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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No peace after progress

How the death of the industrial way of life gave us choice – and stoked resentment and fear.

Now that the making of useful and necessary things in Britain is only a shadow of what it once was, we can see more clearly the effects of the Manufacturing Age. The cost was high to the producers of prodigious wealth; a ten-year difference in life expectancy remains between people living in the richest areas and those in Glasgow. The (fleeting, it now seems) visitation of industrialism has made life more comfortable and its dismantling has liberated millions from choiceless occupations. The legacy is one of spectacular improvement, unequally shared.

Perhaps the most dramatic experience of the 20th century was the suddenness with which profligate plenty replaced a skinflint subsistence. Was it the speed of this that distracted us from wondering why, instead of the secure sustenance that generations of needy people had asked of an unyielding economic system, we were offered a promiscuous spillage of goods, promoted with quasi-religious zeal by the converts of a capitalism that had previously delivered to most of its captive workers a life of penury? Such a rapid reversal might have alerted us to changes beneath the surface that elided losses incurred.

The greatest of these was certainly not the extinction of the industrial way of life itself, release from which has been an unqualified blessing. But the transition from relentlessly work-driven lives (in the 1950s, two-thirds of Britain’s workers were still manual labourers) was marked by perfunctory obituaries for the disintegration of industrial communities, with no acknowledgement that, for a century and a half, they had represented the inescapable destiny of the people they sheltered.

Even less recognition was given to the fortitude with which they had borne a long, coercive labour. A way of life, buried without ceremony in the unmarked grave of progress, could not be mourned; and this has generated some social pathologies of our time: resentment over an arbitrary obliteration of industry, disengagement from a party of labour by those it called, like feudal lords, its “own people”, loss of memory of the economic migrants we also were, passing from the goad of industry into the pastures of consumption, and thence into the liberating servitude of technology.

Grief makes no judgement on the intrinsic value of what is lost. Absence of the known and familiar is the object of melancholy in its own right, even if replaced by something immeasurably better. Objectively, there was little to mourn in the vanished industrial way of life: insufficiency and humiliation, malice of overseer and manager, officiousness of poor-law administrator and means-test man. Male industrial workers exhausted in body and spirit, instead of protecting those for whom the power of their hands was the only shelter against destitution, visited similar punishment on their wives and children. There is nothing to be lamented in an end to the penitential life of women, scrubbing not only the red tiles of the kitchen floor, but even an arc of pavement outside the front door; their interception of men on payday before wages were wasted on beer and oblivion; the clenching against joyless invasion of their bodies in the boozy aftermath. But it was the only life they knew, and they adhered to it with grim stoicism and even pride.

There is much to be said for their resistance. The fragile lattice formed by women’s arms was often the only safety net against destitution. Trade unions and friendly and burial societies that shielded folk from economic violence foreshadowed the welfare state and the National Health Service.

The life of labouring people in Britain was strikingly homogeneous, despite diversity of occupation, dialect and local sensibility. There was the same collective experience: terraced house with parlour reserved for celebration or mourning; the three-piece suite, plaster figure on a stand behind the window, chenille curtain against the draught, engraving of The Stag at Bay on the wall; the deal table and Windsor chairs in the living room, the mantelpiece a domestic shrine with clock, candlesticks and pictures of soldiers smiling before they died; the music of cinders falling through the bars in the grate; cheerless bedrooms where husband and wife slept in high connubial state, more bier than bed, where sexual enjoyment was ritually sacrificed as flowers of frost formed on the inside of the window.

And everywhere photographs: wraithlike children with ringlets or in sailor suits, fated never to grow up; weddings in the back garden, a bouquet of lilies and a grandmother in boots and astrakhan hat; the smudged features of a kinsman no one can now identify. Identical memories, too: the shotgun wedding in the dingy finery of a Co-op hall; the funeral tableau around the grave, amid ominous inscriptions of “Sleeping where no shadows fall”; queues outside the ocean-going Savoy or Tivoli to watch Gone With the Wind; the pub where “Vilia” or “The Last Rose of Summer” was hammered out on a discordant piano.

