50 years of the NHS Act
RATIONING is on the agenda as the NHS enters its 50th anniversary year in 1998.
So deep have Tory cash limits bitten into health authority budgets that increasing numbers are openly discussing which types of treatment and care should no longer be funded by the NHS. In West Hertfordshire, health chiefs suggest that "rare and expensive" treatments should be given low priority, implying that local people should make sure they only contract illnesses which are common and cheap.
This type of austerity on health spending in the midst of what we are told is a booming economy is a farcical echo of the genuine economic hardship that prevailed 50 years ago, when the post-war British economy was still restricted by general rationing of consumer goods, and deep in hock to the USA.
New Labour’s determination to tighten the knots on the Tory financial straitjacket is in stark contrast with the radicalism which led to the formation of the NHS: and there are grounds to fear that the long-promised White Paper on the reform of the bureaucratic chaos of the Tory internal market system will fall far short of the necessary bold steps to undo the damage done.
The post-war reforms set out to sweep away the anomalies of the Liberal Party’s insurance-based scheme of 1911, which had only covered individual workers and not their dependent partners or children. Hospital treatment was excluded from the scheme, as was childbirth.
Labour’s plans, driven forward by Aneurin Bevan as the new Health Minister, went further than the Beveridge Report proposals which suggested a comprehensive health care system should be available to all, whether at home or in hospital. Bevan went two steps further: he nationalised the network of voluntary and municipal hospitals, and he established a system which for the first time offered comprehensive health services free to all at point of use – funded from taxation. There was no weekly stamp to pay, and no qualifying period.
The biggest beneficiaries of the new NHS, which was eventually launched in July 1948, were working class women and children, who had not been covered by National Health Insurance.
As one GP, Julian Tudor Hart, has commented: "A huge backlog of gynaecological surgery was shifted in the 1950s, the accumulated discomfort and misery of the neglected pre-war generations of working class mothers."
But although the new NHS was overwhelmingly popular, it had its diehard opponents. Winston Churchill led the Tory Party through the lobbies to oppose each of the Act’s three Readings and again in February 1948 to oppose its implementation.
Bevan ridiculed the Tory complaints that the new NHS would effectively wipe out the voluntary sector by eliminating the need to raise money through charitable donations and flag days:
"I have always felt a shudder of repulsion when I have seen nurses and students who ought to be at their work going about the streets collecting money for the hospitals."
"The only voluntary part of the hospital service destroyed by the Bill is the necessity to sell flags and to collect money. Honourable Members opposite, as they represent the party of property, always imagine that the only voluntary act which has any sanctity behind it is the writing of a cheque."
Rather more difficult an obstacle to be confronted was that of the British Medical Association (BMA), which at that time was heavily dominated by GPs. They (falsely) accused him of attempting to impose a full-time salaried service – although he had been persuaded early on to abandon that long-standing objective of the Socialist Medical Association in favour of a compromise formula in which GPs would remain "independent contractors".
Bevan’s early moves to placate the BMA, which included offering a lavish £66m compensation in return for ending the buying and selling of GP practices, could not make much headway against those like Dr Alfred Cox who denounced the new NHS as "uncommonly like the first step, and a big one, towards National Socialism as practised in Germany."
The BMA stuck to its guns, demanding the government drop or revise basic elements of the legislation. But the medical profession was becoming divided: some the Royal Colleges swung in favour of the Bill; a majority of medical students announced that they were willing to work in the new service; and the new salary scale offered hospital doctors more than had ever been available before the war.
In February 1948 Bevan arranged for a further Commons debate to endorse the new Act. In his speech he listed some of the concessions he had made to the BMA, which included the provision of private "pay beds" in NHS hospitals; and allowing GPs and consultants to have private patients.
Bevan also made a prophetic observation on the value of the new system for middle class families: "There is nothing that destroys the family budget of the professional worker more than heavy hospital bills and doctors’ bills."
