I grew up with the National Health Service as an ever-present yet little remarked backcloth to my life. Only later in life, when my children and grandchildren were born, and I was treated for a couple of life-threatening illnesses, did I realise how much we take the NHS for granted.
Today we shudder when we hear reports of doctors in the United States asking people for their credit cards before treating them. It’s hard in this country to imagine what life was like without health care available free at the point of treatment, even if we do grumble about paying taxes to finance it.
The NHS is routinely criticised, sometimes with justification, but this pivotal institution of postwar British life has had a huge impact on our culture, and national and international identity. As the columnist Owen Jones put it, the NHS is our most treasured national institution- bringing us into the world, mending us when we’re sick, and caring for us in our final moments.
Before 1948, the poor often had to go without treatment, or rely on quack remedies and the charity of benevolent doctors.
As it struggles to meet soaring demand with stagnating budgets, the NHS, for all its ills, is part of the fabric of our national life- a definition of Britishness. Hospitals have become hi-tech health care hubs, with coffee bars and even High Street shops.
With around 1.7 million staff from all over the world, and with an annual budget of some £135bn, the NHS is the UK’s biggest employer. Yet it took a monumental struggle by the post-war Labour government to set it up.
Founding principles
The National Health Service was founded on July 5 1948. Charismatic Health Secretary Aneurin (‘Nye’ Bevan, who had steered the legislation through parliament, launched it at Park Hospital in Manchester, today known as Trafford General.
The first patient to be treated by the NHS was 13 year old Sylvia Beckingham, who had a liver condition.
It was the culmination of a hugely ambitious plan to ensure every Briton enjoyed decent health care. The NHS was based on principles unlike anything that had gone before, and even today most countries tend to rely on insurance-based schemes.
The key principle was that services would be ‘free for all at the point of use’. This meant it would have to be funded form taxation, whose progressive nature ensured people paid into it according to their means.
For the first time, doctors, dentists, pharmacists, opticians, nurses and hospitals were brought together under a single overarching organisation.
Today, when the NHS is accepted as a bulwark of British life by virtually every politician, it’s hard to believe that Bevan’s legislation was so bitterly opposed- by many doctors and by Conservative MPs.
The idea of combining all the country’s hospitals and doctors’ and dentists’ surgeries into a single state-run organisation had been born during the Second World War.
In 1942 the liberal peer Lord Beveridge had produced his famous report on the Welfare State; and disease was one of the ‘five giants’ that he wanted to eradicate. (The others were poverty, squalor, ignorance and idleness.)
His report was an heroic beacon illuminating the wartime darkness. Its dey title- Social; Insurance and Allied Services didn’t deter people from queuing outside HM Stationery Office for it, and it sold 600,000 copies.
During the war, the number of casualties being treated, on top of the normal flow of patients, almost made the fragmented health service bankrupt, but it also showed what could be achieved by having a uniform, centralised system.
The 2700 hospitals in Britain were run by charities and local authorities, and provision was often patchy and piecemeal. Paradoxically, only people with jobs were eligible for free treatment.
There was a growing recognition that health care was a right, not something bestowed erratically by charity. There was also bipartisan agreement that something needed to be done about health, particularly among younger doctors, but it was the form and financing of it that caused the dissent.
There was even opposition to the plans from Labour’s own side, some of whom thought local councils would be better able to provide health services, which conflicted with Bevan’s’ belief that the system should be universal.
Opposition from the medical profession, particularly its higher echelons, was more of a challenge.
Although he had a reputation as a left-wing firebrand, Bevan showed his pragmatic side in his negotiations with the medical profession. Faced with a threatened BMA strike, he conceded that GPs could retain the freedom to run their practices as small businesses, and consultants were offered more money and allowed to retain their private practices.
In Bevan’s famous phrase: “I stuffed their mouth with gold.”
It was an interesting metaphor, as one of the big fears of the NHS’s opponents was that ordinary people would rush to dental surgeries for free gold and silver fillings.
And indeed, the service did face a huge initial surge in demand, causing spending to soar above budget. Prime minister Clement Attlee even had to go onto the radio to appeal to listeners not to overburden the fledgling service. So NHS cash crises are as old as the service itself.
The theory was that as people enjoyed better health as a result of the NHS, demand for treatment would fall. How endearingly naïve that seems now.
What Bevan and everyone else failed to foresee was that advances in medical science would continually attract new patients and push up costs.
While the NHS was helping people live linger, this very success story exposed a fundamental fault line of the service: older people tended to get ill more often than the young, and so the cost of the NHS would inevitably increase rather than diminish.
In a process that has been repeated may times since, the government did what governments usually do and set up a committee to look at the financing of the health service. To its surprise, the committee reported that the NHS was efficient and deserved more money.
The Conservatives and the consultants finally had to recognise that people loved their free NHS, and today- apart from the odd right-wing think-tank- they are, to their credit, among its stoutest defenders.
Free for all
There have been repeated attempts over the years to chip away at the ‘free at the point of need’ philosophy.
Ironically one of the few successful attempts was by the Labour government in 1951. Chancellor High Gaitskell wanted to introduce charges for prescriptions and for dental and ophthalmic treatment.
A furious Nye Bevan and future Premier Harold Wilson were among ministers who resigned over the so-called ‘teeth and specs’ issue, which would also see patients paying half the cost of their treatment.
The amount involved was relatively small – £13m – but for Bevan it was hugely symbolic as it appeared to violate his pledge that the NHS would be based on the principle of ‘free’ care.
More recently, there have been half-hearted debates about financing health from insurance rather than tax, but they all run up against the same obstacle.
It’s nothing to do with finance or politics; it’s something more intangible. It was a former Conservative Chancellor of the Exchequer who perhaps put it most succinctly. “The National Health Service is the closest thing the English have to religion,” observed Nigel Lawson.
And the last word should perhaps be left to Bevan himself, who in another much-quoted phrase said the NHS “will last as long as there are folk left with the faith to fight for it”.
Reorganisation mania
Whitehall’s answer to problems in the health service has been to reorganise it rather than spend more money by raising taxes. I used to report on health issues, and it seemed as if there was a fresh government ‘initiative’ every year
As long ago as 1962, the medical profession was criticising Health Minister Enoch Powell’s plan to separate the NHS into three parts – hospitals, GPs and local health authorities. But the most significant reorganisation took place in 1990 with the NHS Community Care Act. Condemned by many as a step towards privatisation, it created an ‘internal market’, allowing health authorities to manage theory own budgets and ‘buy’ care from hospitals and other institutions. These ‘providers’ became NHS trusts, independent organisations with their own management.
In 2014 this concept was taken significantly further with the introduction of NHS foundation trusts, independent legal entities with unique governance arrangements. Released from ‘government control’, they were ‘accountable to local people’ and could raise capital from both public and private sector.
Government rhetoric focused on “putting patients at the heart of everything the NHS does”. Patient choice was the other buzzword, and Patient Reported Outcome Measures (PROMs) were added to the lexicon of jargon.
Although claims that this was part-privatisation were overstated, it struck at the central tenet of Aneurin Bevan’s proposals for a uniform, universal NHS. And the results have been clear to see, with hospitals failing and the scandal of Private Finance Initiative schemes saddling the service with decades of debt.
Patients don’t want reorganisation: they simply want effective treatment by a service that is not in a constant state of flux, as policy makers devise ever more tortuous and language-mangling ways of not spending enough on it.
(Article source: Choice)
