understand that the experience of the people we serve, as they judge that experience, is intimately tied into the basic effectiveness of care itself. The way we interact with people (with properties like respect for individual preferences, promptness of reply, dignity, privacy, completeness of communication, involvement of loved ones, and attention to comfort) affects not just their level of satisfaction but also their physiological, functional, and psychological outcomes. Diabetic patients who are coached to ask their doctors questions assertively rather than remaining passive attain lower glycated haemoglobin levels than patients not so counselled.⁷ Surgical patients carefully educated about their conditions and care before their operations are less likely to develop postoperative fevers than patients not so instructed.⁸

The NHS of 2023 understands far better than it did before 1998 that dignity, privacy, individual respect, and communication are not frills; they are care, every bit as tied into the clinical, health status mission of the NHS as are giving the proper drugs or making the correct diagnosis. In its fullest form, this understanding leads to the eighth principle.

8: Patients and families can care for themselves

Powerful as the first seven principles are, they pale in impact when compared with the eighth. More than any other, the principle that patients and families can be their own caregivers transformed the costs, outcomes, and shape of the NHS between 1998 and 2023.

There is, of course, a technical dimension to this. As electronic connectivity grew in the late 20th and early 21st centuries, health care was slow to recognise how this technical revolution could extend its impact. It took us all a while to realise that expertise could move at the speed of photons, and that the very best knowledge could be available almost anywhere at almost any time. Today, you can and do still offer patients the warm human touch and personal presence when they want it, but you also offer, and they accept and value, direct, electronically facilitated access to the knowledge, words, voice, and picture of caregivers who in decades past they could never have reached. Doctors help doctors this way too. Instead of waiting weeks for a consultation with a distant specialist, general practitioners, like patients, are now only minutes from whatever world class help they wish.

But that is only part of the story. Not only do you now know technically how to give patients the knowledge they need, you have also given them more control over their own care. By the late 1990s you began drawing on the example of such doctors as Larry Staker from Intermountain Health Care, who trained his diabetic patients to measure their blood sugar and adjust their insulin doses, achieving far better control than when the doctor was making the insulin adjustments.⁹ You learned from Dr David Sobel at Kaiser Permanente in America, who trained chronically ill adults to provide care and education to other chronically ill adults, achieving better health status outcomes and lower cost for both teachers and students.¹⁰ You built your programmes on evidence of the benefits of patient self care in studies of asthma treatment,¹¹ hypertension treatment, and self diagnosis of urinary tract infection.¹²

By the early 21st century, the NHS was becoming a truly patient centered clinical care system. The emphasis today is on helping people with acute and chronic illnesses to become experts in their own care whenever they wish, able to participate fully in their own diagnosis, treatment, and monitoring. Shared decision making, incorporating every patient’s values and circumstances, is now the norm.¹³ NHS patients today write in and read their own medical records, receive much of their care in their own homes, and remain fully connected with their loved ones and communities.

At first, your doctors resisted this trend—fearing, perhaps, that it would relegate them to second fiddle, demean their expertise, and perhaps subject patients to undue hazards. Instead, this reformulation of the respective roles of doctor and patient has helped everyone—giving patients and their families the chance to establish control over their own lives and giving doctors, nurses, and other healthcare professionals the chance to focus their time and energies on exactly those technical, pastoral, and humanitarian tasks that they are in the best position to pursue.

These principles endure. You are not by any means finished. As in 1998, and as it will be in 2048, you in 2023 seek the continual improvement of an NHS full of knowledge, taking the best as its norm, growing its capacity as a full and integrated system of shared effort, wasting little, and respecting every patient as an individual. You continue to know that you started off right in 1948, and with some important midcourse corrections, you remain well on track. Maybe some day healthcare leaders in the United States will catch up. I am sure you will help them if they ask.

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A nationally organised ...

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... publicly funded ...

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... system of guaranteed health care is still an excellent policy option