By Piyush Pushkar

What is the NHS?

“Stay home. Protect the NHS. Save lives.”

The UK government’s public health messaging from 20 March to 10 May was short and direct. The brevity suggests clarity of meaning, but that clarity begins to dissipate when one asks, “What is the NHS?” The short answer is that the NHS is the UK’s tax-funded, state-run healthcare system. (Commonly, the NHS is used to refer to England’s NHS, as Scotland, Wales and Northern Ireland have independent healthcare systems.)

This article provides an alternative viewpoint on what the NHS is. For the political activists with whom I did ethnographic research in 2017 and 2018, the NHS was important to them because it symbolised something important to their ethical worldviews. If we consider that the NHS is a symbol, as well as a healthcare system, then we must remember that the meanings of symbols change in response to how we use them.

Stay home. Protect the NHS. Save lives.

The UK’s lockdown has been accompanied by the tagline: “Stay home. Protect the NHS. Save lives.” The message is designed to encourage compliance with the lockdown and “flatten the curve”. The purpose of flattening the curve is to reduce demand on health services, thus giving said services a maximal chance of being to cope with an unprecedented crisis.

Social distancing and lockdowns are well recognised public health strategies being employed in multiple countries. However, lockdown has been experienced in different ways by different states. Each place has its own specific social and historical context in which public health strategies play out. The UK context was one in which the health services being protected had seen restrictions in funding for many years, at the same time as an increasing need for healthcare from an ageing population.

Protect the NHS… from what?

In 2017 and 2018, I spent 13 months doing ethnographic fieldwork with people who protested against recent NHS reforms. I was investigating how they brought their own ethical worldviews into their political campaigning, and vice versa. As well as interviewing them, I attended protests, internal meetings, leafleting sessions, social gatherings, and appointments they organised with healthcare managers and politicians.

The activists all disapproved of the aforementioned restrictions in funding, which they described as “cuts”. Most of them also objected to privatisation of health services, which they felt was morally wrong, for multiple reasons I have explored elsewhere.

Years before COVID-19, these activists also spoke of protecting the NHS. They were attempting to “save” or “protect the NHS” from cuts and privatisation. The meaning of protecting the NHS has now turned on its head. Rather than protecting the NHS from being diminished, the new usage of the phrase means to protect the NHS from being overwhelmed by the people it is meant to serve. The government is using the exact same rhetoric as the people who were protesting a reduction in capacity. The irony is that had resources and capacity been maintained, as requested by the activists, the NHS (and England’s public health infrastructure, which was separated from the NHS in 2013, but still subject to fiscal restraint) would have been better prepared for COVID-19.

The difference in meaning raises an interesting question regarding the meaning of the NHS. What exactly are activists and the UK government talking about when they talk about protecting the NHS? For the activists with whom I did research, it was an icon of the kind of society that they felt the UK has been in the past, and ought to be in the future. They referred to their own memories of the NHS, and used these memories as comparators against which they could judge the contemporary NHS. Their memories of a past NHS were powerful because they facilitated an understanding not just of what a good state ought to provide, but also what it could provide. Free, comprehensive, universal healthcare was not just ethically desirable. It was politically possible.

What was the nature of the icon that they considered the NHS to be? For them, the NHS symbolised the values of a solidaristic society in which people cared for and took responsibility for one another. The UK government’s recent references to the NHS also invoke a spirit of solidarity and mutual responsibility. Citizens are encouraged to stay home in order to protect others. The UK government’s messaging can be made to fit Prainsack and Buyx’s definition of solidarity as “an enacted commitment to carry ‘costs’ (financial, social, emotional or otherwise) to assist others with whom a person or persons recognise similarity in a relevant respect”. Citizens are showing solidarity with fellow citizens by being willing to put up with the costs of staying home, to protect everyone’s health by protecting the NHS. So how does this recent messaging differ from how NHS activists conceived of the NHS and solidarity?

The key difference lies in how solidarity is achieved and how responsibilities are fulfilled. For my research subjects, the NHS showed that the state could and should intervene to foster a good society, and provided a model for how. Thus they sought to protect the NHS from a government that they felt was malignantly undermining solidarity, as they imagined it. Conversely, the current UK government uses the same symbol, conscious of its rhetorical power, to redirect responsibility for public health back to the citizens themselves. In this new framing, it is the irresponsible person who has left the house unnecessarily who has undermined solidarity.

Conclusion

I have compared how activists campaigning against cuts and privatization used the symbolism of the NHS to how it is currently being used by the UK government. Clearly, the different usages lead to different moral arguments and different political conclusions, and thus would be likely to lead to different policy prescriptions and health consequences. Therefore, it will be important for us to monitor how and why state actors are talking about the NHS. As we begin to plot possible pathways out of lockdown, the UK government’s messaging has changed. Although the new slogan has been criticized for a lack of clarity, protecting the NHS remains a key discursive backbone of the government’s justifications for current and future actions. For us to evaluate those actions, we must continue to ask what they mean when they talk about the NHS.

Author: Piyush Pushkar

Affiliations: The University of Manchester

Competing interests: I have no financial interests to declare.

Social media accounts of post author: @DrPiyushPushkar