In this post, Dr Oz Gore, Lecturer in Innovation, Technology and Operations in ULSB, discusses his research on the NHS and, in the wake of ‘its’ 70th birthday, the gap between how we conceptualise the NHS and the reality of the organisation of healthcare in the UK.
We frequently hear about the NHS having a winter crisis, about the NHS failing to achieve results, about the NHS lacking in workforce, or about the NHS being privatised. It was only a few weeks ago that the NHS had its 70th birthday. This three-letter signifier features prominently at the head of news items and in the words of politicians. But where is this ‘NHS’ we speak of? Can we locate it? Can we pinpoint what this all-to-familiar acronym covers? ‘The NHS’, and perhaps because it is so rooted as an icon of the British welfare state, has become something of a linguistic black-box; a convenient denomination meant to signal the (also ephemeral) notion of “healthcare”. It is well worth challenging this popular semantic imagination, particularly if we would like to keep “healthcare” in national hands and continue to promote the equitable principles upon which it was founded.
In a recent publication, my collegaues and I have argued that ‘The NHS’ is not so self-evident or easily articulated. From an organisational perspective, healthcare is a fragmented, convoluted terrain, which should not be treated as a single, unified phenomenon. It is made of various organisations, at varying scales of operation and geographical footprints, working with divergent goals, and not all in communication with one another nor using the same providers to deliver services. While historically health provision was never a single, monolithic operation, this was exacerbated in 2012 with the enactment of the Health and Social Care Act (HSCA), a government reform described as “so big it can be seen from space”. The complexity and diversity of organisations introduced by the HSCA now means that it is extremely difficult to generalise about health provision in England.
In particular, the question of whether ‘The NHS’ is privatised becomes almost nonsensical when taking into account the complexity of how health is administered. Take, for example, General Practitioners (GPs). The local practice is where one goes to for healthcare in England, be it for advice, referral, treatment, or medication. And it is, most broadly, truly free at the point of need (although what counts as need is has been subject to change in recent times). This encounter with ‘The NHS’ is in many respects a false encounter, because these practices are private businesses. While practitioners might all wear NHS tags on their clothes and have NHS branding on their buildings, thus reinforcing a popular imagination of a single organisation, these partnerships or ‘single handled’ practices are contractors with government, comprising their own set of concerns and aspirations. From a regulatory and legal perspective, and even though these GPs act as the first and most available point of contact with the public, these doctors are not public employees. My local practice, and all other ones, are not branches of the NHS. Instead of employees of a national not-for-profit service, under the model opted for back in 1948, their services are bought by the government in bulk based on a collective contract.
GPs are but one example of the organisational disparities within the so-called ‘system’, with hospitals, care homes, and a plethora of other providers working under their own regulatory and contractual obligations while undergoing divergent reforms and reorganisations. It is an organisational mess, made worse by the HSCA, which means there is not always a firm foundation upon which to form a position on the political question of privatisation. The answer would be yes if we focus on how private companies are providing health services. It might be no if we focus on public expenditure on services or how these GPs are collectively contracted. Either way, when taking this kind of diversity into account the designator ‘the NHS’ is not very helpful.
‘The NHS’ black-box and the niceties of an acronym makes it easier to cherry pick politically-oriented evidence and harder for the public to maintain a grip on what is happening in their respective constituencies. Indeed, delving into such details is a privileged practice, highly restricted to those with time and expertise. Nonetheless, colloquial and everyday discussions on health in England would benefit from a closer look at where and what we mean when we invoke ‘the NHS’ in political argumentation or news headlines. Speaking of ‘The NHS’ makes it much easier to claim that money will go ‘there’, as did the VoteLeave campaign or the PM with her recent promises of a ‘£20b birthday present to the NHS’.
MPs on both the left and the right talk of ‘The NHS’ in a similar way. However, this sort of political language is potentially much more useful for those wishing to further diminish national expenditure on health than for those hoping to restore it. Talking about ‘the NHS’ fuels an imagination of a seemingly unified welfare state which MPs can be seen to pay lip service while introducing far-reaching change. Under the last two Conservative-led governments, healthcare in England has seen fundamental reconfiguration of working relations for practitioners, of the governance of services and of the kind of accountability the public can expect. For example, more and more GPs are now grouped into ‘Superpractices’ aimed at cost savings and at achieving a mythical ‘Care at Scale’ with questionable impact on health outcomes and equity, and little in the way of ‘system’ level governance to guide, support and regulate this experimentation. These issues remain under the radar when we continue to speak of ‘The NHS’ as if it is a simple organisation, a ‘system’ or a thing, ready for a cash influx that can solve its problems. Worse still, it risks us buying into and reinforcing political marketing designed to create an image of wholeness, unity, and a ‘national’ health service provision.
‘The NHS’, in a sense, is everywhere. It is at local practices, on newspaper pages, in political arguments, or in the fleeting encounter with an ambulance on the high street. In another sense, this monolithic creature, ‘The NHS’, is nowhere in reality. To be more real about what is at stake, it is necessary to change the conversation, in order to focus on the specificities of decision-making armed with the needed contextual information to understand its implications (is it local? national? by private bodies contracted by government? by government employees?). It would be extremely helpful for news outlets, such as this one, to more often name the organisation and localities at stake directly in headlines and titles, rather than the omnipresent ‘NHS’. Perhaps a more radical approach would be to stop speaking of the NHS altogether, and talk about the specificities of medicines, surgeries, and treatments. The forms of how to do this are plenty and context dependant, but we need to sidestep a popular imagination of a single organisation, a mighty ‘NHS’ that does things and has happen to it. This is particularly so as we are approaching the crunch time of the Brexit negotiations, and the future of ‘The NHS’ will feature prominently in any attempt to justify or oppose future relations with Europe and subsequent trade-deals, especially with the privatisation minded United States.
A version of this blog was originally published on the LSE British Politics and Policy blog 4 September 2018 at: http://blogs.lse.ac.uk/politicsandpolicy/where-and-what-is-the-nhs/
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