The opening up of such sombre lives might have been expected to call forth cries of gratitude. Instead, a synthetic joy has emanated largely from the same sources that, until recently, offered people grudging survival only, the change of tune outsourced to producers of manufactured delight, purveyors of contrived euphoria to the people – a different order of industrial artefact from the shoes, utensils and textiles of another era.

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A more authentic popular res­ponse exists beneath the official psalmody, a persistent murmur of discontent and powerlessness. Anger and aggression swirl around like dust and waste paper in the streets of our affluent, unequal society. As long-term recipients of the contempt of our betters, we know how to despise the vulnerable – people incapable of work, the poor, the timid and the fearful, those addicted to drugs and alcohol. Sullen resentment tarnishes the wealth of the world, a conviction that somebody else is getting the advantages that ought to be “ours” by right and by merit.

Rancour appears among those “left behind” in neighbourhoods besieged by unknown tongues and foreign accents: people who never voted for unchosen change, as all political options are locked up in a consensus of elites. “Give us back our country!”
they cry; even though that country is not in the custody of those from whom they would reclaim it. There was no space for the working class to grieve over its own dissolution. If, as E P Thompson said, that class was present at its own making, it was certainly not complicit in its own undoing.

Grief denied in individuals leads to damaging psychological disorders. There is no reason to believe that this differs for those bereaved of a known way of living. The working class has been colonised, as was the peasantry in the early industrial era. When the values, beliefs and myths of indigenous peoples are laid waste, these lose meaning, and people go to grieve in city slums and die from alcohol, drugs and other forms of self-inflicted violence. Though the dominant culture’s erasure of the manufacturing way of life in Britain was less intense than the colonial ruin of ancient societies, this subculture was equally unceremoniously broken. It is a question of degree. The ravages of drugs and alcohol and self-harm in silent former pit villages and derelict factory towns show convergence with other ruined cultures elsewhere in the world.

Depression is a symptom of repressed grief: here is the connection between unfinished mourning and popular resentment at having been cheated out of our fair share, our due, our place in the world. If we are unable to discern our own possible fate in suffering people now, this is perhaps a result of estrangement from unresolved wrongs in our own past. Nothing was ever explained. Globalisation occurred under a kind of social laissez-faire: no political education made the world more comprehensible to the disaffected and disregarded, people of small account to those who take decisions on their behalf and in their name.

Anyone who protested against our passage into this changed world was criminalised, called “wrecker” and “extremist”. The miners’ strike of 1984 was the symbol of this: their doomed fight to preserve a dignity achieved in pain and violence was presented by the merchants of deliverance not only as retrograde, but also as an act of outlawry. Resistance to compulsory change was derided as a response of nostalgics protecting the indefensible, when the whole world was on the brink of a new life. Early in her tenure of Downing Street, Margaret Thatcher, that sybil and prophet who knew about these things, warned that Britain would become “a less cosy, more abrasive” place: a vision confirmed by the Battle of Orgreave – redolent of civil war – and the anguish of Hillsborough.

It is too late to grieve now. Scar tissue has healed over the untreated wound. Though no one expects the ruling classes to understand the distress of perpetual “modernisation”, the leaders of labour might have been able to recognise capitalism’s realm of freedom and a gaudy consumerism that concealed hardening competitiveness and the growth of a crueller, more bitter society.

The ills of this best of all worlds, its excessive wealth and extreme inequality, are on show in hushed thoroughfares of London, shuttered sites of “inward investment”, where the only sound is the faint melody of assets appreciating; while elsewhere, people wait for charitable tins of denutrified substances to feed their family, or sit under a grubby duvet, a Styrofoam cup beseeching the pence of passers-by.

Unresolved feelings about industrialism, enforced with great harshness and abolished with equal contempt for those who served it, are certainly related to the stylish savagery of contemporary life. The alibi that present-day evils are an expression of “human nature” is a poor apology for what is clearly the nature – restless and opportunistic – of a social and economic system that has, so far at least, outwitted its opponents at every turn.

Jeremy Seabrook’s book “The Song of the Shirt” (C Hurst & Co) won the Bread and Roses Award for Radical Publishing 2016

This article first appeared in the 23 June 2016 issue of the New Statesman, Divided Britain