Ironically, subsequent investigations on the widening "health divide" between rich and poor have shown that the more prosperous, articulate and relatively healthy middle classes have been more successful than the poor in gaining access to NHS services.
Bevan had won the public debate: opinion polls showed 69% in favour of the new NHS and only 13% against. Despite BMA polls as late as May 1948 opposing the Act, medical resistance crumbled when the government forged ahead regardless.
By September 1948 93% of the population (39.5 million people) had signed up. 18,000 GPs signed up in the first year. They wrote 187 million prescriptions. 8.5 million patients received dental treatment, and over 5 million were prescribed spectacles – with ophthalmic services costing a massive 22 times the expected £1 million.
Overall the NHS cost £402m in its first year – more than double the allocated sum of £180m. Had Gordon Brown been around, he would no doubt have wanted to put a stop to this spending, which was a clear indication of the level of unmet need from previous years.
As we celebrate the survival of the NHS for its first 50 years, however, we must remember not only a Labour government unlike today’s – one prepared to rest on public support to carry through radical reforms – but also the compromises which were made by Bevan in the process, many of which continue to dog the NHS to this day.
Bevan’s concessions to the doctors left a continued space for private medicine, which re-emerged from almost total eclipse in 1948 to mount a fresh expansion from the 1970s onwards. NHS pay beds are now seen by private health firms as a cheap and profitable option, and the problem of NHS consultants exploiting part-time contracts to "moonlight" in the private sector lingers on.
The vexed issue of the status of GPs, too, remains as difficult today as it was in 1945. The last Tory government deliberately stoked up fresh divisions by its promotion of GP Fund-holding (which pumped extra cash and resources into the larger practices, effectively creating a two-tier NHS) and the obscure notion of a "primary care led NHS" (as a pretext for cutting hospital budgets) which seems likely to be echoed in New Labour’s White Paper.
The structure of the NHS was also seriously deficient: Bevan opposed the election of local or regional health authorities, arguing that they had to be responsible to him, as the minister answerable in Parliament. The opposite view was argued by Herbert Morrison, who argued for control to be handed to local government, warning that the new quango boards of appointees would be "mere creatures of the Ministry of Health with little vitality of their own." In fact many of the old hospital boards of governors simply stepped into appointed positions in the new NHS, creating an inglorious tradition of unaccountability which continues 50 years later.
The buildings, too, were seriously inadequate. Bevan nationalised 3,500 hospitals with 150,000 beds. But almost half of them were already 50 years old, and 20% had been built before 1861. 80% of GP surgeries in working class areas were 50 years old or more. The new NHS had no plan and no resources to develop on this crumbling base. The 1950s – mostly under Tory rule – saw the slowest growth in hospital building for over 100 years. Only in the decade 1962-1972 was serious capital injected into the NHS, until the Heath government slammed on the brakes.
The NHS Act also left a loophole for the imposition of charges for some aspects of the service. This led to a cabinet row and Bevan’s resignation when Labour introduced charges for spectacles and dentistry in 1951.
The Tories weighed in with prescription charges, and these three areas have seen a massive escalation of fees under Thatcher and Major governments. Prescriptions have risen from 20p per item in 1979 to £5.65 today, with New Labour allegedly checking out the chances of foisting these charges on pensioners and others currently exempt.
The Tory years have seen the NHS eroded through the effective privatisation of much continuing care for the frail elderly.
The Tories have also succeeded in getting Labour to implement their disastrous "Private Finance Initiative, allowing private firms to build, own and run NHS hospitals for profit.
The NHS has suffered the imposition of "market" style financial pressures and cash limits, leading to large-scale rationing, first through the ever-rising waiting list, and now through the plans of health authorities to restrict access to certain treatment.
But rumours of the death of the NHS have been massively exaggerated. Even with its faults, the deal secured by Nye Bevan in those years of austerity is a historic gain stronger and more appealing than the feeble echo from today’s timid Blairites. 50 years on, the main threat to today’s NHS no longer comes from the Tories: the fight to save it is still on.