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The NHS at 75: an opportunity to renew a vision the public holds dear

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    Sunder Katwala

The public is not falling out of love with the NHS in principle, despite experiencing the strains on the service in practice, as Dan Wellings has explored in his reflections on how public attitudes to health and care services are changing.

The Covid-19 pandemic paradox for the NHS was that Covid-19 both increased the public’s commitment to its core principles while increasing pre-existing pressures on the health service. So ‘The NHS’ increased its lead as the most popular answer for what makes people proud to be British – at the same time that satisfaction with individual NHS services has fallen to the lowest levels recorded since the British Social Attitudes survey began in 1983.

The level of support for the NHS, with three-quarters of respondents in recent polling agreeing that ‘the NHS is crucial to British society and we must do everything to maintain it’ and the stability of that support over time, closely mirrors public support for the British monarchy. The frustration of conservative commentators who are sceptical about the NHS model – as with former Chancellor Nigel Lawson’s famous complaint that the NHS is a secular national religion – echoes the frustration of left-liberal republican commentators about the enduring consensus in favour of a constitutional monarchy. If those issues divide conservative and liberal commentators, the average member of the public tends to see no contradiction in supporting both the most egalitarian and the most traditional of Britain’s national institutions, as the coincidence of the 75th anniversary of the NHS with a coronation year will demonstrate.

'The NHS is also the paradigm example for the public of the gains of immigration for British society, and the best exemplar of an institution that shows the diversity of modern Britain working together for the common good.'

The NHS stands for several ideals that most people hold very dear. Its universalism makes the NHS the jewel in the crown of the post-war welfare settlement. The commitment to healthcare, free at the point of need, symbolises a consensus on which public goods should not depend on the ability to pay. This consensus on the ends of universal health care extends to broad public support for funding the NHS from general taxation.

The NHS is also the paradigm example for the public of the gains of immigration for British society, and the best exemplar of an institution that shows the diversity of modern Britain working together for the common good. So it is not a coincidence that the 75th birthday of the NHS in July 2023 falls just a fortnight after the 75th anniversary of the arrival of the Windrush in Britain.

Immigration is seen as bringing both pressures and gains to society as a whole – and to the NHS in particular – but there have been significant shifts in a positive direction. A decade ago, the overall public perception was that the pressures of a rising population somewhat outweighed the gains of an international workforce. There has since been a 42-perecentage point net shift towards seeing immigration as positive (+28 per cent in 2022) rather than negative (-14 per cent in 2012) for the NHS. Some 55 per cent of the public say they would like to see an increase in the numbers of doctors and nurses who come to Britain from overseas; just 13 per cent would reduce the numbers. Social care is another area where more people want to increase rather than reduce numbers.

The NHS workforce is the most diverse in Britain. A fifth of employees and four out of ten clinical staff are from visible minority ethnic backgrounds. Yet the NHS has important challenges on race equality, reflected in the mixed experience of its staff. As Lord Adebowale, Chair of NHS Confederation has set out in a clear call for action, critical reviews identified ‘a failure to support BAME staff; to provide equitable access to career opportunities; to stamp out bullying and racist behaviours; and to provide appropriate cultures of care for BAME staff.’

An institution founded on principles of equality must put these principles into practice in the way it treats its staff, as well as its patients.

'The joint 75th anniversaries of the NHS and the Windrush... offer an opportunity to reflect on the history of how we got here – and how the NHS itself both embodies the contribution that migration has made to Britain over those 75 years...'

The joint 75th anniversaries of the NHS and the Windrush show how reflecting on these links can be of both symbolic and practical value. They offer an opportunity to reflect on the history of how we got here – and how the NHS itself both embodies the contribution that migration has made to Britain over those 75 years, and reflects the shifting experiences of three generations of a modern multi-ethnic Britain. Anniversaries can be used to look forward too, and the 2023 anniversary should be a moment when the NHS sets out a vision of the organisation that will mark its centenary in 2048, and the milestones along the way. That should include a clear commitment that that the diversity of the overall workforce should be reflected in the most senior leadership roles.

As it approaches its 75th birthday, the glass remains three-quarters full when it comes to the ideals that the NHS represents. For the public, it is a valuable yet fragile institution. There is a strong public appetite to engage in a conversation about protecting the NHS, not replacing it – helping it to adapt to our changing society and demographics.

The immediate challenges of service delivery and funding pressure make this a challenging time to think beyond navigating the immediate pressures. But the 75th anniversary is also an important opportunity to seek to renew a vision that the public continues to hold dear, and to ensure it will continue to do so in another 25 years’ time.