The New Politics of the NHS, Seventh Edition

Rudolf Klein

• Publisher: CRC Press
• Year: 2019
• ISBN:
  9781909368019
• Edition: 7
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The New Politics of the NHS has become established over 30 years as the key overview of the NHS, its processes and paths of influence. The seventh edition remains a clear, easy-to-read guide to often complex debates. It encompasses both the background of the evolution of the NHS since its foundation, and a completely up-to-date picture of its prese

Chapter 1

The politics of creation

If many simultaneous and variously directed forces act on a given body, the direction of its motion cannot coincide with any of those forces, but will always be a mean – what in mechanics is represented by the diagonal of a parallelogram of forces. If in the descriptions given by historians … we find their wars and battles carried out in accordance with previously formed plans, the only conclusion to be drawn is that those descriptions are false.

Leo Tolstoy, War and Peace

Britain’s National Health Service (NHS) came into existence on 5 July 1948. It was the first health system in any Western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone. It thus offered free and universal entitlement to State-provided medical care. At the time of its creation it was a unique example of the collectivist provision of health care in a market society. It was destined to remain so for almost two decades after its birth when Sweden, a country usually considered as a pioneer in the provision of welfare, caught up. Indeed, it could be held up as ‘the greatest Socialist achievement of the Labour Government’, to quote Michael Foot, the biographer of Aneurin Bevan who, as Minister of Health in that Government, was the architect of the NHS.¹

The transformation of an inadequate, partial and muddled patchwork of health care provision into a neat administrative structure was dramatic, even though the legislative transformation was built on the evolutionary developments of the previous decades. At a legislative stroke, 1,000 hospitals owned and run by a large variety of voluntary bodies and 540 hospitals operated by local authorities were nationalised. At the same time, the benefits of free general practitioner care, hitherto limited to the 21 million people covered by the insurance scheme originally set up by Lloyd George in 1911, were extended to the entire population. From then on, everyone was entitled, as of right, to free care – whether provided by a general practitioner or by a hospital doctor – financed by the State. At the summit of the administrative structure there was the Minister of Health. Under the terms of the 1946 Act setting up the NHS, the Minister was charged with the duty ‘to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services’. The services so provided, the Act further laid down, ‘shall be free of charge’.

How did this transformation come about? It is not the aim of this chapter to provide a history of the creation of the NHS: other sources are available, giving a detailed blow by blow account of what happened in the years leading up to 1948.² The intention, rather, is to analyse the political dynamics of the creation: to identify the main groups of actors in the arena of health care politics and to delineate the world of ideas in which the plans for a national health service evolved. In doing so, it is necessary to explore the complex interplay between the ineluctable pressure on politicians and administrators to do something about the practical problems forced on to their agenda by the clamouring inadequacies of health care in Britain, as it had evolved over the previous century up to 1939, and their resolution of the policy puzzles involved in accommodating competing values and insistent pressure groups. It was the historical legacy which made it inevitable that a national health service would emerge by the end of the Second World War. It was the ideological and practical resolution of the policy puzzles which determined the precise shape taken by the NHS as it actually emerged in 1948.

The emerging consensus

First, let us examine the nature of the consensus that had emerged by 1939: the movement of ideas which made it seem inevitable that some kind of national health service would eventually evolve – dictated, as it were, by the logic of circumstances, rather than by the ideology of politicians or the demands of pressure groups. Basically, this consensus embodied agreement on two linked assumptions. These were that the provision for health care in Britain, as it had grown up over the decades, was both inadequate and irrational.

Health care, it was agreed, was inadequate in terms both of coverage and of quality. Lloyd George’s 1911 legislation had provided insurance coverage only for general practitioner services. In turn this coverage was limited to manual workers, excluding even their families. Hospital care was provided by municipal and voluntary institutions on the basis of charging those who could afford to pay and giving free care to those who could not. Even though the bewildering mixture of State insurance, private insurance and the availability of free care in the last resort meant that everyone had access to some form of medical treatment, the quality varied widely. The general practitioner, operating usually on the small shopkeeper principle of running his own practice single-handed and relying mainly on the income from the capitation fees of his insured patients, was isolated from the mainstream of medicine. ‘It is disturbing to find large numbers of general practitioners being taught at great trouble and expense to use modern diagnostic equipment, to know the available resources of medicine and to exercise judgement as between patient and specialist’, the 1937 Political and Economic Planning (PEP) survey of health care in Britain commented,³ ‘only to be launched out into a system which too often will not permit them to do their job properly’. In the case of the hospital sector, the quality of specialist care varied greatly; indeed there was no officially agreed definition of who should be considered a specialist – the title of consultant being attached to specific posts, mostly in the prestigious teaching hospitals, rather than being a generally accepted description of doctors with special skills recognised according to explicit criteria. In many of the smaller voluntary hospitals, especially, it was general practitioners who carried out both medical and surgical procedures, with no check on their qualifications or competence for the job.

