The BMJ’s NHS commission: an emphatic recommitment to the founding principles
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj.q187 (Published 31 January 2024) Cite this as: BMJ 2024;384:q187Read the full series: The BMJ Commission on the Future of the NHS
Just before the National Health Service began in the UK, Aneurin Bevan, the minister of health in 1948, wrote in The BMJ: “On July 5 there is no reason why the whole of the doctor-patient relationship should not be freed from what most of us feel should be irrelevant to it, the money factor. The picture I have always visualized is one … of a nation deciding to make healthcare easier and more effective by pooling its resources—each sharing the cost as [they] can through regular taxation and otherwise while [they are] well, and each able to use the resulting resources if and when [they are] ill.”1
Since Bevan outlined his vision, health, healthcare, and wider society have vastly changed. Life expectancy has improved from 70 years for females and 66 years for males in 1948, to 83 years and 79 years respectively in 2020.2 Healthcare is transformed through innovations in diagnostics, imaging, and therapeutics. The expectations of a growing and ageing population are spiralling, placing great strain on the NHS, with staff burnt out from working in poor environments and living with the moral distress of being unable to provide adequately for their patients.34
During the covid-19 pandemic, NHS staff stepped up to deliver the care needed in the most challenging of circumstances. But the pandemic clearly showed that the NHS had little or no spare capacity following a decade of health policies and austerity measures that eroded both the health service and baseline population health.5 Widening inequalities meant that the pandemic differentially affected people on low incomes and from ethnic minorities.6
The societal shock delivered by the pandemic has been likened to the societal shock that gave birth to the NHS after the second world war.7 Today’s attempts to recover and refashion the NHS are complicated by long term challenges in recruitment and retention of a skilled workforce, brought to the fore by a year of industrial action.8 International staff, who historically have had a major role in the success of the NHS, are alienated and harder to recruit in a political environment hostile to immigration.9
The NHS has been envied and copied by other countries, an established model of universal health coverage in a world struggling to achieve this internationally agreed goal.10 However, recent data suggest that, although the NHS may be cost effective and provide equitable access, it ranks low on clinical quality outcomes.611 The health service is in crisis, stretched beyond breaking point. This has led some to voice doubts about the model of the NHS.12 Is it even possible to continue to provide high quality care for all, regardless of ability to pay, funded through general taxation? We believe it is.
Realising the NHS vision
Fundamental questions about the future of the NHS will be examined intensely in a year of a general election and a new government. The BMJ Commission on the Future of the NHS was established from the perspective that a high quality health service, free for all at the point of care, is too precious to be allowed to fail.13 Our aim was to identify the key challenges and priorities and make recommendations aimed at ensuring that the vision of the NHS is realised. We did not seek to create a textbook on how to run a health service, or to be comprehensive. Commissioners were selected from a range of disciplines and professional backgrounds in healthcare.14 We divided the work into seven main themes and formed working groups of commissioners to consider each theme and propose solutions.
The first paper in the series examines the relevance of the founding principles of the NHS, now and for the future, and recommends critical changes in the scope, organisation, and governance of the service.15 The commission calls on the newly elected government, of whichever political hue, to recognise the existential threat to the NHS, and the damage that is being done to population health and wellbeing, by declaring “a national health and care emergency”; recommitting to the founding principles of the NHS, including its ongoing funding through general taxation; and launching an urgent review and national conversation to agree a long term vision and plan for the NHS. We propose additional principles for the NHS to embrace and a new arm’s length body, akin to the Office for Budget Responsibility,16 to hold government to account for delivery of the NHS plan.
Future papers will examine and produce recommendations on how we deliver health and equity; how we should fund and pay for the health service; how we develop a motivated, happy, well trained workforce that is appreciated and valued; how we address the wider determinants of health through an approach that properly incorporates public health, prevention, and other sectors; how we can breakdown silos by creating a “one health and care system” with seamless patient pathways and public involvement; and how we achieve all this while prioritising sustainability and producing a greener NHS. Each working group will also consider cross-cutting themes such as technology and partnership with patients, public, and civil society.
The national health and care crisis we are facing requires an urgent, robust, and values based response. It requires new thinking and old values. It requires a clear long term vision and long term planning. It requires the voices of health professionals and patients to be heard. It requires a recognition of the inequalities and wider social determinants that drive health outcomes. It requires prioritisation of health and care, of people and the planet. Above all, it requires us to recommit to the founding principles of the NHS, to put the health and wellbeing of our population first, and to revive the spirit of Aneurin Bevan and a nation that came together in the hope of creating a better, fairer, healthier world.
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
The BMA, which owns The BMJ, grants editorial freedom to the editor in chief of The BMJ. The views expressed in this editorial, and in the papers of the BMJ Commission on the Future of the NHS (https://www.bmj.com/nhs-commission), are those of the authors and may not necessarily comply with BMA policy. The BMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. The BMJ was responsible for the peer review, editing, and publication of the papers of the commission.