NHS Turns 75: Reflections on the BMJ

The British Medical Journal celebrates 75 years of the British NHS with a question that interests us closely: what has the pandemic taught us about the benefits of local autonomy, and what should instead be centralised?

The basic model on which the Italian National Health System was built, i.e. the NHS of the United Kingdom, is 75 years old. On this occasion, the British Medical Journal, the absolute reference journal for public health, dedicates ample space to a series of reflections, very little celebratory and with considerable critical cues.

The editorial contributions wonder if it is a happy birthday after all¹and if the original model shouldn't instead be radically transformed to keep up with the times²The problem becomes even more complex when analysing what happened after the COVID-19 emergency, with the widely expected problems of waiting lists and staff under stress due to high workloads, on top of which we should add the dissatisfaction due to salary levels that are not commensurate with the actual cost of living.

In the NHS, as in Italy, the universal coverage model is resisting, allowing citizens to remain sheltered from catastrophic expenses, which instead affect people in need in other highly industrialized countries, as in the striking case of the United States.

Colleagues from Birmingham, R.Mannion and M.Exworthy, together with international experts S.Wiig (Norway) and J.Braithwaite (Australia), addressed the question on how to strike the balance between centralization and decentralization, to recover from the pandemic shock of COVID-19 in the best possible way³.

According to the authors, the question should be asked by seeking the right balance between the local and central autonomies, learning from what happened during the pandemic emergency.

The thesis of Mannion and colleagues is quite clear: in the transition from emergency to reconstruction, from a phase in which some important functions at the local level have been delegated to provide immediate services to the affected population, to another of planned restart, the risk is that excessively centralized health policy at national level, may lose all positive spinoffs generated by the emergency.

During the COVID-19 emergency, both in the United Kingdom and in Italy there was a strong centralization of decision-making in key areas such as lockdown policies, the distribution of vaccines, the procurement of personal protective equipment.

At the same time, very effective processes for the population have been deployed at the local level, giving local authorities the opportunity to act and experiment as never before (just thinking of teleconsultation and the rapid reorganization of personnel).

All this, according to the authors, follows a clear logic, as a greater autonomy allows to act more quickly, favouring innovation. On the other hand, the centralization of funding policies and the setting of performance standards can be crucial to guarantee the efficiency of the system

According to Mannion and colleagues, "resilience" (the ability to adapt to changing conditions) needs to guarantee the development of territorial and social services through a solid ”bottom-up” approach

Compared to the Italian health system, the British NHS has historically always been more centralized, albeit showing tendencies towards autonomy as in the field of hospital trusts and primary care.

However, the pandemic has accelerated self-determination policies, helping to increase sensitivity towards local responsibilities and decisions, which have therefore favoured innovation.

For the growth of both national health systems, it is important that such heritage of experience and responsible participation are not wasted

The warning that comes from the article in question is aimed at the ability of central decision-makers to understand that the will to be autonomous derives fundamentally from the active participation of health professionals in the reform processes

As demonstrated by some field studies cited by Mannion and colleagues, the staff must be able to act in a flexible manner, to fully exploit the organizational skills capable of giving effective responses to new challenges. In particular, "everyday clinical performance" has shown to work as a remedy to often inadequate and confusing operating conditions for the personnel involved

On the other hand, the delegation of services at the local level may be advantageous if the resources granted are insufficient and/or linked to often unrealistic performance objectives, which are inconsistent with the general objectives, limiting the active participation of operators

The main implication is that reforms cannot be imposed from the top, stating “what needs to be done”, but must instead start from the bottom, asking every worker “where are you trying to go, and how can we help you get there”

According to Mannion and colleagues, a crucial aspect for the promotion of autonomy is to guarantee the involvement of patients, the public and caregivers in the co-design of services, creating those person-centred systems everyone is addressing, but only few are able to describe in terms of actual operating conditions

These aspects have been investigated in depth in Italy, as in the case of participatory evaluation, where AGENAS has developed tools made available to the Regions and Autonomous Provinces, to help standardize how we measure the centrality of the person in local services⁴.

The reflections of Mannion and colleagues, 75 years after the birth of the British NHS, offer an opportunity to critically evaluate to what extent are the same principles applicable to the new challenges of proximity care in Italy

With best wishes for a happy birthday to the British NHS.

• Bibliographical references:

1. Walker I. The NHS at 75—a happy birthday? BMJ 2023; 381:p1460 doi:10.1136/bmj.p1460, https://www.bmj.com/content/381/bmj.p1460.
2. Coombes R, Graham A, Leaf N, Pakunwanich N, Ugwuja J. Lifesaving yet frustrating, requiring transforming not dismantling—reflections on the NHS at 75 BMJ 2023; 381 :p1422 doi:10.1136/bmj.p1422, https://www.bmj.com/content/381/bmj.p1422.
3. Mannion R, Exworthy M, Wiig S, Braithwaite J. The power of autonomy and resilience in healthcare delivery BMJ 2023; 382 :e073331 doi:10.1136/bmj-2022-073331, https://www.bmj.com/content/382/bmj-2022-073331.
4. Cardinali F, Carzaniga S, Duranti G, Labella B, Lamanna A, Cerilli M, Caracci G, Carinci F. A nationwide participatory programme to measure person-centred hospital care in Italy: Results and implications for continuous improvement. Health Expect. 2021 Aug;24(4):1145-1157. doi: 10.1111/hex.13231. Epub 2021 May 20, https://onlinelibrary.wiley.com/doi/10.1111/hex.13231.