The system, it was further agreed, was irrational. Specialists gravitated to those parts of the country where the population was prosperous enough to pay for private care, since hospital consultancies were honorary and they were thus dependent on income from private practice. By definition, the most prosperous parts of the country were not necessarily those which generated most need for medical care. Voluntary and municipal hospitals competed with, and against, each other. The distribution of beds across the country was determined by historical hazard, not the logic of the distribution of illness: Birmingham, for example, had 5.7 beds per 1,000 population, while Liverpool had 8.6. Hospitals shuffled off responsibility for patients to each other: the voluntary hospitals regularly dumping chronic cases onto the municipal sector. Municipal hospitals could, and indeed did, refuse admission to patients coming from outside their local authority area. A further article of faith in the emerging consensus was, therefore, the need to coordinate the various systems – voluntary and municipal – that had emerged, and to introduce some rationality into the distribution of resources.

The consensus had another ingredient. There was widespread acceptance of the fact that the voluntary hospital system was no longer viable financially. By the mid-1930s traditional forms of fund-raising from the public – the appeal to altruistic charitable instincts – were not yielding anything like enough to support their activities: only 31 per cent of the income of London teaching hospitals and 20 per cent of the income of the provincial teaching hospitals came from this source. More important was income from charges to patients, financed – on a 50:50 basis – either out of their own income or out of contributory insurance schemes. The bankruptcy of the voluntary sector was staved off by the Second World War, when these hospitals drew large-scale benefits from the Government’s scheme of paying for stand-by beds for war casualties. But it was clear that, in the long term, their dependence on public finance was both irremediable and likely to increase.⁴ Equally, it had long since become clear that the original purpose of the most prestigious of the voluntary hospitals – to provide free care for the poor – could not be fully carried out, since financial pressures were forcing them to rely on attracting precisely those patients who could afford to pay. The price of survival was, to an extent, the repudiation of the inspiration which had led to their creation in the first place.

Not surprisingly, therefore, the years between the two world wars – between 1918 and 1939 – were marked by the publication of a series of reports from a variety of sources, all sharing the same general perspective. In 1920 the Minister of Health’s Consultative Council on Medical and Allied Services (the Dawson report) enunciated the principle that ‘the best means of maintaining health and curing disease should be made available to all citizens’ – a principle to be later echoed by Aneurin Bevan when he introduced the 1946 legislation – and elaborating this principle in a detailed scheme of organising health care; a hierarchy of institutions starting from the Primary Health Centre and culminating in the Teaching Hospital.⁵ In 1926 the Royal Commission on National Health Insurance came to the conclusion, although it baulked at spelling it out in its immediate recommendations, that ‘the ultimate solution will lie, we think, in the direction of divorcing the medical service entirely from the insurance system and recognising it along with all other public health activities as a service to be supported from the general public funds’.⁶ In 1930 the British Medical Association (BMA) came out in favour of extending the insurance principle to the dependents of the working population and supported a co-ordinated reorganisation of the hospital system, while in 1933 the Socialist Medical Association added its radical treble to the conservative bass drum of the BMA and published its plan for a comprehensive, free and salaried medical service, to be managed by local government but with a regional planning tier.⁷

There are a number of strands within this consensus which need disentangling. In the first place, the consensus speaks with the accents of what might be called rationalist paternalists, both medical and administrative. This is the voice not so much of those outraged by social injustice as of those intolerant of muddle, inefficiency and incompetence: a tradition going back to the days of Edwin Chadwick, via the Webbs. It is further, the voice of practical men of affairs, trying to find solutions to immediate problems. In the second place, the consensus reflects a view of health care which was rooted in British experience, though not unique to it: an intellectual bias which helps to explain why the institutional solution devised in the post-war era was unique to Britain.

The second point requires elaboration. When, confronted by the muddle of health care, men started thinking about possible solutions, they had before them two models – either of which could have been developed into a fully-fledged national system. The first model was that of Lloyd George’s insurance scheme for general practice: an import from Bismarck’s Germany. In theory, there was no reason why such a model could not have been elaborated into a comprehensive national insurance scheme: the road followed by nearly all other Western societies in the post-war period, and advocated by the BMA not only in the 1930s but also subsequently (see Chapter 3). The other model, however, was that of the public health services, developed and based on local authority provision in Britain in the nineteenth century: a model based on seeing health as a public good rather than as an individual right. While the first model emphasised the right of individuals to medical care – a right to be based, admittedly, on purchasing the appropriate insurance entitlements – the second model emphasised the obligation of public authorities to make provision for the health of the community at large. While the first model was consistent with individualistic medical values – given that the whole professional ethos was to see medical care in terms of a transaction between the individual patient and the individual doctor – the second model was consistent with a collectivist approach to the provision of health care. Indeed throughout it is important to keep in mind the distinction between medical care in the strict sense (that is, care and intervention provided by doctors with the aim of curing illness) and health care in the larger sense (that is, all those forms of care and intervention which influence the health of members of the community).

