Introduction

Like many other health systems, the NHS has been regarded as more like a sickness than a health service, failing to place health before healthcare, and to focus ‘upstream’ on the ‘social determinants of health’ (SDH) (for example, Wanless 2002; Marmot and Wilkinson, 2005; Hunter 2016a). This has implications for both aggregate health and health inequalities. First, while life expectancy in the UK in the twentieth century increased 38 years for men and women, equivalent to an increase of 4½ months per year (ONS, 2015), much of this improvement in life expectancy and health status more generally, is associated with the SDH (Marmot, 2010). It has been estimated that only 10–25 per cent of the health of a developed population is attributable to the healthcare system (McGinnis, Williams-Russo and Knickman, 2002: 83; Harrison and McDonald, 2008: 165). However, only ‘around 5% of the total UK government healthcare expenditure’ is devoted to preventive healthcare, with about half of NHS staff not regarding prevention as a core part of the work of their organisation (Faculty of Public Health, 2019; see also Exworthy and Morcillo, 2019).

Second, the temporal pattern for health inequalities is more complex. There has long been a recognition of health inequalities in terms of geographical and social class differences in life expectancy since at least the Chadwick Report 1842 (for example, Bambra, 2016). However, while overall health, in terms of life expectancy, broadly increased for much of the twentieth and early twenty first century before stalling or reversing in recent years (Marmot et al 2020a), health inequalities have increased at some times and reduced at others. For example, according to Robinson et al (2019), absolute inequalities in the infant mortality rate (IMR) increased between the most deprived local authorities and the rest of England between 1983–1998, decreased during the period of the English health inequalities strategy (1999–2010), but increased again in the period 2011–2017.

This chapter will thus examine the ways in which the NHS has addressed the issue of health and health inequalities. First, it focuses on four chronological periods of policies on health and health inequalities in the 75 years of the NHS. Then, it explores health and health inequalities through the four analytical lenses introduced in Chapter 1, before moving to evaluate policies concerned with health and health inequalities.

Introduction

We opened this book (Chapter 1) by observing that the NHS was in a parlous and unprecedented position. Now that the contributors have surveyed the period across a range of domains, there seems to be very little evidence to revise that verdict. Over its 75 years, the NHS has seen a number of ‘big bang’ reforms and many more, smaller incremental reforms (Tuohy, 2018). While there has been a great deal of analysis on the former (Robinson and Le Grand, 1994; Le Grand, Mays and Mulligan, 1998; Thorlby and Maybin, 2010; Exworthy Mannion, 2016), there is a danger that the smaller but cumulative changes of the latter may be missed (Powell, 2016).

Cumulative incremental changes are harder to detect and assess and receive less publicity than large-scale (big bang) reforms which are often heralded with much fanfare and public debate. Large-scale reforms of health systems such as the NHS may be somewhat constrained by its own logics (Tuohy, 1999) but they might also have a negative impact on the resilience of the NHS. Individual reforms (or a programme of them) may not necessarily lead to a loss of resilience at that time but repeated reforms may undermine the cohesion of its structures and processes. The rapidity of such change might only serve to weaken such cohesion further (Thorlby and Maybin, 2010; Exworthy and Mannion, 2016: 8; Timmins, 2012; Exworthy and Mannion, 2016: 8). Without a comprehensive and longitudinal evaluation programme, the cumulative impact of healthcare reforms will remain uncertain or unknown.

In this book, we have sought to offer a comprehensive analysis of the state of the NHS in its 75th year. The four analytical axes (governance; public/private, central/local, and profession/state; introduced in Chapter 1 and reprised next) provided an overarching framework which applied, more or less, to the individual chapters. The subjects of these chapters enabled, we argue, a comprehensive coverage of the main dimensions of the NHS in its first 75 years. We note, however, the absence of topics, such as workforce wellbeing and diversity, and environmental sustainability (among others), from our analysis but we urge others to engage with these topics in future research.

Introduction

In its 75th year, despite the hallowed role that the NHS plays in the UK national psyche, the NHS found itself in a parlous position. Across a range of measures, the NHS was facing unprecedented pressures in 2023. First, public satisfaction with the NHS had fallen to its lowest recorded level – 29 per cent, falling 7 percentage points from 2021. Equally significant was the level of dissatisfaction with the NHS, at 51 per cent (Morris et al, 2023). Second, waiting lists were at an all-time high of 7.2 million (as of December 2022). Much of this can be explained by delayed care due to COVID-19 (a rise of 2 million since the start of the pandemic). This was despite the ‘elective recovery plan’ published in 2022 (NHS England, 2022). Third, there were 133,000 (full-time equivalent) vacancies in the NHS in September 2022, a vacancy rate of 9.7 per cent (Health Foundation, 2022). Vacancies in social care stood at 165,000, a vacancy rate of 10.7 per cent (King’s Fund, 2023). Fourth, there was a wave of strikes among NHS staff. Members of the Royal College of Nursing went on strike for the first time in their history. They were joined by ambulance staff and junior doctors. NHS consultants had also voted for strike action. Fifth, while pay can explain some of the causes of these strikes, it is likely that high levels of stress and burnout were also significant factors. The 2022 NHS Staff Survey (published in March 2023) indicated that 45 per cent of staff were unwell due to work-related stress and 57 per cent had come to work despite feeling unwell. Overall, 34 per cent of staff felt burnout, with ambulance staff being especially prone (49 per cent) (Nuffield Trust, 2023).

The conditions prevailing in 2023 were the confluence of factors in the previous several years – financial austerity from 2010, the Brexit referendum vote in 2016 (and the consequent impact upon recruitment and retention of staff and pharmaceuticals) and COVID-19 pandemic (from March 2020). Arguably, the conditions were also the result of the NHS’ politics, policies and organisational structure over the previous 75 years. So it is timely to reassess the contribution and state of the NHS in the past, in the present and in the future.

The Stone-Campbell Movement combined the evangelical revivals of the American frontier, the Enlightenment philosophy of John Locke, Thomas Reid, and Francis Bacon, and the democratic ideals of the United States. The “restoration plea” of early Stone-Campbell leaders emphasized four interrelated themes: restoration, unity, missions, and eschatology. Early leaders believed that the restoration of the teachings, practices, and terminology of the New Testament church would lead to visible unity in an increasingly divided Christianity, which in turn would aid global missions and usher in the millennium. They thought restoring the New Testament church would promote greater faithfulness to God and individual freedom of conscience, as Christians would be united around the teachings, practices, and terminology of Scripture alone, not those promoted by later teachers or found in creeds of human origin. Today the movement represents the ongoing desire in American Protestantism for a Bible-based, mission-oriented, non-denominational Christianity.