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 secret anti-capitalist history of McDonald’s

As a new film focuses on the real founder of McDonald’s, his grandson reveals the unlikely story behind his family’s long-lost restaurant.

One afternoon in about the year 1988, an 11-year-old boy was eating at McDonald’s with his family in the city of Manchester, New Hampshire. During the meal, he noticed a plaque on the wall bearing a man’s face and declaring him the founder of McDonald’s. These plaques were prevalent in McDonald’s restaurants across the US at the time. The face – gleaming with pride – belonged to Ray Kroc, a businessman and former travelling salesman long hailed as the creator of the fast food franchise.

Flickr/Phillip Pessar

But this wasn’t the man the young boy munching on fries expected to see. That man was in the restaurant alongside him. “I looked at my grandfather and said, ‘But I thought you were the founder?’” he recalls. “And that’s when, in the late Eighties, early Nineties, my grandfather went back on the [McDonald’s] Corporation to set the history straight.”

Jason McDonald French, now a 40-year-old registered nurse with four children, is the grandson of Dick McDonald – the real founder of McDonald’s. When he turned to his grandfather as a confused child all those years ago, he spurred him on to correct decades of misinformation about the mysterious McDonald’s history. A story now being brought to mainstream attention by a new film, The Founder.


Jason McDonald French

“They [McDonald’s Corporation] seemed to forget where the name actually did come from,” says McDonald French, speaking on the phone from his home just outside Springfield, Massachusetts.

His grandfather Dick was one half of the McDonald brothers, an entrepreneurial duo of restaurateurs who started out with a standard drive-in hotdog stand in California, 1937.

Dick's father, an Irish immigrant, worked in a shoe factory in New Hampshire. He and his brother made their success from scratch. They founded a unique burger restaurant in San Bernardino, around 50 miles east of where they had been flogging hotdogs. It would become the first McDonald’s restaurant.

Most takeout restaurants back then were drive-ins, where you would park, order food from your car, and wait for a “carhop” server to bring you your meal on a plate, with cutlery. The McDonald brothers noticed that this was a slow, disorganised process with pointless costly overheads.

So they invented fast food.

***

In 1948, they built what came to be known as the “speedy system” for a fast food kitchen from scratch. Dick was the inventor out of the two brothers - as well as the bespoke kitchen design, he came up with both the iconic giant yellow “M” and its nickname, the “Golden Arches”.

“My grandfather was an innovator, a man ahead of his time,” McDonald French tells me. “For someone who was [only] high school-educated to come up with the ideas and have the foresight to see where the food service business was going, is pretty remarkable.”


The McDonald brothers with a milkshake machine.

McDonald French is still amazed at his grandfather’s contraptions. “He was inventing machines to do this automated system, just off-the-cuff,” he recalls. “They were using heat lamps to keep food warm beforehand, before anyone had ever thought of such a thing. They customised their grills to whip the grease away to cook the burgers more efficiently. It was six-feet-long, which was just unheard of.”

Dick even custom-made ketchup and mustard dispensers – like metal fireplace bellows – to speed up the process of garnishing each burger. The brothers’ system, which also cut out waiting staff and the cost of buying and washing crockery and cutlery, brought customers hamburgers from grill to counter in 30 seconds.


The McDonald brothers as depicted in The Founder. Photo: The Founder

McDonald French recounts a story of the McDonald brothers working late into the night, drafting and redrafting a blueprint for the perfect speedy kitchen in chalk on their tennis court for hours. By 3am, when they finally had it all mapped out, they went to bed – deciding to put it all to paper the next day. The dry, desert climate of San Bernardino meant it hadn’t rained in months.

 “And, of course, it rained that night in San Bernardino – washed it all away. And they had to redo it all over again,” chuckles McDonald French.

In another hiccup when starting out, a swarm of flies attracted by the light descended on an evening event they put on to drum up interest in their restaurant, driving customers away.


