What Would the NHS Look Like if it Took Health Promotion Seriously?

By Collective 20

[Collective 20 is a group of writers located in different places throughout the globe. Some young, some older; some long-time organizers and writers, others just getting started, but all equally dedicated to offering analysis, vision, and strategy useful for winning a vastly better society than we currently endure. The members of Collective 20 hope their contributions concerning social, political, economic, and environmental issues will generate more useful content and better outreach through a collective publication effort as opposed to individuals doing so on their own. Collective 20’s cumulative work can be found at collective20.org, where you can learn more about the group, see an archive of its publications, and comment on its work.]

On Sunday 5th July 2020, the British Prime Minister, Boris Johnson, wished it a happy 72nd birthday. Spitfires flew over in celebration and buildings were lit up in blue as people poured out into the streets at 5pm to clap in appreciation of Britain’s favourite institution. We’re talking, of course, about the National Health Service (NHS).

The NHS, it seems, is loved by everybody. During the COVID-19 pandemic the public have consistently shown their appreciation of NHS staff with public displays of “thank you NHS ” art and coordinated nation-wide rounds of applause. More generally and consistently, the NHS is also celebrated by the Left.

            The reasons for this are both historical and ideological. The NHS was founded in 1948 by the Labour Party and based on the following three principles; (1) to meet the needs of everyone, (2) to be free at the point of delivery, (3) and to be based on clinical need, not ability to pay. This, of course, was part of the broader programme of establishing a welfare state.

            Since the 1980s, however, the NHS – and the welfare state in general – has been under attack. A new generation of right-wing politicians – of which the hypocrite, Boris Johnson, is the successor – managed to galvanise sufficient support for the privatisation of large parts of the welfare state, including aspects of the NHS. This reactionary politics was started by Thatcher (as leader of the Conservative Party) and continued by Blair (as leader of New Labour), making it establishment orthodoxy by the end of the century. Since then, the Left has been on its backfoot, struggling to defend the progressive institutions introduced following the devastation of WW2.

            This, of course, makes sense. Defending actually existing progressive policies and institutions is always a good use of resources. However, in and of itself, it is probably not enough. We cannot simply call for the renationalisation of the privatised sections of the economy. In addition to these defensive measures, the Left needs vision. We need to be able to say what a good health system for the 21st century would look like. This, however, means looking at our beloved NHS critically.

            Whilst it is true that the establishment of the NHS represented a great leap forward and that – even in its partly privatised form – the NHS constitutes a much better health system to those in operation in many other countries – including some that are much richer than the UK – it is also true that the NHS could be much better. After all, there is always room for improvement. So what – beyond the renationalisation of the privatised sections of the NHS – should the progressive-left be calling for?

            This question raises another, more basic question – namely, how to proceed? One answer to this question – perhaps the best one – is to draw on the latest research into health promotion. Leading public health scholars have referred to such an approach as “evidence based politics” (Wilkinson and Pickett) and “ideology with evidence” (Marmot). In his 2010 review, Marmot highlights the seriousness of health as a social justice issue:

“Reducing health inequalities is a matter of fairness and social justice. In England, the many people who are currently dying prematurely each year as a result of health inequalities would otherwise have enjoyed, in total, between 1.3 and 2.5 million extra years of life.”

            The review then goes on to point out that “There is a social gradient in health – the lower a person’s social position, the worse his or her health” and that “Health inequalities result from social inequalities.” Furthermore, “This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus.” This, of course, applies as much to the NHS as it does to any other social institution. The difference, however, is that the NHS has a commitment to health promotion and to evidence based practice. So what are the implications of these findings for the NHS? Could the answers to this question help inform a progressive-left programme for NHS reforms?

            If the NHS is, once again, to become a genuine symbol of progressive-left politics then we need to identify the sources of social inequality inside the NHS. Anyone who has engaged with the NHS – either as a patient or a member of staff – cannot help but notice how hierarchical it is. The most obvious illustration of this is the differences in colour of the nurses uniforms – typically the darker the blue the higher up the nurse is in the hierarchy. Nurses in light blue uniforms – who often have the most patient contact – are not formally recognised as professionals.

However, it is a set of institutional structures that gives backbone to this hierarchical colour coding. The first, and perhaps most obvious, is the division of labour. This refers to how tasks are shared out within the workplace. In the NHS there is a corporate division of labour. This means that empowering and disempowering tasks are shared out unevenly. Some jobs – at the top of the hierarchy – are made-up of tasks that are almost, if not entirely, empowering. Empowering jobs are those that give access to information and authority, making it possible to implement decisions that impact large parts of the workplace – including, of course, the staff. These jobs are taken by a minority of staff who use their power to influence how the NHS is organised and run. All other employees endure, to varying degrees, relatively disempowering jobs.

The corporate division of labour is one way in which social inequalities are institutionalised within the NHS. This, however, means little unless it is supported by a pay scheme that complements the hierarchy. Not surprisingly, in the NHS the higher up the hierarchy you are the more you get paid. Put simply, differences in pay reflect differences in power and one source of economic power within the workplace is for a minority to monopolise empowering tasks. So, in addition to the corporate division of labour we also have complementary criteria for remuneration that institutionalises social inequalities within the NHS.

Another important factor – that runs parallel with the corporate division of labour – has to do with decision-making. Anyone who has worked in the NHS – in any capacity – will tell you that you are expected to follow orders from above. As with virtually all other workplaces, all democratic rights to participate in the management of our own place of work go unrecognised. Authoritarian decision-making is another way in which social inequalities are maintained within the NHS.

Public ownership of the NHS remains an important part of any campaign to protect the public services from privatisation. However, if the NHS is to become a beacon of the progressive-left in the 21st century, in addition to this we also need to push for reforms that address institutionalised forms of social inequality inside the NHS. The corporate division of labour, the pay scheme that complements that division and the authoritarian decision-making that is accommodated by it all need to be replaced.

This means redesigning jobs within the NHS so that empowering and disempowering tasks are more evenly distributed amongst the staff. Bringing pay in-line with these redesigned jobs will also need to happen. In the absence of an elite of authoritarian managers, new egalitarian and participatory forms of decision-making and self-management will have to be institutionalised. Each of these measures would directly address social inequalities (that the NHS currently institutionalises) and with it the social gradients in health that we know emerge from these social inequalities. Given that the NHS is one of the world’s largest employers, the health implications of this would be very significant.

Clearly, this has implications for education and training. However, given that inequalities in education constitutes a major social determinant of health, nobody with a serious commitment to health promotion and social justice should see this as an obstacle to trying. The introduction of these kinds of radical reforms to the NHS would also have implications for the broader economy. It would help expose the pathological myth on which the current system rests. As the Marmot Review puts it:

“Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and sustainability are important social goals.”

[INITIAL SUBMISSION: Mark Evans | AUTHOR: Collective 20 (Andrej Grubacic, Brett Wilkins, Bridget Meehan, Cynthia Peters, Don Rojas, Elena Herrada, Mark Evans, Medea Benjamin, Michael Albert, Noam Chomsky, Oscar Chacon, Paul Ortiz, Peter Bohmer, Savvina Chowdhury, Vincent Emanuele)]