In his welcome paean to the National Health Service (NHS) as it approaches 70, Klein rightly points out that while the NHS has been reorganised (mainly redisorganised) almost continuously since the 1970s, its architect, Nye Bevan, would still recognise it.

While in many ways this is an undoubted strength demonstrating both resilience and an ability to survive the political rapids in which the NHS has to swim, it has also become a serious weakness. It is one to which many observers have drawn attention over the years, but it may be that a tipping point has been reached heralding an overdue paradigm shift. Far from threatening the survival of the NHS, such a shift may be the best guarantee of its continuation. Yet, it is not a threat that Klein considers.

In his mention of prophecies of the NHS’s impending implosion, Klein only refers to the threat of privatisation, which he claims has not happened. Whether he is right to be so sanguine about the issue rather depends on what is meant by privatisation (Hunter, Reference Hunter2013). While it is true the financing of the NHS remains publicly sourced, concerns are once again mounting over the growth in the number of contracts to provide NHS services that have been awarded private providers, and fears abound over whether the move to Accountable (or Integrated) Care Systems (ACSs)/Integrated Care Systems (ICSs) and Accountable Care Organisations (ACOs or ICSs) could result in these being run by private providers. The NHS would then exist primarily as a brand or logo, but in reality be little more than a hollowed out public service. Whether such an outcome is likely depends on how the political landscape evolves over the next few years. For now the jury is out and there is no room for complacency in the uncertain world being fashioned post Brexit.

What is arguably a more urgent and pressing threat facing the NHS is that it is no longer appropriately aligned with, or capable of addressing, the range of contemporary challenges facing it. We have entered what has been termed the third era of health and care, which includes a focus on life-course health development; getting a grip on non-communicable diseases, which according to the World Health Organization Regional Office for Europe account for over 86% of the disease burden; rebalancing acute care and prevention; creating capacities to achieve goals for equitable health; and viewing individuals and communities as co-designers of their health (Halfon et al., Reference Halfon, Long, Chang, Hester, Inkelas and Rodgers2014).

It was a former banker, Derek Wanless, who in 2002, when he reported to the then Labour government on whether the NHS could survive as a tax-funded service beyond 2022, reiterated what many experts had been saying for years. He described the NHS as a sickness rather than a health service and warned that its survival depended crucially on the extent to which it could be rebalanced to attach a higher priority to prevention and public health. Only in doing so could the NHS meet the growing demands on it arising from largely avoidable and preventable lifestyle-related illnesses. In his ‘fully engaged scenario’, which the government signed up to at the time, Wanless argued that its attainment depended on the extent to which health literacy in the population was raised and greater priority was attached to public health (Wanless, Reference Wanless2002).

But public health remains a victim of a persistent policy dilemma that has yet to be resolved. As Wanless opined in his review of the state of public health:

The warnings Wanless issued went largely unheeded until NHS England published its Five Year Forward View in late 2014 (NHS England, 2014). Largely the work of the NHS chief executive, Simon Stevens, who had been Prime Minister Blair’s health advisor when Wanless reported, the review opened with an indictment of the government’s failure to commit to the fully engaged scenario and a stark warning that the sustainability of the NHS ‘depends on a radical upgrade in prevention and public health’ (NHS England, 2014, paragraphs 3 and 4). Much of the thinking underlying the New Care Models and Vanguards initiative set out in the Five Year Forward View have their roots in the attempt to shift the balance of the NHS towards prevention, and care and support outside hospital. None of these policy pronouncements is especially novel, but their implementation has proved stubbornly difficult. Until now, that is, as it may be that the NHS is finally running out of road unless it chooses a different route.

In an effort to shift responsibility for public health to a more sympathetic location where it was more likely to be taken seriously, the Health and Social Care Act 2012 involved the transfer of the public health function to local government. For many it was one of the more, if not the only, welcome proposal in what was otherwise widely viewed as a highly dysfunctional exercise in putting political ideology ahead of sound policy. Within the public health community, it was widely acknowledged that the move in 1974 of public health to the NHS from local government had not been a resounding success (Hunter et al., Reference Hunter, Marks and Smith2010). For the most part, public health was regarded as a ‘Cinderella’ sector, and even when funds were allocated to it invariably there were regular budget raids in order to keep A&E and essential hospital services running.

Despite the unforgiving financial climate facing local government and public health, a direct consequence of political decisions taken by the Coalition government 2010–2015, and the current Conservative one, there are encouraging signs that some local authorities have risen to the challenge and begun to adopt a health in all policies approach, acknowledging that public health entails changes in sectors beyond health in order to improve health and well-being (Local Government Association, 2016). It also requires a shift from ‘lifestyle drift’, with a narrow focus on individual behaviour change, to a population health perspective that demands attending to the social and structural determinants of health (Popay et al., Reference Popay, Whitehead and Hunter2010). When the NHS was responsible for public health, the focus was all too often on individual lifestyle interventions that had little success in tackling lifestyle risk factors associated with obesity, alcohol misuse, sedentary lifestyles and so on.

Looking ahead beyond its 70th birthday, for the NHS to prosper it needs urgently to adapt to, and adopt, a whole health systems place-based approach. For this to occur, it requires the NHS to work in a quite different and co-equal way with local government in order to ensure that effective systems leadership can develop. But for this to happen, or even be possible, a major hurdle needs to be overcome – one that has arguably dogged the NHS from the start. As Klein points out, Bevan’s design for the NHS rejected any local government involvement, which has resulted in a service that has become progressively ‘more centralised and heavily regulated’.

Yet, ACSs/ICSs can only succeed if local government is at their centre and this will mean the NHS having to abandon its traditional top-down command and control style. It is early days, but it may be that developments underway as a result of devolution in Greater Manchester and a few other places could point the way forward. The NHS Five Year Forward View was also motivated by a desire to move away from what Klein terms ‘the frequency of disruptive and expensive organisational changes’ and focus on culture change driven from, and by, the frontline. Reforms were no longer to be uniformly imposed by the centre but instead allowed to flourish and take shape in accordance with local contexts and circumstances. The centre’s role was to be an enabler and facilitator.

Perhaps not unexpectedly in a tax-funded service where politicians are keen for quick and positive results, things have not turned out quite as intended. But if there is a lesson from what has happened since the NHS Five Year Forward View appeared, and resulting from the numerous initiatives it has spawned culminating in ACSs/ICSs and ACOs, it is that if the NHS is serious about ensuring its survival then it has no option but to change the way it does business.

Klein’s fourth conclusion concerning Bevan’s legacy is ‘that there are more reorganisations to come’. If the ‘itch to reorganise’ continues to prove overwhelming, as it surely will, then reforming the NHS in much the same way as has been in evidence for most of its 70 years will only result in the same problems re-emerging or remaining unresolved. In such a scenario it is hard to see the NHS surviving to celebrate its 80th birthday. At the same time, what a delicious irony that the very survival of the NHS and its fate should be so inextricably linked to its old adversary, local government.