The great survivor: another 60 years

Liam Donaldson looks to the horizon and considers some of the issues that may arise for health servi

The founding fathers of the National Health Service (NHS), calling to mind the decline in major infectious diseases, foresaw a future for the NHS where it would be concerned primarily with the maintenance of health. They even predicted falling demand for its services.

Current predictions about the challenges for the NHS in the short and medium term point to the "usual suspects": an ageing population, advances in medical technology, growing consumer expectations and burgeoning pools of chronic disease.

It is difficult to contradict the assumption that, a decade from now, the NHS will face more of the same. Need and demand for healthcare will continue to grow, particularly among an elderly population where many individuals no longer suffer from one disease but several: so-called "co-morbidity". A woman in her late 70s who has had a minor stroke but also suffers from diabetes, arthritis and heart disease is not an unusual patient. However, she would have been when the NHS was founded.

The care needs of millions, often compounded by absent family support, will turn on coordination of care and long-term support to maximise independence. Add to this the ethical and anti-ageism point that new drugs and other treatments should not be denied to older people and the inexorable rise in the volume and complexity of NHS workload will continue unabated.

In response, the NHS, a decade ahead, will surely have shifted its organisational structures and processes towards integration of primary, hospital, community and social elements. Currently, they are too compartmentalised and patients move across care boundaries like ships in a storm. Many of the structures of the NHS were designed to provide reliable, comprehensive care for people with health emergencies and one-off illnesses. New models of patient-centred care will engage expert patients in the long-term management of their own health, with clinicians there to advise, guide and support their choices. These services will need to be planned and designed in a way that has never been done before.

The consumerist nature of an increasingly demanding society of baby boomers, generations X and Y and their successors will require a significant shift from the stoic "make do and mend" of the wartime generations. While there are differences between the roles of patient and customer, these boundaries will blur. Advanced internet systems will enable patients to consult with expert doctors across the world. Pressure to go with the digital, rather than traditional, referral channels will be enormous. The NHS will have adapted to this, incorporating a new notion of customer service into its ethos and functioning.

A future service must be free from the geographical variations in quality of care that are too common now. The new focus on quality that has emerged from Lord Darzi's NHS review will have driven the service towards a radical reinvention, where decisions are made to enhance quality rather than minimise cost. Quality will be the currency of the NHS a decade from now.

Over the horizon, into 2030 and beyond, new medical frontiers will have opened up. Today's young Turks of medical research will be stroking their grey beards with satisfaction as science and technology bring untold benefits to the bedside. Stem cells will repair damaged, diseased and ageing organs and tissues; gene therapy will cure inherited diseases such as cystic fibrosis and muscular dystrophy. Techniques that can control the immune system will switch off autoimmune disease; drugs and cell manipulation will suppress many forms of cancer; and robots will allow surgeons to perform intricate operations on the beating heart.

Three decades from now, it will be routine for babies to have their genetic profile stored on a microchip for life. Faulty genes will be corrected. However, only a proportion of disease is genetically determined and, with the growth of new therapeutic opportunities, most of us will be patients. Advances in diagnostic equipment and scanners, their miniaturisation and intelligent features will move them out of hospital and into the hands of patients.

The impact of these changes will be profound: patients and families diagnosing, monitoring and treating their own conditions will bring about a sea change in the traditional relationship between health professional and patient and the organisational structures of the NHS.

Underpinning all this is the hope that citizens in all walks of life will take responsibility for their own health and its maintenance. In some ways, this is the most uncertain field of prediction, given the intractability of unhealthy lifestyles, addiction and health inequalities. Yet, surely future generations will look back with incredulity at newsreel footage of smokers, obese children and city centres swarming with binge drinkers.

With all these changes must be the imperative to transform global health inequality, with new generations of vaccines and the benefits of advanced technology and medical science.

Predicting the health and healthcare landscape on the 120th anniversary of the NHS, 60 years from now, requires a step into the kingdom of futurology. Here, what wonders could the "medicine of the impossible" yield? Walk-in, walk-out chambers which diagnose disease and then reset the body's functions to normal? Replacement of diseased or aged organs with advanced tissue engineered or digital alternatives? Doubling of the human lifespan? The digitisation of the human mind?

The NHS has been remarkably resilient in absorbing 60 years of change in disease patterns and advances in medical science. There is every reason for us to be confident that it is a success story that will run and run.

