An ageing population, an increased expectation to achieve and treat, and all within a “finite” resource.
The National Health Service, at the age of 70, is not without its challenges, says Professor Paul Johnstone, regional director for the north for Public Health England (PHE).
But it is something to be proud of. To honour, and cherish, and prize. And, in years to come, to protect, with a recognition that we all have a responsibility for our own health.
“It’s a very precious gift, the NHS,” he said. “It’s seen huge change. Aneurin Bevan wouldn’t recognise the national health service today - but he would be proud.
“And the rate of change is going to be much quicker - we will see as much change in the next 15 years as we have in the past 70.”
Prof Johnstone, a man tasked with protecting and improving the nation’s health in the north of England, has an impressive resume.
Director of public health for NHS North of England, regional director, visiting professor at Leeds Beckett University, and crisis support in Pakistan, Sudan and the West Indies.
He began as a junior doctor, in a different time for the NHS. One, he says, in which training was almost free, but only in recognition that it would be paid back in effort and time.
Such investments were returned in “horrendous” 120-hour working weeks, jumping in at the deep end; at his own admission out of his depth with his first patient, a pregnant teenager.
It was seen - and is still seen - as an honour to be trained within the NHS, he said, an institution still regarded as a world-leader for healthcare.
“We are lucky,” he said. “That’s not to say it’s all roses - it’s certainly got it’s problems. But what we have forgotten as a country is just how well regarded the NHS is.”
Looking back, he cites achievements for change. A smoking ban for public spaces, which has led to a dramatic fall in case rates for early heart disease. The days are gone, he adds, when he couldn’t see across Leeds train station on his daily commute because of tobacco smoke.
A sea-change in recognition of the NHS as an economic player, demanding respect not just as a provider of health services but as a major employer, investor, and purchaser.
And driving change for strategic health directives within local authorities, in recognition that the NHS alone cannot solve public ill health.
But there are challenges ahead. The NHS, which once saw a million people every 36 hours, now treats 1.4m every 24 hours. Nearly a doubling of the workload, but not resource.
Change is needed, he warns, and a recognition that prevention is key.
“Providing a service when people need it is important, but this is more important,” he said. “I hope to see more of people saying ‘we can take responsibility for our own health’.
“The NHS is for us, we should support it any way we can - there’s only a limited amount of resources for the NHS. The more we take control of our own health, the better.”
The reality of a finite resource is ever-present. But there are big challenges. An ageing population, set to increase, and inequalities in health between the most affluent and the most deprived.
“Without doubt, the proportion of elderly people we are seeing is set to increase exponentially over the next few years,” he said. “It’s fantastic news that we are living longer, but the benefit is not spread across the whole of the population.
“Life expectancy and security in some deprived areas is set to get worse. We are in a world where this tension is set to get worse. Our elderly, more affluent people are set to live longer, but not those in more deprived areas.
“The most fundamental way of tackling health inequalities is through tackling deprivation.
“We are still to see that really implemented as it’s needed, and we are going to see increasing tension between rich and poor. Without greater focus on these inequalities, the north-south divide will widen.
“Encouragingly, Yorkshire leaders are working on devolution. In other parts of the country, devolution deals focused quite a lot on tackling these inequalities. That can help to stem the tension of increasing inequalities.”
The NHS, he adds, is almost a victim of its own success. In developing new treatments, new technologies, it has created new demand.
“As we discover more, the demand will increase, and we are working with a finite resource,” he said. “It’s a tax-payers’ service, and it’s a limited pot.
“The NHS enjoys huge public backing. This - it’s 70th birthday - is an historic moment for us - to celebrate and support it.
“I hope that the younger generation coming through can support it as much. The alternatives are just not nearly as good.”