An original McDonald's restaurant, as depicted in The Founder. Photo: The Founder

***

These turned out to be the least of their setbacks. As depicted in painful detail in John Lee Hancock’s film, Ray Kroc – then a milkshake machine salesman – took interest in their restaurant after they purchased six of his “multi-mixers”. It was then that the three men drew up a fateful contract. This signed Kroc as the franchising agent for McDonald’s, who was tasked with rolling out other McDonald’s restaurants (the McDonalds already had a handful of restaurants in their franchise). 

Kroc soon became frustrated at having little influence. He was bound by the McDonalds’ inflexibility and stubborn standards (they wouldn’t allow him to cut costs by purchasing powdered milkshake, for example). The film also suggests he was fed up with the lack of money he was making from the deal. In the end, he wriggled his way around the contract by setting up the property company “McDonald’s Corporation” and buying up the land on which the franchises were built.


Ray Kroc, as depicted in The Founder. Photo: The Founder

Kroc ended up buying McDonald’s in 1961, for $2.7m. He gave the brothers $1m each and agreeing to an annual royalty of half a per cent, which the McDonald family says they never received.

“My father told us about the handshake deal [for a stake in the company] and how Kroc had gone back on his word. That was very upsetting to my grandfather, and he never publicly spoke about it,” McDonald French says. “It’s probably billions of dollars. But if my grandfather was never upset about it enough to go after the Corporation, why would we?”

They lost the rights to their own name, and had to rebrand their original restaurant “The Big M”. It was soon put out of business by a McDonald’s that sprang up close by.


An original McDonald restaurant in Arizona. Photo: Flickr/George

Soon after that meal when the 11-year-old Jason saw Kroc smiling down from the plaque for the first time, he learned the true story of what had happened to his grandfather. “It’s upsetting to hear that your family member was kind of duped,” he says. “But my grandfather always had a great respect for the McDonald’s Corporation as a whole. He never badmouthed the Corporation publicly, because he just wasn’t that type of man.”

Today, McDonalds' corporate website acknowledges the McDonalds brothers as the founders of the original restaurant, and credits Kroc with expanding the franchise. The McDonald’s Corporation was not involved with the making of The Founder, which outlines this story. I have contacted it for a response to this story, but it does not wish to comment.

***

Dick McDonald’s principles jar with the modern connotations of McDonald’s – now a garish symbol of global capitalism. The film shows Dick’s attention to the quality of the food, and commitment to ethics. In one scene, he refuses a lucrative deal to advertise Coca Cola in stores. “It’s a concept that goes beyond our core beliefs,” he rants. “It’s distasteful . . . crass commercialism.”

Kroc, enraged, curses going into business with “a beatnik”.


Photo: The Founder

Dick’s grandson agrees that McDonald’s has strayed from his family’s values. He talks of his grandfather’s generosity and desire to share his wealth – the McDonald brothers gave their restaurant to its employees, and when Dick returned to New Hampshire after the sale, he used some of the money to buy new Cadillacs with air conditioning for his old friends back home.

“[McDonald’s] is definitely a symbol of capitalism, and it definitely sometimes has a negative connotation in society,” McDonald French says. “If it was still under what my grandfather had started, I imagine it would be more like In'N'Out Burger [a fast food chain in the US known for its ethical standards] is now, where they pay their employees very well, where they stick to the simple menu and the quality.”

He adds: “I don’t think it would’ve ever blossomed into this, doing salads and everything else. It would’ve stayed simple, had quality products that were great all the time.

“I believe that he [my grandfather] wasn’t too unhappy that he wasn’t involved with it anymore.”


The McDonald’s Museum, Ray Kroc’s first franchised restaurant in the chain. Photo: Wikimedia Commons

Despite his history, Dick still took his children and grandchildren to eat at McDonald’s together – “all the time” – as does Jason McDonald French with his own children now. He’s a cheeseburger enthusiast, while his seven-year-old youngest child loves the chicken nuggets. But there was always a supersize elephant in the room.

“My grandfather never really spoke of Ray Kroc,” he says. “That was always kind of a touchy subject. It wasn’t until years later that my father told us about how Kroc was not a very nice man. And it was the only one time I ever remember my grandfather talking about Kroc, when he said: ‘Boy, that guy really got me.’”

The Founder is in UK cinemas from today.

Anoosh Chakelian is senior writer at the New Statesman.