The 75th anniversary of the founding of the National Health Service this summer would seem as good a time as any to reflect on its beginnings in comparison to what it has become.
In the euphoria of a world war victory and the near record, but unexpected, landslide victory of the Clement Attlee government, it must have seemed that anything was possible. At its lowest in 1990, around 20% of the gross domestic product, UK government ‘debt’ has risen in recent years to just under the 100% mark; yet in those early post-war years it peaked at about 250%. Even so, Attlee and his team embarked upon easily the most radical programme of reform ever attempted in this country.
They nationalised utilities, major industries and rail transport and following the recommendations of the all-party Beveridge report they made significant changes to education provision. And of course, they created the National Health Service. All this is significant because it clearly indicates what is possible under the worst of conditions, if only the will to achieve is present.
Since 1951, when Attlee was defeated, it can reasonably be asserted that there has never been another government so committed to the fundamental principle of state health care – which can be summarised as the equality of provision according to medical need, financed from general taxation (with contributions according to ability to pay.)
Nibbling away at the edges
Even Attlee agreed to charges being imposed on dentures and spectacles (notionally because of the cost of the Korean war), prompting Aneurin Bevan’s resignation. However, every government since 1951 has, to a greater or lesser degree nibbled away at the edges of the original model, beginning with the introduction of a one-shilling prescription charge by the Churchill government.
None has had the political courage actually to end the basic principle (that would be political suicide), but many have changed the terms of reference significantly, and have done so by so-called ‘salami tactics’ in which numerous small slices over the years are seen as being more effective in the long term than attempting to take one large chunk and risking serious opposition.
Nonetheless, a radical step-change did occur around the late 1980s when the new economic model of neoliberalism emerged. Its UK proponent, Margaret Thatcher famously asserted that there was “no such thing (as society). There are only individual men and women, and families …” David Cameron spoilt things a little by referring, about 20 years later, to the “Big Society”, but that is another matter.
Profit becomes a motive
Neoliberalism could be seen as the antithesis of Attlee-ism.
It sought to diminish as far as possible the role of the ‘state’, and therefore of government, in the lives of the people, and instead to transfer the provision of goods and services as far as possible into the hands of private enterprise. In other words, to change the prime motivation of such provisions from providing service to acquiring profit.
To be absolutely fair, it was declared that both motivations were to be seen as equally significant, and in times when economic constraints were less imperative this appeared to be possible. But since the early days, we have endured financial collapses and a decade of ‘austerity’ when the two motivations were cast in direct conflict with one another; the loser was always inevitable.
Indeed, according to UK law, and to the law of other nations, for this to be otherwise would be unlawful; company directors may take secondary factors into consideration, but their primary fiduciary concern must be the interests of the shareholders. That this conflict has occurred in other areas of concern, such as rail transport, military recruitment and procurement, and the disposal of sewage, is apparent.
Sell-offs begin
The big administrative change introduced by the Thatcher government was the switch from local authority accountability of the health authorities to the new status of Health Trust. Declared to be the means by which local managers could make their own financial decisions based on local factors, it proved to be nothing of the sort; all the process did, in fact, was to transfer decision making from local people to the office of the secretary of state, whilst at the same time making cash resources more difficult to access.
Simultaneously, plans were implemented to sell off various NHS functions to private providers, such as domestic services, catering, estate management, ambulance services and a number of pathology services. Other diagnostic and therapeutic functions were also considered, such as radiology, but so far these remain within the aegis of the NHS.
The most costly innovation was arguably the introduction of the private finance initiative, or as it was initially called, the public-private partnership (PPP). Happily, this has now been repudiated, but however it was presented by successive governments of various colours, it was always nothing more than a fiscal con-trick.
The PPP replaced up-front, government capital investment, which was bad for borrowing figures, with long-term current account debt, which became someone else’s problem. Whatever may have been claimed for it, the net effect (in many more fields than simply in health care) has been vastly more cash being transferred from the public to the private purse.
Lack of detailed policies from the opposition
We now find ourselves facing a general election no more than 18 months away, and if current polling results persist, the present shadow health secretary must surely feel confident that in the very near future he will become the actual secretary of state. This being the case, it is notable that policies and proposals for the NHS are curiously absent from his public statements.
He quickly condemns the activities of his government counterparts and laments the strictures which seem to grow year upon year, but the radical measures that, presumably, he would positively need to take, seem still not to be in the public domain. A recent speech from the Labour Party leader was strong on principles and broad objectives, but as far as specific policies were concerned it referred simply to future statements – now time is getting very short and more detail is becoming urgent.
It is good to hear that many more nurses and doctors will be recruited and paid appropriately, but both professions need long periods of time for training and the need is immediate. To parasitise the training programmes of other countries by poaching their graduates (crucially needed in their own health care systems) is a highly unacceptable option. Serious attention to current pay demands will go a very long way to improving staff retention and halting the feedback effect on staff numbers.
It’s worth noting that the rate at which nurses and health visitors are leaving the NHS has been increasing. In April 2023 the Health Foundation reported that over the last two years, “the leaver rate for NHS nurses and health visitors increased from 9% to 11.5%. This runs counter to the NHS Long Term Plan’s stated (albeit pre-pandemic) ambition to bring the nursing vacancy rate down to 5% by 2028.”
A massive recruitment and retention plan has to be the first priority.
It is good to hear that waiting lists and ambulance queues will be things of the past, but both improvements will need significant investment in those provisions which are now the responsibility of local authorities. As with staffing levels, lead times will be extensive and plans need to be made specific without delay.
It is good to hear that seriously neglected services such as NHS dentistry (in some areas of the country, this is now non-existent) and juvenile psychiatric care will be prioritised, but there are gaping gaps in the policies which demand to be considered and filled.
What we still need to know
Is it appropriate for end-of-life care in hospices to be financed essentially by unpredictable charitable donations; is it appropriate for the necessary provision of care homes for the elderly to be dominated by transnational, profit-taking conglomerates; and is it appropriate that during unexpected times of great demand, such as the Covid crisis, the service should be so unable to cope that governmental panic measures result in the squandering of billions of pounds to private speculators?
The serious area of concern already referred to, but absent from the Labour leader’s speeches, is the increasing admixture of health care provision – the public and private financing of care. It must surely be clear that the two are always uneasy partners and that in difficult times the interests of the private capital investors will take precedence over quality of care. This must be ended.
We need to hear unambiguous intentions to return to the clear, simple principles enunciated by Attlee and Bevan, that health care will be provided for all who need it, in all circumstances, free of charge at the point of use, and funded from general taxation.
Any deviation from that simple position will serve only to perpetuate the conflicts and prolong the current dire situation.
