Introduction

Like many other health systems, the NHS has been regarded as more like a sickness than a health service, failing to place health before healthcare, and to focus ‘upstream’ on the ‘social determinants of health’ (SDH) (for example, Wanless 2002; Marmot and Wilkinson, 2005; Hunter 2016a). This has implications for both aggregate health and health inequalities. First, while life expectancy in the UK in the twentieth century increased 38 years for men and women, equivalent to an increase of 4½ months per year (ONS, 2015), much of this improvement in life expectancy and health status more generally, is associated with the SDH (Marmot, 2010). It has been estimated that only 10–25 per cent of the health of a developed population is attributable to the healthcare system (McGinnis, Williams-Russo and Knickman, 2002: 83; Harrison and McDonald, 2008: 165). However, only ‘around 5% of the total UK government healthcare expenditure’ is devoted to preventive healthcare, with about half of NHS staff not regarding prevention as a core part of the work of their organisation (Faculty of Public Health, 2019; see also Exworthy and Morcillo, 2019).

Second, the temporal pattern for health inequalities is more complex. There has long been a recognition of health inequalities in terms of geographical and social class differences in life expectancy since at least the Chadwick Report 1842 (for example, Bambra, 2016). However, while overall health, in terms of life expectancy, broadly increased for much of the twentieth and early twenty first century before stalling or reversing in recent years (Marmot et al 2020a), health inequalities have increased at some times and reduced at others. For example, according to Robinson et al (2019), absolute inequalities in the infant mortality rate (IMR) increased between the most deprived local authorities and the rest of England between 1983–1998, decreased during the period of the English health inequalities strategy (1999–2010), but increased again in the period 2011–2017.

This chapter will thus examine the ways in which the NHS has addressed the issue of health and health inequalities. First, it focuses on four chronological periods of policies on health and health inequalities in the 75 years of the NHS. Then, it explores health and health inequalities through the four analytical lenses introduced in Chapter 1, before moving to evaluate policies concerned with health and health inequalities.

Introduction

We opened this book (Chapter 1) by observing that the NHS was in a parlous and unprecedented position. Now that the contributors have surveyed the period across a range of domains, there seems to be very little evidence to revise that verdict. Over its 75 years, the NHS has seen a number of ‘big bang’ reforms and many more, smaller incremental reforms (Tuohy, 2018). While there has been a great deal of analysis on the former (Robinson and Le Grand, 1994; Le Grand, Mays and Mulligan, 1998; Thorlby and Maybin, 2010; Exworthy Mannion, 2016), there is a danger that the smaller but cumulative changes of the latter may be missed (Powell, 2016).

Cumulative incremental changes are harder to detect and assess and receive less publicity than large-scale (big bang) reforms which are often heralded with much fanfare and public debate. Large-scale reforms of health systems such as the NHS may be somewhat constrained by its own logics (Tuohy, 1999) but they might also have a negative impact on the resilience of the NHS. Individual reforms (or a programme of them) may not necessarily lead to a loss of resilience at that time but repeated reforms may undermine the cohesion of its structures and processes. The rapidity of such change might only serve to weaken such cohesion further (Thorlby and Maybin, 2010; Exworthy and Mannion, 2016: 8; Timmins, 2012; Exworthy and Mannion, 2016: 8). Without a comprehensive and longitudinal evaluation programme, the cumulative impact of healthcare reforms will remain uncertain or unknown.

In this book, we have sought to offer a comprehensive analysis of the state of the NHS in its 75th year. The four analytical axes (governance; public/private, central/local, and profession/state; introduced in Chapter 1 and reprised next) provided an overarching framework which applied, more or less, to the individual chapters. The subjects of these chapters enabled, we argue, a comprehensive coverage of the main dimensions of the NHS in its first 75 years. We note, however, the absence of topics, such as workforce wellbeing and diversity, and environmental sustainability (among others), from our analysis but we urge others to engage with these topics in future research.

Introduction

In its 75th year, despite the hallowed role that the NHS plays in the UK national psyche, the NHS found itself in a parlous position. Across a range of measures, the NHS was facing unprecedented pressures in 2023. First, public satisfaction with the NHS had fallen to its lowest recorded level – 29 per cent, falling 7 percentage points from 2021. Equally significant was the level of dissatisfaction with the NHS, at 51 per cent (Morris et al, 2023). Second, waiting lists were at an all-time high of 7.2 million (as of December 2022). Much of this can be explained by delayed care due to COVID-19 (a rise of 2 million since the start of the pandemic). This was despite the ‘elective recovery plan’ published in 2022 (NHS England, 2022). Third, there were 133,000 (full-time equivalent) vacancies in the NHS in September 2022, a vacancy rate of 9.7 per cent (Health Foundation, 2022). Vacancies in social care stood at 165,000, a vacancy rate of 10.7 per cent (King’s Fund, 2023). Fourth, there was a wave of strikes among NHS staff. Members of the Royal College of Nursing went on strike for the first time in their history. They were joined by ambulance staff and junior doctors. NHS consultants had also voted for strike action. Fifth, while pay can explain some of the causes of these strikes, it is likely that high levels of stress and burnout were also significant factors. The 2022 NHS Staff Survey (published in March 2023) indicated that 45 per cent of staff were unwell due to work-related stress and 57 per cent had come to work despite feeling unwell. Overall, 34 per cent of staff felt burnout, with ambulance staff being especially prone (49 per cent) (Nuffield Trust, 2023).

