The Good Enough NHS

This is my first blog posting of 2019. I wish all my readers a very happy New Year and I hope everyone achieves what it is they hope for over the next 12 months. Having enjoyed the Christmas and New Year celebrations, I then began with a particularly nasty head cold that has laid me low over the past week. Things that I would normally do with relish have been left undone, and my daily walks (something I’m passionate about) have been considerably reduced. I’m not out of the woods yet. And today is the 6th January, the day that more people in the UK die than any other day of the year. Today is what James Dunn from Beyond (a funeral directors comparison service) describes as the ‘Day of the Dead.’ I’m going to keep a very low profile, I may not even move out from under the duvet! 

However, it is merely a cold and considering what others must endure, I am very grateful. I have been able to self-treat without recourse to the National Health Service. Sitting in the warmth, with a box of tissues by my side, and mug of honey and ginger Lemsip in hand, I had plenty of time to think about the NHS last week. It was of course the first week following its 70th Birthday year, during which, and rightly so, we all took pride in celebrating what had been achieved. There was much of which to be proud. The first hip replacement carried out in late 1948 saw the patient spend many weeks in hospital. On the 28th November last year, surgeons at Wrightington, Wigan and Leigh NHS Trust performed the first day-case hip replacement. The patient, Charlotte, was first on the list and up and walking with crutches just 3 hours later. She was discharged home and has experienced no ill effects, infections or problem with her new hip! She is also a nurse.

The NHS is the fifth largest employer in the world. Of the 1.7 million people it employs, nurses make up by far the biggest group of professionals in the workforce. There are about 300,000 nurses working today in the NHS, which is about three times the number employed when it was established. Currently there are over 42,000 nursing vacancies and given the global shortage of nurses that figure looks likely to continue to rise. Whilst there are also similar difficulties in recruiting certain medical staff, the number of doctors is 10 times more now than in 1948. In so many ways, the NHS is the same as it was when first created, but in other ways it is very different.

Innovations, such as the one Charlotte benefitted from, have allowed hospital bed numbers to be reduced. There are four times fewer beds now than when the NHS first began! Today, the emphasis is very much on developing more comprehensive primary and community-based care and getting people to take more responsibility for living a healthier life. I was reminded of this in the context of a comment made by one of my twitter friends (@NickiSparling1), who in a tweet last week remarked that she couldn’t accept the ‘good enough approach’ some folk adopt to improving the quality and safety of service for patients. When I read the tweet, I immediately thought about the work of Donald Winnicott, the paediatrician and psychoanalyst whose famously wrote about the ‘good enough Mother’. 

Winnicott argued that in the early days of a baby’s life, the Mother is entirely devoted to meeting all the baby’s needs, even if this means a loss of sleep or other needs being sacrificed. As the baby grows, the Mother allows a little bit of frustration to enter the relationship. For example, despite being caring, she might not respond immediately to a baby’s crying before a feed. The frustration is short-lived, but it begins to form a connection between the baby’s cognitive abilities, their growing sense of self and of the external world. The Mother is not ‘perfect’, but she is ‘good enough’. Importantly, Winnicott argued that if the Mother’s adaptation of her own life in deference to her baby’s goes on too long, the baby’s sense of the ‘real world’ becomes distorted, unreal and with fantasy overtones. A balance between living in the sometime harsh realities of the real world and the unreal fantasy world is perhaps a healthy state of being for most adults. Sometimes we can linger in that unreal fantasy world too long and our perception of what is possible and/or desirable can get distorted. 

To some extent, I think this is what has contributed to the exponential rise in demand for health care. Emergency Departments saw a 6% rise in demand in admissions in November; December last year, and January look certain to follow suit. 30% of all attendances at A&E don’t need the services available. They are time-limited conditions or those that can be dealt with in the community. Just like Winnicott’s Mother, an integrated NHS does need to be high quality for those who need it, but it also needs to borrow some of that ‘good enough’ approach and promote patients taking greater control for their own health and wellbeing – even if that cause a little frustration.

Illness prevention and health promotion are said to be major imperatives in the so called ‘10-year NHS Plan’. This should have been released in December, and possibly will now only be published sometime this month. What has been leaked so far are recommendations for some reorganisation of different parts of the management and organisational structures of the current NHS. For those long in the tooth observers of the NHS like me, these feel like the NHS of the 1980s (regional health authorities that we won’t be able to refer to as regional health authorities), the disappearance of the Clinical Commissioning Groups and possibly even the entire quasi market approaches. Primary care will be in the ascendency, but probably not led, as today, by GPs. We will see what the final details of the plan look like in the fullness of time. But I hope the 10-year plan will be firmly aimed at truly regaining the impact the NHS, and each of us, as  individuals, can have on improving the nation’s health.