open space

Published: 27/02/2003, Volume II3, No. 5844 Page 31

The concept of the NHS, and what people expect of it, is constantly changing. Celia Davies looks at the service's current definition, or lack of it

The NHS - as politicians have repeatedly learned - is one of the few ideas that still serves to unite the country. The state of the NHS and the fate of the government are tightly interwoven. Prime minister Tony Blair has gone so far as to stake his career on it. But what do people want of the NHS?

Back in 1948, the emphasis was on the first of those initials. Universal provision - free at the point of use but owned by the public and paid for by workers' insurance contributions - was the jewel in the crown of the new welfare state.My generation of university students - another product of that post-war welfare state - was taught to admire the machinery of 'social administration' in the UK.Welfare services, we learned, embodied the highest principles of collective responsibility, fairness and even-handedness.

Today, all this has unravelled. Each of the three words that make up the NHS is in need of a new look. In New Labour terms, 'national'means standard-setting at the centre. The white paper Modernising Social Services makes things most overt, with its claim that for the first time people will now be given a clear statement of what they can expect from public services.

In the health field, the creation of the National Institute for Clinical Excellence, the growing programme of national service frameworks and the reforms to the professional regulatory bodies are all making what we can expect more explicit. The new bodies that set and monitor standards are all required to demonstrate direct patient and public involvement.

Old power balances between professionals, bureaucrats and politicians have disappeared. In this context, new relationships and, in particular, new accountabilities are far from well-established.

If standards are set nationally with new forms of patient and public involvement, just what space is left for local people to intervene? 'Central standards and local control, ' was health secretary Alan Milburn's slogan, when quizzed on Radio 4 on the foundation hospitals idea after the Queen's Speech in November. 'Central standards and local delivery, ' insisted public health minister Hazel Blears at a seminar hosted by the Smith Institute at around the same time. But if we want a truly national service (and once that question was asked at the seminar the agreement was strong), then just what is it that can happen locally?

Commentators have long pointed out that politicians can't afford to decentralise far - not when at any time they can find themselves answerable for questionable practice. But in the current climate, a national service must have real meaning in a local setting.

What then of 'health' in the NHS? The vision of 1948 was about medical care.The surgery and the hospital epitomised the NHS promise for just about everyone.A decade and more on, commentators were saying that we had a national sickness service rather than a national health service.The acute hospitals got the lion's share of the glamour, the status and the resources.

There has been a sea change, with the majority of funding now being channelled through primary care trusts.Capacity building in PCTs is undoubtedly a major challenge.

Bigger still is the task of joining up the initiatives - the one-stop shops, the nurse-led clinics, the healthy living centres, the new roles for pharmacists and others on the high street.Are we doing this in ways that give real meaning to the vision of an empowering, health-creating and health-sustaining service in the local community? The vision of just what a full range of primary care services might offer to a local community remains out of focus.

Looking again at the 'service' in the NHS is perhaps the biggest challenge of all.Today, it is perhaps only the NHS that manages to motivate staff and generate public commitment in anything like the same way that local government, the civil service and the emergency services did in the 1940s.

But this motivation is fragile.The idea of public service is in need of renewal.My dictionary reminds me that 'having seen your service'means 'to have been put to long and hard use'. Putting into words just what the 'service'means in the NHS, creating a new and positive consensus around it, is an urgent task for our time.

A national and local NHS, in service of a diverse population, requires different leaders and a very different leadership debate from the one we are having.The NHS needs people with the foresight to grow capacity, who can contribute to public understanding and health citizenship for young and old and the poorest and most excluded.One key leadership task is to spell out those familiar initials, NHS, rather than reeling them off as if we all knew just what they meant.

Celia Davies is professor of healthcare, Open University.