Intended for healthcare professionals

Rapid response to:

Analysis The BMJ Commission on the Future of the NHS

The NHS founding principles are still appropriate today and provide a strong foundation for the future

BMJ 2024; 384 doi: (Published 31 January 2024) Cite this as: BMJ 2024;384:e078903

Read the full series: The BMJ Commission on the Future of the NHS

Rapid Response:

Re: The NHS founding principles are still appropriate today and provide a strong foundation for the future

Dear Editor

Two months ago, I was asked to give a public lecture about the NHS in Shillong, India; unlike previously enjoyable and proud occasions when I promoted NHS in India (1,2) I was rather nervous this time. With daily, shocking, news about choked A & E departments, ambulances delays, large and long waiting lists generally, maternity failures, and strikes for example, how would I defend and ‘sell the NHS? When asked about how we got to this sorry state, I shared my recent analysis (3): neo-liberal ideological grip, political interferences, lack of leadership, and the failure to innovate. About the potential for much needed reforms, I was ambivalent, since what I saw was political gimmicks and entrenched/polarised groups without any conceptual clarity or consensus on the fundamentals (4).

So, I had been looking forward to the report from the BMJ Commission. As expected there is much to commend in this first paper, my comments here are restricted to what I see as the most important issue.

It seems that the Commission has taken up positions and closed down conversations too early, and seems to be rushing to solutions. Founding principles are the bedrock for the edifice, and we need more honest, detailed and robust debates to refine them and make them relevant to the current environment, in order to create a more fit for purpose future health and care system.

What does comprehensiveness mean with rapid advances in science and technology - latest and best to everyone? Clearly a balance will need to be struck between comprehensiveness and budget, but where, when and how? Should we not nail this issue down at the start, and in doing so clarify the role of the state vs individual? This may require another look at Defined Benefits: take cataract as an example where most of the world gets thick glasses post-surgery (cheap) but the NHS offers high quality intraocular lens (expensive); the defined benefit in both is restoration of vision. So, what is the State’s role in services, and why should the NHS not then have Co-payments? Many of us are happy to pay extra – I certainly would have done so recently, sadly the choice was not available.

Saying that ‘shared health and care management’ is beyond their scope brings into question the Commission’s relevance – acute care cannot be solved without tackling ‘bed blocking’.

NHS is a wicked problem requiring creative ways of solving it by overcoming psychological barriers (5). “We are living today in tomorrow’s world with yesterday’s ideas” said Milovan Djilas, the Late Yugoslav Marxist Theoretician, and “Politics is the art of devising temporary remedies for recurring evils (sic) – a series of expedients, not a project of salvation” said John Gray, the political philosopher, and maybe we should reflect on these.

There is very little difference ideologically between the two main parties, and regardless of who wins the election, NHS will remain a political football. I am a supporter of the NHS (6) and desperately want the Commission to succeed. The most important task right now is clarity and consensus on the basics, to create a strong foundation, for another ‘temporary remedy’ for our times. Health care can be a ‘bottomless’ pit (sadly) and if we do not get it right the NHS will become the cause of health inequalities, as political imperatives and pressure groups will prioritise it over much needed housing, education, policing, jobs and everything else that creates a flourishing society and healthy and happy citizens.

Rajan Madhok

1. Madhok R. Reflections of a UK-based Indian doctor on promoting Indo–UK health collaboration. Natl Med J India 2023; 36:192. DOI: 10.25259/NMJI_485_2022
2. Madhok R. Indo-UK health collaborations: the story of an Indian doctor in NHS.
3. Madhok R. Reflections on the state of the NHS: In the last chance saloon.
4. Madhok R. Rapid response to The BMJ’s Commission on the Future of the NHS
5. Vazirani, A.A., McCaffrey, T., Savulescu, J. et al. BrainSwarming, blockchain, and bioethics: applying Innovation Enhancing Techniques to healthcare and research. Sci Rep 14, 832 (2024).
6. Madhok R. Why I went on a 300 mile march to save the NHS.

Competing interests: I am a non-executive director on the Board of Wirral University Teaching Hospitals NHS Foundation Trust and an independent member on the Board of Llais (in Wales). This letter, however, is written in my personal capacity.

05 February 2024
Rajan Madhok
Retired Public Health Doctor
Llanbder DC, Denbighshire