Richard Smith: The NHS is a fiction, but what’s the story?

richard_smith_2014Ask somebody “What is the NHS?” and they are likely to answer to “The people who work in it, the buildings they work in, and the tools they use to do their work.” But it clearly isn’t that. The people who work in the NHS come and go, and none were working in the NHS when it began. Buildings too come and go, and the tools are constantly changing. The NHS is not a thing but a fiction, and none the worse for that. Indeed, if we recognise the NHS as a fiction we are more likely to be able to keep it alive.

Fiction, argues Yuval Noah Harari in Sapiens: A Brief History of Humankind, is what has allowed Homo sapiens to move from a perilous positon in the middle of the food chain 100 000 years ago to the top. The first step was the cognitive revolution that allowed Homo sapiens to think about things that don’t exist. No other animal, including other humans, can or could do that. The next step was to create fictions that hundreds would follow, allowing Homo sapiens to act in much larger numbers than the standard 150 or so that can be maintained through mutual knowledge and trust.

Religion is one great fiction. Millions build their lives around it, and some are willing to behead and burn those who pursue a different (and often very similar) fiction. Nations are fictions, and hundreds of millions have died fighting for their fiction. Britain’s future will be decided by whether people prefer the fictions of Britain (plus or minus Scotland) or Europe. Corporations are legal fictions, and the NHS is fiction.

So if the NHS is fiction what is the story? For some the story may be staff, buildings, and tools, but that’s a stuck, uninspiring story. For others it’s a public service—funded, owned, provided, and regulated by the state and infused with a “public sector ideology,” whatever exactly that is. This too is a rigid, inflexible story that if adhered to with too much devotion may mean the end of the NHS. It’s also an inaccurate story in that many services, particularly primary care and end of life services, are provided by the private sector.

The best fiction, I suggest, is that the NHS is simply three values—universal coverage of health services, provision by need rather than ability to pay, and equal quality care for all. Equal quality of care has never been achieved but remains an important aspiration. Universal coverage and provision by need rather than ability to pay have been eroding ever since 1948—think prescription charges, dentistry, and long term care.

This story is, however, a flexible one that provides greater resilience. The values, the centre of the fiction, should stay, but we need to develop the subplots. To keep the NHS alive we need to move rapidly from a service dominated by hospitals, doctors, disease, death denial, and drugs and surgery to one that is more about community services, teams including patients, health, life enhancement, and a wider range of interventions, including urban redesign, changes in food supply, and much more.

And should we move beyond health to include social care? In fact, health and social care are also fictions. Health was the fiction we cared most about in 1948 because treatable disease killed many prematurely and spending on services could bankrupt people—just as happens today in low and middle income countries. But now in Britain the need is different: the provision does not fit the need, and yet must for the NHS or a National Care Service to survive—and not degenerate to a rump service for the poor. For many of the elderly people who cost the NHS most social care matters much more than health care.

Is there a story we can agree on? I fear not now, but perhaps we will as we come closer to the collapse of the NHS.

Richard Smith was the editor of The BMJ until 2004. 

Competing interest: RS was until February 2015 employed by UnitedHealth Group, a company that provides services to the NHS, and he still has shares in the company. He was also a member of the Labour Party’s Independent Commission on Whole Person Care and has a pension from the BMA.