Did Bevan's bedpan test set the NHS on the wrong track?

The NHS is 70 years old this week. With a long-term funding settlement now in place, in a short series of blogs from the RSA’s Public Services & Communities team, we are highlighting different approaches that NHS policy makers and senior leaders should consider in making the NHS fit for its 80th birthday.

Alongside being ‘free at the point of use’, another much vaunted characteristic of the NHS is that it is very firmly ‘National’ with a capital N. From the outset, Aneurin Bevan famously announced that the sound of a dropped bedpan in Tredegar should reverberate around the Palace of Westminster. Seventy years on, ministerial accountability for ‘dropped bedpans’ still looms large. Scandals such as those uncovered at Stafford Hospital, Bristol Royal Infirmary and most recently Gosport War Memorial Hospital resonate not only for the local suffering they have caused but also because of the collective concern generated by the possibility they might happen elsewhere in the system.

Somewhat paradoxically, the other thing that seems to preoccupy our worries about the ‘N’ in NHS is the possibility of postcode lotteries and that somehow, somewhere, someone might be getting a better quality bedpan. Not only do we want the NHS to be free at the point of use we seem to want it to be the same at the point of use too. Yet even a cursory consideration of health inequalities, whether within or between regions, shows that whether or not there are lotteries in service provision, there are certainly gross disparities concerning health outcomes.

The fact that such a centralised health system is still prone to local scandal while presiding over some of the worst health inequalities in the developed world suggests perhaps that the N in NHS deserves some further reflection in the decade ahead. Could it be in fact that a more localised approach might actually mitigate our worst fears? There are three reasons to think so.

First, in very simple terms, the geography of ill health presents a mixed picture. Although there is much in common when it comes to disease, from neighbourhood to neighbourhood, region to region, there are distinctive characteristics about the health profile of an area and different places might benefit from different types of health provision. Too often nationally determined programmes are too big and too clunky to allow for – let alone promote - local innovation. Lansley’s botched reforms exemplified a system unable to let go. Where local practitioners might spot a quick fix to a specific issue, too often their hands are tied by national frameworks and well-meaning bureaucracies that prohibit  experimentation or risk and where innovation is encouraged, it generally comes in the form of large-scale, top-down programmes like CQUIN.

Second, few doubt that the integration of health and social care is probably the biggest challenge facing the future of the NHS but that to solve it we will need far more local co-ordination. The formation of STPs, while presenting a plausible basis for strategic planning for acute care, make little sense when it comes to service integration. Very few have boundaries which marry up with other public sector partners, not least local authorities. In contrast, Greater Manchester Combined Authority is now a step ahead with its newly devolved approach beginning to open up new ways of working through a number of Local Area Groups closely integrated with programmes such as Age Friendly Manchester and the work of the voluntary and community sector. There is still a long way to go and such approaches will require significant rethinking – and funding – at the centre to stop the NHS simply subsuming local government altogether, but planning health and care services across combined authority areas could enhance their effectiveness and inject a more effective form of accountability than that which we see today.

Thirdly, more local approaches are needed to make the big switch from treatment to the prevention of ill health. Little did Beveridge know that in calling for a national service to rid the nation of the ‘giant evil’ of disease that seventy years later we might have forgotten the corollary of his call for action: his calls for a system of social security included the idea that the state “should leave room and encouragement for voluntary action by each individual to provide more than that minimum for himself and his family.”

The RSA’s recent work on Health as a Social Movement has brought such ideas front and centre with its call to mobilise more people in social movements that improve health and care outcomes. As the various examples of good practice demonstrate. The success of this approach depends upon shifting control to enable people to have more access to, and more control over, the resources in their community that impact on health and wellbeing.

Gareth Southgate recently lauded the diversity of his England team as being characteristic of “modern England”. While we may rightly celebrate the national triumph that is the NHS in the week ahead, we would do well to understand that devolution and diversity of provision are the friends of a truly National Health Service and not its enemies, and as such they must be embraced not feared in the decade ahead.

If you’d like to debate these issues – and the future of the RSA’s work on public services – then please come along to one of our forthcoming events.