In writing To Provide All People, I hoped to create a lyrical bridge between the birth of the most radical and beautiful idea we’ve ever made manifest and the people who embody that idea today: the staff and patients of the National Health Service. Moving between the story of its coming into being in 1948 and personal experiences of the service today, my aspiration was to paint a philosophical and emotional map of our NHS rather than a journalistic or political survey. I wanted to excavate what the idea of healthcare free at the point of delivery means for us as individuals and as a society. What are the patterns of psychological resonance of such a national act of compassion and how has the ethos of the idea informed and formed us, as individuals and as a country?
Researching the creation of the service was inspirational. It’s an extraordinary story of vision and action. In the wake of the second world war, Aneurin Bevan, the youngest member of Clement Attlee’s newly elected Labour government, created – in the space of only two years and against considerable opposition from the Conservatives, members of his own cabinet, the medical profession and the press – an organisation that totally altered the nation’s cultural position in relation to health. On 4 July 1948 an individual’s healthcare was largely their own financial responsibility. Health, employment and wealth were intricately braided. At one minute past midnight on the 5th, however, an individual’s health became a communal concern, a legal right and with that right financial worry was removed from the consulting room. Overnight, the shadow of poverty in Britain became a few shades lighter.
It is hard to imagine what an equivalent cultural shift would look like today. A one-tier education service suddenly brought into being perhaps? Private schools abolished and the very best of education available to all, regardless of their social position or wealth.
It should be acknowledged that whoever had won the 1946 election would have made an attempt to create a national service of some form. Pressure had been growing for a comprehensive system since the end of the first world war and the country had just witnessed, via the war effort, the possibilities of state intervention and collective action. The process had already begun before the end of the war. In 1944 Bevan’s predecessor, the Conservative minister for health, Henry Willink, published a white paper titled A National Health Service, in which the principles of a free-at-point-of-care service funded through general taxation were proposed. No one, however, had foreseen the extent to which Bevan, influenced by his socialist background as an activist and councillor in Tredegar, in what is now Blaenau Gwent, would drive the concept. When he revealed his plans for nationalising the nation’s hospitals there was an outcry. The press rallied against the proposal, Churchill strongly opposed it while Willink prophesied “the plan would destroy so much in this country that we value”.
Seventy years later and the opposite is true. The NHS has instead become a symbol of what we value and an essential thread in the worn fabric of British national identity. Somehow, a deeply socialist idea has become a cherished institution at the heart of a wider society which has, in the years since its birth, only ever travelled further in the other direction.
The contemporary research for To Provide All People was also frequently inspirational. To be reminded how the NHS has created and inhabits the most diverse, equal and non-commercialised public spaces in our society was invigorating. As was speaking to staff from every level of the service, all bonded by its ethos and the sense of being links in a vast network of care, passing on to their patients and their juniors their knowledge and compassion. To interview individuals who owed their lives or the lives of their loved ones to the service was especially moving; to witness, at intimate, family level, what care free of financial concern actually means and how, under other systems, some of those to whom I spoke would no longer exist. To talk with these patients was also to be reminded of what Bevan called the service’s “secret, silent column” – those who, having been healed by the service, are once again able to contribute to society, financially through their taxes, but also by performing their own acts of compassion in turn. As one woman with Crohn’s disease said to me: “I’m setting up an arts centre in Newport and I used to volunteer in the Calais refugee camp. Just think, without the NHS the people of Newport wouldn’t get that centre, and those refugees wouldn’t have had my help.”
As often as these interviews were inspirational, however, they were also just as frequently saddening, frustrating, as again and again I came across the consequences of that tension between the ethos of the service and the increasingly capitalist wider society in which it sits; a society where the principles at the NHS’s heart have been eroded to scarcity. As one A&E consultant put it to me at 2am, halfway through her night shift: “Sometimes it feels like we’re an island of care in a society that doesn’t any more. This service was designed as a part of a network of welfare, but if the rest of that network is dismantled, then where does that leave us?”
