Oli Usher – Political science
THE conventional wisdom on the left is that the National Health Service has been hollowed out by recent turbulent years of reform. The relentless move of private companies into the NHS is supposed to have undermined its ethos to the point where we barely have a truly national health service left.
It is surprising how wrong this view is. This does not mean that those on the left have nothing to fear from health reforms. But they are wrong to say the basic principles of the NHS are under threat. The aims and objectives of the NHS have not moved an inch in 60 years. A glance at The New National Health Service, an information leaflet sent out by the Government to every home in Britain in early 1948 demonstrates how little has changed.
It begins: “[The NHS] will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a ‘charity’. You are paying for it, mainly as taxpayers.”
Apart from dental care, eye cover and free prescriptions, that remains a good description of the NHS we have today. Turn over the page and the parallels with today’s health service are even more striking: “A dental service will be provided, but at present there are too few dentists to make a full service available to all without delay… Care of the eyes will be undertaken by specialists at hospitals or at special clinics… as fast as these can be organised.”
On prescription medicines, true, the NHS of 1948 gave free drugs to all who needed them, but the difference with the NHS of today (which doesn’t) is not so clear cut. The majority of drugs dispensed in Britain go to the elderly, expectant mothers, children, cancer patients and those on income support – the people who don’t pay for their prescriptions.
So we have essentially the same service now as we did 60 years ago: a free, state directed, state funded system that covers hospitals and GPs, that dispenses drugs, but does not have a functioning optical or dental service.
Whenever the left complains about creeping privatisation and the destruction of the public sector ethos in the NHS, it should bear this remarkable continuity in mind. Every few years, the Government proposes new reforms and the left cries foul, insisting that the NHS is being destroyed and that its public service ethos will not survive the changes. This is neither productive nor convincing. People who use the NHS can clearly see that past reforms have not significantly altered the patient experience –so why should future ones?
This is not to say that the changes we have seen are all benign. But the Private Finance Initiative is bad because it is inefficient and costly, not because it has undermined the principles of the NHS. And the Balkanisation of hospital services from large regional authorities into stand alone trusts and foundations linked by an internal market is not bad because this is an inherently sinister way to organise a health service. Rather, it is bad because it has brought chaos and waste, and would make it easy for a future government to introduce charges or sell off part of the service. The danger is not that they have destroyed the NHS, because they clearly haven’t, but that such reforms could make it easier to do so in future. This is an important distinction which doesn’t get mentioned nearly enough.
In many senses, the organisation of the NHS looks a lot like British Rail did in the early 1990s: not yet privatised, still run as a public service, but clearly on the free-marketeers’ shopping list. The institutional changes that made BR’s privatisation possible were made many years before the final sell-off, through its division in 1982 and again in 1994 into the chunks that would later be sold off to investors. But privatisation was not an inevitable result of these reforms.
Change is not something to fear – merely a reason to be vigilant. The NHS was a massive reforming endeavour from the start: 1948 didn’t see the sudden creation of a perfect service from nothing – it was built by moulding already existing hospitals and services into the new health service. The importance of 1948 was not in the structures that were created but in the principle that was set out – healthcare, free at the point of use, based on clinical need, not ability to pay. So long as that is not attacked, we can approve or disapprove of reforms, but we shouldn’t pretend that the very existence of the NHS is under imminent threat.
What is striking about the 1948 leaflet is that it does not just describe the new service that was brought in on July 5 1948, but also outlines further reforms that would be carried out in the future. Continued modernisation of the health service is no new fad, it was planned from the very start. In its final lines, the leaflet says: “Special premises known as health centres may later be opened in your district. Doctors may be accommodated there instead of in their own surgeries … these centres may also offer dentistry and other services on the spot.”
All of which sounds rather like the polyclinics that have caused so much controversy of late. Perhaps Ara Darzi and Nye Bevan have more in common than we thought.
