Free For All: Why the NHS is Worth Saving
Dr Gavin Francis 
Wellcome Collection, £7.99

Can we afford the NHS? That question may seem outrageous. Most people in the UK have lived our whole lives believing that when we give birth, break bones, get sick and – when the time comes – die, we’ll be supported by highly trained, caring professionals within hygienic facilities, without having to worry about the bill. That, after all, is the promise on which our “cradle-to-grave” welfare state was founded.
Of late, however, though respect for medical personnel remains high, satisfaction with the service is at an all-time low as sufferers languish on waiting lists, in hospital corridors and in ambulances queueing outside A&E front doors. Many patients struggle to get NHS dental treatment or even, in some cases, in-person appointments with their family doctors. 
The blame clearly doesn’t lie with diligent health professionals like Gavin Francis. The acclaimed Fife-raised author has been a qualified physician for almost a quarter-century and – though his new book doesn’t name his practice – we know from his website that he works as a GP in Edinburgh and the Scottish Highlands. A passionate defence of the NHS’s founding principles, Free For All begins by describing a typical day in his working life, disguising patient details to protect confidentiality but offering eye-opening insight into the scale of his workload and the extent to which the NHS is toiling. 
Among his packed caseload is an elderly woman who broke her hip falling from bed in an understaffed hospital ward. There’s the daunting task of informing a youngish man that his colonoscopy, delayed for months by the Covid backlog, has revealed advanced cancer that should have been eminently treatable had he been scanned more promptly. And, amid the mountain of bureaucracy to be negotiated via the NHS’s antiquated IT system, there’s a warning that the wait for blood tests at the local paediatric clinic is three months – an untenable delay, observes Francis, in any circumstance that might lead him to refer a child for testing. 
Published to mark the NHS’s 75th birthday, this short, pithy book includes a brief history of the service’s idealistic origins. In the 1930s, one in 10 children didn’t reach school age and, writes Francis, “illness could ruin a family’s prospects and frequently did”. In 1937, The Citadel, by Scots doctor and author AJ Cronin, did much to expose “the ways in which poverty and illness perpetuate one another” and Francis cites that novel, along with an early Highlands and Islands medical aid service, among the inspirations for the NHS’s formation in July 1948. 
Its post-war impact was dramatic as childhood mortality plummeted and life expectancy soared. But today the NHS is at risk amid growing calls for the “unsustainable” state-funded system to be replaced with a  mix of personal insurance-funded treatments and basic-level provision for those who can’t pay. 
Although his book lays bare some of the symptoms of an ailing service, Francis dismisses this prognosis, arguing that administratively, such systems are more expensive to run than the NHS. Health services, he implies, are as good as the governments that oversee them and – though he never veers into partisan political territory – it’s plain he traces the roots of the current malaise to the Tory-LibDem coalition that took the reins in 2010. What’s happened now, he suggests, is that the crisis conditions which prevailed during the Covid-19 pandemic have been normalised. Last autumn, every clinician in the country received a letter equating the coming winter to an emergency, and he expects to receive another such missive every November “until the chronic underfunding of the NHS is abandoned as an electoral liability, or the NHS collapses”.
So what is Dr Francis’s prescription? He believes the institution can and should remain taxpayer-funded and free at the point of need but that we must, as a society, reconsider what it can realistically be expected to deliver. Scientific advances mean medicine can now offer effective interventions for illnesses once considered fatal. And along with an increasing array of effective drug treatments for once-fatal illnesses, there’s a burgeoning list of physical and mental conditions that were undreamt of in 1948 – each, one might add, with its own campaign lobby vying for therapeutic priority and a lucrative pharmaceutical industry stoking demand.  
In a chapter examining “over-treatment and over-diagnosis”, he mentions an elderly patient who asked to come off high blood pressure drugs she said made her “feel dreadful”. Five years on, she remains as fit as can be expected for someone in their late 90s yet “every time I open her medical notes, the computer flashes an alert telling me that I should be doing something about her high blood pressure, and prescribe her more pills”, writes Francis.
Given more time, he believes, doctors could take “a more realistic approach to medicine, and explore with each patient what the benefits of a particular treatment might be, what their significant risks are, and whether it might actually be better to do nothing”. Time with patients seems to be what Francis craves most and he quotes research showing that people who have a good relationship with a familiar GP are less likely to need emergency treatment and have significantly lower mortality. 
Francis sounds like the kind of doctor everyone would want: compassionate, respectful of people’s dignity and constantly going the extra mile to plug service gaps as he bicycles around making house-calls. His treatment plan for the NHS includes “dramatic investment in a new kind of primary care in the community”, adequately staffed to help keep elderly people at home, and more of those “woefully undervalued” district nurses. He also says a reduced time-frame for pharmaceutical patents would cut the drugs bill. 
In order to kick-start this revolution, he calls for “an urgent national conversation, perhaps through citizens assemblies” about the priorities for an NHS that’s fit for the 21st century. Quite how those might work is presumably beyond the scope of this slim volume. But this wise and deeply humane polemic certainly makes an eloquent and convincing case that our national health service is worth saving.