The conditions prevailing in 2023 were the confluence of factors in the previous several years – financial austerity from 2010, the Brexit referendum vote in 2016 (and the consequent impact upon recruitment and retention of staff and pharmaceuticals) and COVID-19 pandemic (from March 2020). Arguably, the conditions were also the result of the NHS’ politics, policies and organisational structure over the previous 75 years. So it is timely to reassess the contribution and state of the NHS in the past, in the present and in the future.

Introduction

This chapter brings together the literatures on policy-learning and lesson-drawing on the one hand, and intra-crisis learning on the other, in order to examine the UK's response to the COVID-19 pandemic. The policy-learning literature explores issues such as what lessons were learned by whom. The lesson-drawing literature examines the content and process of policy transfer, focusing on the fungibility or transferability of lessons. However, most existing work is based on ‘ordinary’ policymaking rather than ‘extraordinary’ or ‘crisis’ policymaking characterised by elements of threat, urgency and uncertainty such as that during the pandemic.

We critically examine three different ‘real time’ lenses, drawing on three main sources: political (government documents, and Hansard debates); scientific (minutes of advisory groups such as the Scientific Advisory Group for Emergencies, SAGE) and media (national news media). These three sources provide different perspectives on the rapidly evolving government agenda. Political sources provide a record of what was being discussed by policymakers, who often claimed that they were ‘following the science’, as well as debates between the government and opposition, providing an insight into the scientific sources they were making use of in their deliberations. The scientific sources explore the extent to which the advisory bodies were looking at emergent research from their own countries, from the past or from abroad. The news media provide a rapid (daily) commentary on issues, giving a contemporary record of what was happening in other countries and material from the past that could inform learning about the virus. As Wolfe et al (2013) suggest, which issues are on the agenda, which ones are not, when and why, are the central questions that drive agenda-setting in communications and policy studies, and become even more important during a period of extraordinary policymaking. Our study cannot trace the links between policymaking and media reporting, but it can throw light on how the media aims to influence the public and policymaking. In particular, we focus on the lessons that the media suggest the pandemic offers to policymakers.

The chapter focuses in particular on the early stages of the pandemic, especially during January to April 2020 when key decisions were being made about policy in respect of testing, lockdown and border controls – the three elements highlighted by prominent public health advisors such as Edinburgh University's Chair in Global Public Health, Devi Sridhar (see Appendix 2: articles on 15 March and 4 May) as being crucial to pandemic response.

Introduction

It has been claimed that the first half of the 2010–15 Coalition government was taken up with debate on the Health and Social Care Bill 2012 (HSCB), which was introduced by Conservative Health Secretary Andrew Lansley, while the second half was devoted to limiting the damage caused by the Bill and dealing with the effects of growing financial and service pressures in the National Health Service (NHS) (Ham et al, 2015: 1; Powell, 2016). This chapter examines the longer period of the cold climate of a decade of austerity in the English NHS, focusing on two broad moves. First, there was a broad move from the optimism of the NHS's 60th anniversary to the greater pessimism of its 70th anniversary. Second, there was a similar game of two halves based on the argument of Timmins (2018) of the rise and fall of marketisation and privatisation, with the Health and Social Care Act 2013 (HSCA) perhaps being the high-water mark of faith in ‘competition and choice’ as the key drivers of NHS reform, and the period since then seeing efforts to ‘work around’ the Act. However, in addition to the ‘constant’ of austerity, some things stayed the same, such as the continuation of inquiries into failings in the NHS, continuing inaction on social care and ‘policy retreads’ on issues such as prevention and integration.

A tale of two birthdays

This section focuses on the move from the optimism of the NHS's 60th anniversary in 2008 (under the Labour government of 1997–2010) to the greater pessimism of its 70th anniversary in 2018. In 2008, some ‘official’ accounts entered the celebratory birthday spirit, for example, according to then NHS Chief Executive David Nicholson: ‘the NHS is performing extremely well’. He continued that the NHS was on course to achieve the historic 18-week maximum waiting time by the end of 2008, and to meet challenging targets for reducing rates of health-care-associated infection. Mortality rates for cancer and cardiovascular disease had been substantially reduced, while access to GP and other primary care services was quickly improving. In its 60th anniversary year, public confidence in the NHS and patient satisfaction with the quality of NHS care were both at their highest level for years (DH, 2008a: 3).