The covid-19 pandemic has challenged and stretched the NHS as never before. What kind of service is likely to emerge, asks David Zigmond
The ubiquitous blue NHS logo does its PR task well: for many it continues to reassure us by symbolising an integrated and freely accessible health service that will endure beyond our individual lives. The sign thus serves as a kind of shield or amulet saying: your socialised welfare is secure, here, to care for and protect you. But we have seen, increasingly, how the sign may also conceal many conflicts of interest and agencies of control. Like a franchised commercial network, the individual units may be conducting other business behind the friendly, familiar sign. The illusion, though, is mostly successful, even when specious: it comforts, calms, and reassures.
This observation is not new to some, but has become clearer and greater with this government’s response to the covid-19 pandemic. A few months ago there was a national wave of ebullient relief at the pioneering rollout of a covid vaccine. Yet, overall, apart from the government and its tribal loyalists, few observers are in any doubt that the UK’s earlier response to the pandemic was often inconsistent, incoherent, and lacking in holistic intelligence.
Of course, this newly emerged virus has confounded much of our previous knowledge and working assumptions, but most nations of similar economic status initially performed much better: the UK’s egregious early pandemic mortality statistics demonstrated this. The vaunted “Moonshot,” “world beating” Test and Trace system, and “cutting edge,” “game changing” apps have proven to be more like advertising slogans or bar-room braggadocio than the considered measures of a socially responsible, scientifically informed government. This is all the more remarkable and tragic to have happened in a nation that was, until 30 years ago, often held to be a model of efficiently sustainable, socialised national healthcare.
How has this descent happened? Over the past 18 months—since covid became a crisis—we have seen the inherent limitations of a service that has been all too easily devolved to divisive, profiteering market forces and remotely managed cybernation.
Early on in this pandemic, the government again disregarded the long experience and expertise of established laboratory and community based NHS staff in delivering Test and Trace. Instead, with swift stealth and massive expense, they subcontracted this work out to large business corporations: Sitel, SERCO, Randox etc. Aside from the probable profligacy of cronyism involved, there is now the even more indisputable evidence that although these business conglomerates may have the financial and resource capacity for these tasks, they do not have the competence or commitment to understand, engage, or influence local communities or individuals. These crucial kinds of service used to come far better from the combination of long established clinical and community teams—from the “real” NHS, not the expediently and expensively hired giant businesses borrowing and vaunting the “trust us we’re the NHS” blue logo.
What the last three decades of government have, cumulatively, failed to understand is that the more we commodify and commercialise our health service, the less well we address the human nuances of communities and individuals. This has been long argued by those alarmed by the erosion and displacement of personal continuity of care, particularly in primary and mental healthcare. Yet similar caveats are now clear in the mass scale public health activities administered to a population threatened by a pandemic: the clumsy confusion of the recent “pingdemic” shows us some serious flaws of remote app management and the like. Will the government learn from the exposure of its specious bluster and dangerously extravagant rhetoric? This currently looks unlikely.
The previous health secretary, Matt Hancock, recurrently broadcast personal ideas about what, post-covid, he hoped and predicted for the NHS: particularly a pre-eminent role for digital technology. Computers have, of course, been increasingly important to all kinds of clerical, administrative, and logistical work through the NHS since the millennium. But Hancock’s proposals went far beyond this: he did not see phone and digital media, apps, etc as augmenters or ancillaries for direct human contact in NHS consultations, he saw them as replacements. The current health secretary, Sajid Javid, has not demurred from this vision of an NHS where face-to-face consultations are mostly made redundant by phone and video links, apps, emails, and the like “wherever possible.”
Such remote, even automated, contacts will function much like a giant network of call centres. In general practice these will increasingly be located in mega polyclinics, staffed largely by part time, rotated professionals who either hot desk or—even more expedient and inexpensive—can work from home. Commercial operators will be encouraged to cherry pick parts of this. The gains seem attractively evident: rapidity of response, ease of access, flexibility of staff deployment, and—not least—significant cost savings. All good, surely?
But our erstwhile health secretary opined all this with apparent oblivion to the mass of evidence showing us how ill suited are such high tech, impersonal, cybernated systems to engaging with our covid Test and Trace. As David Heymann, chair of Public Health England, has explained and warned us: “Face-to-face trust is what’s important . . .You can’t do contact tracing from a central location [and expect it] to be effective.”
So the government should be learning what many public health experts have been trying to tell them: there is no adequate (no matter how expensive) substitute for local professional knowledge of, then engagement with, individuals within their neighbourhoods and communities. Hancock’s preferred devices may well have been suited to handling data, but meaningful human engagement requires much more than that. There is no sign (yet) that the government—albeit with a replacement health secretary—recognises or understands the nature and importance of the gap between the two.
If this is the case with expediently subcontracted public health, what will be the fate of those more essentially personal healthcare sectors, particularly primary and mental healthcare?
The government’s current trajectory has sent a dispiriting chill through the heart of those practising, and those sustained by, any personal continuity of care. For that threatened culture is actually the larger part of our frontline NHS activity; this is because it includes anything that is not a singular, clear problem that can be swiftly and completely “fixed” with generic technology or simple advice. So it comprises the myriad problems of maturation, adjustment, and development; all chronic illness (by definition); stress related illness and mental health; degenerative conditions of ageing; palliative and terminal care.
All of these will sometimes require technical devices but they are mostly addressed by pastoral healthcare: healing or comforting consultations that skilfully guide, support, and encourage. Such interactions must draw from growing personal knowledge, trust, faith, and understanding. These are subtle processes of communication that depend on relationships that are individual, local, and relatively enduring. So if remotely generated apps or automated algorithms fare poorly with Test and Trace, how much worse will they be when consigned to contain and caretake such personally embedded complexity as general practice or psychiatry? These systems may work fine for the healthy, busy young professional with early tonsillitis—an easy problem. But what will happen with the lonely, frightened nonagenarian whose recent widowhood is exacerbating her degenerative spinal pains?
The relationships we grew in our NHS work were, before our serial reforms, the means by which we could best comfort, understand, and heal—not just our patients, but ourselves too. The new tools of the digital evolution may emblazon the comforting NHS logo, but how can they possibly offer the anchorage and sanctuary of the practitioner who knows and understands those who are fearful and sick or the worried well?
David Zigmond is a retired GP and psychiatrist in London.
Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.