The heart of the NHS
03 September 2025
Principal consultant Dr Anna Barnes hopes the NHS will retain its unique place in our affections as healthcare continues to progress
Alan Milburn is back, and he has made headlines in his view of the NHS as “one part of an ecosystem”, not the sometimes monolithic ocean tanker of an institution we sometimes see it as. [1]
His remarks ostensively were made as part of a challenge to providers who sometimes find collaboration with external organisations difficult. The thinking is that they would prefer to see the NHS as the public face of healthcare, and the other independent providers as outsiders wanting to muscle in.
It is interesting to think of the NHS as an institution that is simultaneously loved but also perhaps currently failing in its duty to look after us from cradle to grave. Change then, seems inevitable.
I have a long-standing interest in the history of the NHS and pre-NHS healthcare after interviewing people for various oral history projects over the years and from research into old psychiatric hospitals I undertook initially as part of my PhD when I interviewed patients from the old long-stay institutions and then much later when I was working on various large capital schemes across the NHS.
The stories I heard of nurses attending chapel with their cloaks red side out for Christmas, the riotous escapes from restrictive nurses’ homes, the romances with colleagues in the police, and the rapid integration of nurses from ‘The Commonwealth’ are rich and compelling.
I was continuously struck by how much our hospitals are part of the fabric of our cities and towns as anchor institutions: major employers, huge training organisations and hotbeds of local history and culture.[2] Having visited and worked at more than 50 of them, I can also guarantee that there will be fish on a Friday, and the porters will store your bike for you at the smaller hospitals.
It’s all about the hospitals
NHS culture is epitomised by its hospitals. Ask any staff member to talk to you about their history (as the UHSX did in their reflective sessions on culture in 2024) and you will find people who met their partners there, had their children there, and had relatives who died there. I used to love reaching out to estates colleagues across the NHS when I was about to start a new programme; they were always so generous in sharing knowledge and experience about their programmes for the benefit of the wider NHS.
So, what does this tell us about the NHS? Mainly that it is woven into the fabric of our lives, and its staff are incredibly loyal. And yet, it must change. A search of old record books at Royal County Hospital in Brighton revealed that most patients had one of the following outcomes: Cured, Relieved or Died…. We have come such a long way since then! This was in the days of premodern healthcare, in the 1850s-1860s when the railways were being built and before penicillin.
In Brighton there was an influx of men working on infrastructure projects, but their outcomes were variable, as described. Patients could not expect much and were only treated if they were insured or were paid for out of charitable funds.
We have transformed health care for the better since these times. Tracking the changes in hospital buildings as I have, we have repurposed most of the network of psychiatric hospitals into housing and reinvested the money into modern facilities (see for instance, the groundbreaking work at South West London and St Georges).[3] The advent of modern effective treatment made them redundant, coupled with an understanding that much mental illness is better treated close to home.
We have also managed to close all our old TB hospitals since we found effective treatment for the disease – or knocked them down and repurposed the land. I was particularly fond of an old sanitorium in my hometown, with its decorative red brickwork and huge arched entranceway. My daughter, however, who was treated there in occupational therapy as a child, said it was scary. Exactly, the Victorian benefactors wanted to show off their wealth and mere patients were supposed to be grateful. Architecturally, our buildings now need to communicate care and compassion rather than just grandeur and civic pride.
More change ahead
Milburn’s words, and the heavy emphasis on the forthcoming revolution in personalised approaches to health referenced throughout the NHS 10-year plan, remind us that we are about to embark on a similar transformation in care and treatment, one that will once again change the way we utilise our hospital estate.
We expect genomics to improve our health by mapping out our genetic inheritance and helping us maintain our health as we age. Modern technology will take over some of the less skilled work in surgery, and AI will provide enhanced diagnostics in our own homes, if the plan comes to fruition.
I hope, though, amid these giant steps forward, that the sense of the NHS family, the mutual interconnections and careers built up over a lifetime, and the sense of belonging remain. NHS staff will rightly mourn the loss of identity and kinship if they become instead contractors in a pluralist health landscape, even if this is ultimately for the benefit of the patients themselves.
