Ahead of the NHS 72nd anniversary on Sunday 5 July, Sally Morris writes about the changes she’s seen over the years she’s worked in the NHS and considers the future.
Throughout my career the NHS has gone through more structural changes than I could ever have envisioned.
I joined the NHS as the commissioner/provider split started. The FHSA (responsible for GP practices) had just merged with Health Authorities and the first NHS Trusts had been created. The idea was that a “market” approach would drive up quality and reduce costs, and this theme remains constant throughout the many infrastructure changes during my NHS career.
I worked for a Health Authority when GP fundholding began, with the aim of bringing healthcare decisions as close as possible to patients (ie: the GPs) making local services more responsive, appropriate and cost effective. There’s no doubt we had some excellent innovation at this time but, as is often the way in large organisations like the NHS, it was dependent on the interest and passion of individuals. In the end, fundholding didn’t deliver all that it promised. Fund-holders weren’t responsible for all patient care, so costs were shunted around and statutory organisations destabilised. The short-lived Total Purchasing Pilots didn’t fare much better.
A number of years followed during which we saw the creation of Primary Care Groups, then Primary Care Trusts and, currently, Clinical Commissioning Groups. All aimed to be more responsive to patients and enable more influence by local health care professionals over local services. And now, we have STPs and ICS’s waiting in the wings looking to do this for specific populations in partnership with Local Authorities, service users, carers and the voluntary community and social enterprise sector (to name but a few). The aim remains to drive up quality and to deliver services in partnership; a recognition that the creation of a market environment and independent NHS provider Trusts back in 1991 had made partnership working extremely difficult. I truly hope they succeed.
Whilst all of this goes on, frontline staff continue to deliver services to patients, caring for the vulnerable and those in need. And they innovate, adapt and improve services over the years. Whilst developments in acute care during the past 72 years, and even during my time in the NHS, are phenomenal, it is mental health and community services I want to reflect on most.
I have seen many elements of care originally seen as essential to be provided in a hospital, now predominantly delivered in the community – and by nurses and allied health professionals, not only doctors. Diabetic care has been transformed and the majority of patients now receive all their care either at their GP practice, or from a community nurse, never going near a hospital – I speak from experience! Patients with respiratory problems are supported at home and where hospital stays used to be measured in weeks, they are now down to days (or a day), safe in the knowledge that community health and social care services can support people effectively in the community. At the other end of the scale, the modern end of life services treat people with dignity and support them to die at home or in a hospice, as most people prefer, rather than in hospital.
But it is in mental health services I have seen the greatest changes. From being the “Cinderella service” of the NHS – underfunded and largely ignored – the National Service Framework for Mental Health in 1999 finally brought with it the funding to modernise and improve these services. The creation of new community services, including Crisis Resolution, Assertive Outreach and Early Intervention Teams to build on existing Community Mental Health Teams, meant there was a real alternative now to inpatient admission.
Our inpatient services also modernised; old long-stay institutions were finally closed and “modern” purpose-built facilities replaced them. Over the past 25 years, these facilities have changed, and changed again. Now we are in the last throes of removing dormitories, so every inpatient can have their own room. I look back and wonder why we ever thought it was appropriate for six distressed people to share a room? But then I recall that it usually came down to a choice of a bed in a dormitory here, or an Out of Area placement, or no bed at all. So there wasn’t really a choice at all. Our own dormitories will all have been replaced by the end of next year (if not sooner), about which I am most pleased.
There have also been leaps and bounds in the Children and Adolescents Mental Health Services (CAMHS) arena. If we thought mental health was underfunded, then CAMHS was being especially short-changed. Over recent years that has started to change and we are beginning to reach those who need help earlier. This will, inevitably, assist positively in their long-term prognosis, but there is still a way to go.
One area which has received significant investment during the past 12 years is IAPT (Improving Access to Psychological Services), aimed at treating adult anxiety disorders and depression. This service reaches over one million people each year and helps fill the gap between specialist mental health services and primary care. My personal reflection is that although this is a very worthwhile service it has, sadly and through no fault of the IAPT services themselves, meant that investment in specialist mental health services has been reduced or delayed. The new mental health investment standard seeks to address this anomaly going forward and, finally, we are seeing new perinatal mental health services, and 24/7 crisis intervention services being developed to meet the needs of people in extreme distress. I look forward to more mental health services flourishing in this way in the future.
I’ve seen various attempts to regulate and monitor services in my NHS career, some more successfully than others. Whilst inspections by regulators can be seen as a distraction by service providers, there is no doubt in my mind that they are necessary to protect patients and our staff. Sadly, we have learned from the official inquiry reports into, for example, the former Mid Staffordshire NHS Foundation Trust and the Bristol Royal Infirmary that patients may lose their lives if there isn’t sufficient scrutiny. This learning and the subsequent system-wide changes help to make the NHS safer for everyone. I believe firmly that regular inspections by the CQC has helped our Trust drive up standards and quality in our services. I’m extremely proud that EPUT has been rated by the CQC a ‘Good’ overall, as ‘Outstanding’ for Caring and our End of Life and CAMHS inpatient services both rated ‘Outstanding’ overall. The changes in these services came from us learning from previous CQC inspections and other learning opportunities and our overwhelming determination to improve.
Which leads neatly to my final reflection: the NHS would not be the amazing organisation it is now without the people who work in it. Frontline clinicians, nurses, doctors, allied health professionals, social workers, as well as support staff in a huge range of disciplines, all work together to deliver care to the public. The NHS is the biggest employer in the UK, with staff from diverse backgrounds with different perspectives and aspirations. It feels as though we are now really trying to understand that diversity and to value and support all NHS staff to maximise their potentials – to have real equality in our services for staff and patients.
I will finish by recognising the way NHS staff have responded to the current COVID-19 crisis – it truly has been amazing. Coping with uncertainty and putting patients first is second nature to them and has continued to be so despite so many across the world losing their lives to this horrible virus. I know that I and my colleagues have personally felt the loss of our own staff.
Throughout its 72 years, the NHS has provided healthcare to people of this country – regardless of financial status. I recall vividly visiting America and needing their health service once. I sat in a waiting room and a man was brought in with an injured eye. Before he was seen by a clinician, he was asked for his insurance details. He had none, so had to pay $250 up front. He only had $180, so he was turned away without any treatment. I don’t know where he went, or if he received care, but his experience stayed with me and, if possible, made me value our NHS even more. We don’t charge for most healthcare services we provide and I sincerely hope we never do. Free at the point of delivery healthcare should be available for everyone who needs it, especially the most vulnerable in society.
This is my 25th year of full time service in the NHS. It is also my last, as I retire (early!) this year. So much has changed during this time and, despite the ups and downs along the way, I am grateful to have been part of this grand British institution. I am especially proud of our own Trust and grateful to colleagues who support me and to all the staff who work in it. I honestly couldn’t have worked in a better organisation. Happy Birthday NHS and here’s to many more!