Low nurses’ salaries, pay freezes and axed nurses’ bursaries; extreme short-staffing; having no time to do your job properly; the disastrous financial and medical consequences of public-private initiatives and PFI repayments; cuts to social care passing on pressures to hospitals; the undermining and demoralising effect of a steady tide of negative stories in the press; years of under-investment compared with health services in other developed countries; the alienating effect on an entire generation of the recent standoff between junior doctors in England and the government; the harmful effects of Brexit on recruitment, retention of international staff and the NHS’s ability to benefit from European research; the threat of American healthcare companies waiting in the wings for post-Brexit US trade negotiations; the strain of possible litigation and the heavy loads of paperwork to protect against it.
These were some of the most common sources of concern and anxiety among the doctors, nurses, porters, domestics, psychiatrists and surgeons with whom I spoke. If there was one word to summarise their collective state it would be embattled – as if 70 years after the founding of the NHS they had become the victims of a 180-degree turn. Where once it was the minister of health who had been the visionary, the believer, and members of the British Medical Association who’d been the sceptics, now it seemed as if it was the medical staff who were left defending an idea for which their government appeared to have lost its commitment.
“It’s as if they want us to break,” one coronary care nurse said to me, sitting in a cubicle in the intensive care unit. “But surely they can’t want that?” Minutes earlier she had welled up over a patient she’d thought she’d lost but who had recently returned fully recovered to thank her team. Now she cried in front of me once again, but this time, because of her fear for the life of the NHS.
That nurse’s worries were echoed in many other conversations. Almost 50% of my interviewees thought the NHS, as we understand its core principles, would no longer exist in 10-15 years. A “kitemark” was a common word used to describe how this might happen: “The NHS logo will become a kitemark of sorts, representative of a brand more than an idea.”
Increasingly, what I felt I was witnessing in these interviews were the intimate symptoms of systemic pressure, the cellular breakdown on the level of an individual, a team, a ward caused by the denial to the wider service of its rightful nutrition of support, investment, belief. What I also repeatedly witnessed in these conversations, though, was the positive aspect of that double-scaling, of a mammoth organisation still able to be so human, a gigantic machine still attentive to the personal. It’s this quality, when you engage with the idea and the staff of the NHS, that is so consistently surprising and uplifting, to be at the heart of such a humane entity at both the level of society and the individual simultaneously.
No one else I met so embodied this quality of the service than its nurses, the men and women who enact Bevan’s vision every day in the most intimate and unseen offerings of tenderness, kindness and empathy. They are the most consistent and vital connective tissue that binds the grand scale of the NHS’s philosophy with the intimacy of its practice.
A month before the NHS act came into effect Bevan opened a speech to the Royal College of Nursing with the simple statement: “Nurses are the most important part of the service.” Two years earlier, when addressing the college, he had touched on the practical implications of this importance. “I realised from the very start,” he said, “that no matter how distant my relationship with the doctors might become, I had to be most friendly with the nurses, if I was ever to get our health service going properly.” Later in that same speech Bevan addressed a pressing issue facing the nascent NHS – a shortage of properly trained nursing staff. “As we become increasingly civilised,” he told the crowd. “We attach more importance to health, and nurses acquire a higher and higher status: they become more and more valued and the shortage has arisen because of greater demand.”
Seventy years later, and a shortage of nursing staff has once again become a critical challenge facing the NHS. From what I gleaned from my interviews, however, the cause of this shortage is the exact opposite of that identified by Bevan. The nurses I met were passionately attached to the ethos of the service and the nature of their jobs. But they were also stressed, underpaid, overtired and often felt undervalued, their salaries more a mark of disregard than a mark of value. As one midwife said to me: “I know a few midwives, good ones, too, who are working the tills in Waitrose now. They just couldn’t take the stress any more, the hours, the pay.” What, I couldn’t help thinking, in the light of Bevan’s measurement of civilisation, does that say about us as a nation? The NHS is the best of us, as a concept, a practice and a people. If we are to hold on to the belief that each generation is a step forward, not backwards, in our growth as a species, we need to remember that and cherish both the idea and the people who make it live. If we don’t, we risk passing on to our children and grandchildren not an inspiring communal act of empathy, as envisioned by Bevan, but rather a diminished offering of humanity, the product of an age of squander, not wonder.
To Provide All People: A Poem in the Voice of the NHS by Owen Sheers is published by Faber (£12.99). To order it for £11.04 go to guardianbookshop.com or call 0330 333 6846. A film poem of the work will be broadcast on BBC One Wales on 28 June and on BBC Two on 30 June