Thus the whole logic of the Dawson report was based on the proposition that ‘preventive and curative medicine cannot be separated on any sound principle. They must likewise be both brought within the sphere of the general practitioner, whose duties should embrace the work of both communal as well as individual medicine’. Nor was this just a matter of intellectual tradition. Local government was already in the business of providing health care, ranging from curative medicine in its hospitals to chronic care for the elderly and mentally ill in its institutions, from the provision of maternity clinics to looking after the health of schoolchildren. Organisational bias thus reinforced intellectual bias in the sense that the services provided by local government would have to be incorporated into any national scheme that might emerge. To have adopted an insurance-based scheme would therefore have meant actively repudiating the service-based legacy of the past.

Given this convergence of views on the necessity of devising some form of national health service, as distinct from some form of national health insurance, it is tempting to interpret the eventual emergence of the 1948 NHS in a deterministic fashion: to see it as the child not of Labour ideology, not as a Socialist triumph, but as the inevitable outcome of attempts to deal with a specific situation in the light of an intellectual consensus, both about what was desirable and about what was possible. Equally, given this convergence, it would seem redundant to search for explanations in Britain’s wartime experience, whether administrative or emotional. The acceptance of the need for a national health service long predates, as we have seen, the wartime administrative experience of running the emergency medical service: an experience which, at best, can have generated confidence that it was actually possible to run a complex web of hospitals and services. Similarly, this acceptance long predates the wartime commitment to a collectivist solution of welfare problems: a commitment epitomised in the 1942 Beveridge report which assumed, without elaborating in detail, the creation of a ‘comprehensive national health service’.

Accepting a general notion is, of course, one thing. Devising and implementing a specific plan is, however, a very different matter. The consensus may have provided a foundation. It did not provide a blueprint: when it came to detail, the various proposals put forward during the inter-war period had all come up with somewhat different schemes. To examine the evolution of plans from the outbreak of war in 1939 to the enactment of the 1946 legislation for setting up the National Health Service is to identify a whole series of clashes not only between interest groups but also between competing values. If everyone was agreed about the end of policy in a general sort of way, there was little by way of consensus about means – and much awareness of the fact that the means chosen might, in turn, affect the end. It was a conflict of a peculiar sort: conflict contained, and limited, by an overarching consensus – a constraint which forced compromise and caution on all the protagonists. Indeed, as we shall find, the theme of conflict within consensus is one which runs through the entire history of the NHS.

The curtain goes up

An appropriate starting point for tracing the evolution of policy is a memorandum written only a few days after the outbreak of the Second World War, on 21 September 1939 by the Ministry of Health’s Chief Medical Officer, Sir Arthur MacNalty. This formed part of a series of papers⁸ prepared for discussion by a small group of civil servants who, already in 1938, had started considering the future development of health services. At the first meeting, the Permanent Secretary – Sir John Maude – had outlined two possible lines of approach: ‘either the gradual extension of National Health Insurance to further classes of the community and by new statutory benefits, or the gradual development of local authority services.’ But in his memorandum, MacNalty addressed himself to a third option: ‘the suggestion that the hospitals of England and Wales should be administered as a National Hospital Service by the Ministry.’

Since it was precisely this suggestion which prevailed – in so far as the 1948 NHS was, essentially, a national hospital service – it is worth examining MacNalty’s arguments in some detail. First, he pointed out that a National Hospital System ‘is already practically established for purposes of a national emergency’. Second, he argued that ‘it will be difficult and in many cases be impossible for voluntary hospitals to carry on owing to the high costs of modern hospital treatment and the falling off of voluntary subscriptions after the war’. But then, turning to the case against such a solution, MacNalty outlined the possible objections. First, ‘the nationalisation of the hospitals would dry up the flow of voluntary subscriptions which largely contribute to relieving the ratepayer and the taxpayer of the cost of hospital provision’. Second, ‘the majority of the medical profession would be bitterly opposed to it. This would cause much dissension, controversy and ill-feeling at a time when it is vitally important that national unity should be preserved’. Third, the proposal implied ‘a radical change in the policy of the Ministry. Hitherto, we have always worke...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• 1 The politics of creation
• 2 The politics of consolidation
• 3 The politics of technocratic change
• 4 The politics of disillusionment
• 5 The politics of value for money
• 6 The politics of the big bang
• 7 The politics of The Third Way
• 8 The politics of reinvention
• 9 The politics of transition
• 10 The politics of confrontation
• 11 From church to garage
• Index