An NHS that belongs to you

This essay was first published in Ordinary Hope: A Mission to Rebuild (Download PDF)

It might be reasonable to assume that the state is responsible for building an NHS fit for the future. It is. But just as economic growth will not come without the input of civil society, nor will the health service reach its goals.

That means going beyond the formal civil society organisations already involved in healthcare. They are vital but we need to take a broader view. We should include the social infrastructure that brings people together with those they know well, and those they know not at all. Think cafes, parks and the school gates. These are contexts auspicious for conversations about how to live peaceably with each other, and for mutual aid, our natural propensity to help, and be helped. This is the foundation for a continually updated Almanac that records our shared moral order. It tells us unequivocally ‘thou shalt not kill’ but also sets out norms for what we eat and drink, and how much we exercise.

This civil society is as powerful as the state. It is the source of fundamental social change, and several health service innovations. Its power is most evident when the state is hamstrung by pandemic or catastrophe as exemplified in the response to Hurricane Katrina so powerfully described by Rebecca Solnit in A Paradise Made in Hell. And yet, civil society is messy. It is a self-correcting system. There is no director of civil society, and no committee to propose ‘let’s change our relationship to food’.

Its function is to strengthen social bonds. It creates shared meaning. It generates a sense of shared destiny, that feeling of ‘together we can’. It gives or denies us permission to be responsible for others. There are technical terms -for example collective agency, collective efficacy- and measures for each of these functions.

When the measures are favourable, people experience their world as predictable. They feel a sense of order. This encourages investment, in themselves, in their family and in their communities. That investment reinforces the bonds, and shared destiny and responsibility for each other. This virtuous circle gets us to better health (and less crime, and more economic growth and…)

The balance between NHS and civil society

By the reckoning of some, for example Robert Putnam and Shaylyn Romney Garrett in their book The Upswing, collective institutions of the post-war age like the NHS are best seen as the product of the power and innovation of civil society. At its creation, citizens and residents rightly felt that the NHS belonged to them. My mother would resist going to the doctor so as not to waste the scarce resources of something precious.

But unhealthy dynamics generated by the size and power of the NHS and the medical professions has unsettled the relationship with civil society. Take one example. The Lancet Commission on The Value of Death found hospitals to be working ever harder to keep patients alive in the last year of their life, sometimes prolonging and increasing suffering. As more people die in hospital civil society is robbed of the experience, conversations and rituals that surround death. That, in turn, diminishes resistance to clinicians wanting to try one more procedure to keep a loved one alive.

These days, nearly half of deaths take place in hospital. Most people want to die at home. No clinician or health manager entered their professions to fill hospital beds with dying patients. The cause is an imbalance in the relationship between civil society and the institutionalised NHS. I see this imbalance undermining maternity services, efforts to reduce long term conditions, and the effective use of scarce mental health services.

Recovering equilibrium

There are some technical fixes for this disequilibrium, for example using system science to tackle the dynamics of addition, the propensity for health systems to find slots for every patient. But lasting solutions require a change in mindset not only in the NHS but also across government.

The starting point is shifting our conception of civil society. It is powerful -with the potential to enhance and undermine health- not powerless. It will engage with the NHS and other services on its own terms. It will not be co-opted. This means finding room for a ‘we’ mentality alongside the ‘I’. When Julianne Holt-Lunstad finds that loneliness is as bad for health as smoking a pack of cigarettes a day, health and social care agencies rush to find and treat lonely patients. They don’t know how to do that. So how about supporting civil society’s natural capacity for social connection for all?

It is reasonable often beneficial for health experts to want to restrict people’s agency, for example to smoke or eat processed food. But many of the greatest advances in health come from releasing individual and collective agency. The California Endowment’s support for citizens and residents in Fresno to win a fight for more park space is one of many examples. The parks are health enhancing. But so too is the sense of shared destiny across Fresno’s neighbourhoods that came from residents winning a multi-billion-dollar lawsuit.

We can turn this idea on its head. The collective will of the people can enhance health policy. Health policy can enhance the collective will of the people. I am impressed, for instance, with the design of social insurance policies for ageing populations in Germany and Japan that have strengthened social solidarity in those countries.

Ultimately, it is in everyone’s interest for the NHS to belong, once again, to the people. It is in health managers’ self-interest to welcome greater accountability to the electorate. Overall, the electorate want the same thing as those managing the NHS. The smart thinkers will create an NHS fit for the future with the people as well as for the people.

The politics of change

As earlier pieces in this collection have shown, we know government must recover trust. The ‘how’ is now as important as the ‘what’.

Over the last year, my colleagues and I scrutinised examples of mission-led government that have been inclusive of civil society. They have shared features. Policy making tends to be proximal to the electorate. Devolution to combined and local authorities and Integrated Care Boards will aid the government missions. Policy tends to be tailored to places that mean something to citizens and residents, their town, or neighbourhood or travel to work area. Progress is facilitated by politicians who can relate to, listen to and debate with local people. The work of councillors and members of parliament in wards and constituencies matters as much as their work in town halls and the Palace of Westminster.

This is difficult territory for the NHS, which has thrived on its relationship with central government. But the readiness to devolve, be place based, and listen to local people and their elected representatives might well determine whether the Government gets the 15 years needed to rebuild an NHS fit for the future.

Getting started

Let me bring all of this back to the lessons of Ordinary Hope for practical change, underpinned by human relationships and led by heroes everywhere.

There are now templates for civil society led change. Some focus on the citizens’ capability to design policy and practice. Some rest on giving civil society the power to hold public systems to account. Some seek to find a common purpose between civil society and public services. And some simply give decision making power to service users, using direct payments for example.

When they work, these types of reform operate at scale. But one small example illustrates the potential. A few years ago, Ordinary Hope core group member Maff Potts and his Association of Camerados erected teepees in the foyers of UK hospitals. A thousand staff members, patients and visitors a week entered each space to connect and reflect. The objective impact was measured in terms of increased altruism and mutual aid in each hospital. The subjective impact was a tangible sense of ‘together we can’. It is a simple way of discovering the power and potential of civil society.