This post first appeared at the Radiixuk blog...
Now that both paramedics and nurses are set to strike over the Christmas period, it is at least worth asking the question – can the NHS survive?
Especially when you understand where all the extra money came from over the past three decades (it was the ‘peace dividend’).
But don’t forget two other vital resources that are available to us all in healthcare – which could be mined and then put to use.The first is our natural ability to support friends, families and neighbours as part and parcel of our own recovery.
The second is our willingness and determination to get well again.
I will write about the first of these this time, and the second I will have a go at covering next week.
The main problem is that – despite their official commitment to ‘co-production’ – there are no official mechanisms to give a chance of this happening. I have suggested a few in my chapter for Henry Tam’s book, Tomorrow’s Communities.
The basic underlying issue is that Beveridge assumed that an NHS would cost less to run over time, because need would be reduced. That was the assumption on which the new welfare state rested and it was wrong – in fact it has been wrong everywhere, not just in Britain.
Beveridge set out to slay what he called the Five Giants – Ignorance, Want, Squalor, Disease, Idleness. The problem is not that he failed to vanquish them. He killed them stone dead, but something he never expected happened. They come back to life again every generation and have to be slain all over again and, every time, it gets more expensive.
Through 75 years of peace and plenty, Beveridge’s legacy has not managed significantly to narrow inequalities of income or health or to strengthen mutual support. Neither, in general, has the welfare state successfully tackled the underlying reasons why problems emerge in the first place.
What went wrong? This is such an important question that we hardly dare ask it, in case it is taken as a political excuse to wind up the Beveridge experiment altogether, and because the failure of the welfare state to create a sustainable improvement in social welfare threatens to overwhelm the public finances.
It is true that Beveridge was in some ways a victim of his own success – the welfare settlement led to longer lives, which sometimes (though not always) led to higher costs. It led to different diseases and to disabled children surviving into adulthood. These are partial explanations, but they don’t really cover everything. Why has health spending risen so fast for all generations, not just the old? Why is 70 per cent of NHS time dealing with chronic health problems? Why has crime risen so much in the same period? It isn’t just that people are living longer.
But Beveridge himself was more aware of this conundrum than his reputation suggests. He was aware that the NHS was being rolled out by the Attlee government on lines very different to those he had suggested.
His overlooked third report, Voluntary Action, crystallised his thinking and his warnings about what might happen if the welfare state became too paternalist, and if people’s instincts for self-help, and their ability to find solutions, were allowed to atrophy.
He wrote that the state had an important role but equally important were what he called: “Room, opportunity and encouragement for voluntary action in seeking new ways of social advance … services of a kind which often money cannot buy”.
He was afraid that his reforms were encouraging people to focus passively on their needs.
We need to take the decline in voluntary action seriously, especially as rationed public services increasingly use ‘need’ as their currency of access. The only assets people have then are their own needs, which must be maximised if they are to access help. It is hardly surprising that needs seem to grow.
But there is another problem as well, as the needs increase: the over-professionalisation which Beveridge warned against seems to have widened the basic divide in all public services – between an exhausted, remote professional class and their clients, who are expected to remain passive and easy to process.
This is not just disempowering, it can also be corrosive.
The co-production critique follows Beveridge’s third report. It suggests that the reason our current services are so badly equipped to respond to a changing society is that they have largely overlooked the underlying operating system they depend on: the social economy of family and neighbourhood, also known as the ‘core economy’.
We can no longer rely on continuing economic growth to provide enough finance for public services, and we find that our services have also become constrained by the New Public Management of centralised targets, deliverables, standards and customer relationship management software, which has narrowed the focus of many services and often undermined the relationships between professionals and patients, or between teachers and pupils.
The difficulty is that, although you can point to highly successful small examples of co-production in action in almost every service, very little has been written that sets out what taking these ideas to scale might mean.
From my experience setting up time banks in health settings, where people are encouraged and enabled to support each other in human ways – using the skills that everyone possesses – gives back some value to those skills, which have been slowly excised from our public services.
I know from this that this kind of co-production is effective – especially when it is applied to excluded communities.
It allows surgeries and hospitals to reach out into their surrounding neighbourhoods and to start the urgent process of healing.
And near the anniversary of the first vaccines against Covid being delivered so effectively with the help of ordinary people – that is worth its weight in public spending.