'Happy birthday to you' - 70 years since the founding of the NHS, what are the new giants public services must battle?

06 July 2018

Russell Jones, Consultant

Yesterday marked the 70th birthday of the NHS, the most publicly treasured part of the UK welfare state. NHS colleagues rightly deserve praise for the amazing work they do but in this moment of national celebration we must also reflect on the wider history and future direction of public services moving forward.

Alongside the NHS, housing, social care, welfare, and education systems were designed to the giants identified in the original Beveridge report: want, ignorance, squalor, disease, and idleness. These systems operate in a very different environment today from 70 years ago with rising and increasingly complex demand, a radically different socioeconomic climate, and a transformed demographic profile (the list could go on). There has, however, been no accompanying national conversation about the new ‘giants’ we are now trying to tackle.

In my view, they can be summed up in five I’s:

Isolation – Although advances in technology mean we have more potential for connection than ever before, loneliness and social isolation have become major issues for communities, with serious implications for public services. Across the UK, an estimated 9 million people – more than the total population of London – are either ‘always’ or ‘often’ lonely. Loneliness cuts across age groups. For example, 43% of 17-25 year olds experience loneliness and there are 1.2m chronically lonely older people in the UK. The implications of this are stark. Studies suggest that loneliness is as bad for you as smoking 15 cigarettes a day, worse for you than obesity, and likely to increase risk of death by 29%.

Insecurity – Across the labour economy and the housing market conditions for citizens have become more precarious. Jobs for life are increasingly a thing of the past. 0-hours contracts are increasingly prevalent (covering 1.8m people, up from 1.7m in November 2016) as is freelancing (between 2008 and 2016, the number of freelancers in the UK increased by 43%.) An increasing number of people are renting rather than buying (an estimated quarter of households are expected to be privately renting by 2021) – often in poor standard properties and insecure tenancies. Studies highlight that those on contracts that do not guarantee a minimum number of work hours are 41% less likely to report having good physical health than those with secure contracts, and are also one and a half times more likely to report having a mental health problem. Statistics on the impact of insecure housing are equally troubling, with 53% of private renters reporting they are stressed or anxious, compared home owners at 35%.

Inequality – Despite successive pledges around social mobility, inequality continues to profoundly affect both quality of life and life chances across the country. In the UK, 50% of a parent’s pay advantage is passed onto their children. Opportunities for social mobility are moreover unequally distributed across the country with nearly two thirds of all social mobility ‘hot spots’ being in London. Inequality has a serious impact on public services – while only 5% of better-off young people become NEET (not in employment, education or training) within one year of GCSEs, 12% of disadvantages young people do. Inequality also has stark effects on individuals and communities – for example, the life expectancy gap between England’s most affluent and poorest people has widened since 2001 – from 7.2 years to 8.4 years.

Intergenerational (un)fairness – We stand at a crossroads. The ageing population has grown significantly in recent years, with increasing years of life spent in ill health. This leaves a dilemma on how to fund sustainable health and care services and how to provide for a younger generation that for the first time in more than 100 years will earn less than their parents. With the intergenerational contract broken there are fundamental questions we must ask about how to give young people a better deal and how to sustainably fund the needs of older people.

Independence – Public services in the post-war period have adopted a paternalistic role. There have been some encouraging shifts in this space with a greater focus on doing with and asset based working but there is still a long way to go. We need to rebalance the social contract so citizens take greater responsibility for achieving their own outcomes and the state becomes more of an enabler.

We have public services that were set up to treat people, fighting the giants of seventy years ago. We need to recognise that the challenge has changed and reconceive them to tackle the giants of today, which I believe will involve empowering people and preventing problems rather than “doing to citizens”.

These are, of course, only suggestions intended to open up conversations. As I have blogged previously, I don’t expect central government to emerge with a bold proposal and nor do I think the solutions lie in Whitehall. What we need is to start these conversations in the town hall and with communities – what are your giants?