Sir Liam Donaldson is chief medical officer

This article first appeared in the 02 February 2009 issue of the New Statesman, Interview: Alistair Darling

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The New Times: Brexit, globalisation, the crisis in Labour and the future of the left

With essays by David Miliband, Paul Mason, John Harris, Lisa Nandy, Vince Cable and more.

Once again the “new times” are associated with the ascendancy of the right. The financial crash of 2007-2008 – and the Great Recession and sovereign debt crises that were a consequence of it – were meant to have marked the end of an era of runaway “turbocapitalism”. It never came close to happening. The crash was a crisis of capitalism but not the crisis of capitalism. As Lenin observed, there is “no such thing as an absolutely hopeless situation” for capitalism, and so we discovered again. Instead, the greatest burden of the period of fiscal retrenchment that followed the crash was carried by the poorest in society, those most directly affected by austerity, and this in turn has contributed to a deepening distrust of elites and a wider crisis of governance.

Where are we now and in which direction are we heading?

Some of the contributors to this special issue believe that we have reached the end of the “neoliberal” era. I am more sceptical. In any event, the end of neoliberalism, however you define it, will not lead to a social-democratic revival: it looks as if, in many Western countries, we are entering an age in which centre-left parties cannot form ruling majorities, having leaked support to nationalists, populists and more radical alternatives.

Certainly the British Labour Party, riven by a war between its parliamentary representatives and much of its membership, is in a critical condition. At the same time, Jeremy Corbyn’s leadership has inspired a remarkable re-engagement with left-wing politics, even as his party slumps in the polls. His own views may seem frozen in time, but hundreds of thousands of people, many of them young graduates, have responded to his anti-austerity rhetoric, his candour and his shambolic, unspun style.

The EU referendum, in which as much as one-third of Labour supporters voted for Brexit, exposed another chasm in Labour – this time between educated metropolitan liberals and the more socially conservative white working class on whose loyalty the party has long depended. This no longer looks like a viable election-winning coalition, especially after the collapse of Labour in Scotland and the concomitant rise of nationalism in England.

In Marxism Today’s “New Times” issue of October 1988, Stuart Hall wrote: “The left seems not just displaced by Thatcherism, but disabled, flattened, becalmed by the very prospect of change; afraid of rooting itself in ‘the new’ and unable to make the leap of imagination required to engage the future.” Something similar could be said of the left today as it confronts Brexit, the disunities within the United Kingdom, and, in Theresa May, a prime minister who has indicated that she might be prepared to break with the orthodoxies of the past three decades.

The Labour leadership contest between Corbyn and Owen Smith was largely an exercise in nostalgia, both candidates seeking to revive policies that defined an era of mass production and working-class solidarity when Labour was strong. On matters such as immigration, digital disruption, the new gig economy or the power of networks, they had little to say. They proposed a politics of opposition – against austerity, against grammar schools. But what were they for? Neither man seemed capable of embracing the “leading edge of change” or of making the imaginative leap necessary to engage the future.

So is there a politics of the left that will allow us to ride with the currents of these turbulent “new times” and thus shape rather than be flattened by them? Over the next 34 pages 18 writers, offering many perspectives, attempt to answer this and related questions as they analyse the forces shaping a world in which power is shifting to the East, wars rage unchecked in the Middle East, refugees drown en masse in the Mediterranean, technology is outstripping our capacity to understand it, and globalisation begins to fragment.

— Jason Cowley, Editor 

Tom Kibasi on what the left fails to see

Philip Collins on why it's time for Labour to end its crisis

John Harris on why Labour is losing its heartland

Lisa Nandy on how Labour has been halted and hollowed out

David Runciman on networks and the digital revolution

John Gray on why the right, not the left, has grasped the new times

Mariana Mazzucato on why it's time for progressives to rethink capitalism

Robert Ford on why the left must reckon with the anger of those left behind

Ros Wynne-Jones on the people who need a Labour government most

Gary Gerstle on Corbyn, Sanders and the populist surge

Nick Pearce on why the left is haunted by the ghosts of the 1930s

Paul Mason on why the left must be ready to cause a commotion

Neal Lawson on what the new, 21st-century left needs now

Charles Leadbeater explains why we are all existentialists now

John Bew mourns the lost left

Marc Stears on why democracy is a long, hard, slow business

Vince Cable on how a financial crisis empowered the right

David Miliband on why the left needs to move forward, not back

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times