Category Archives: NHS history

Front Cover

Do we need a State Medical Service?  If so, on what lines should it be planned?

This pamphlet summarises the Labour Party’s answers to these two questions, which concern everyone in the land.

PART I IS A STATE MEDICAL SERVICE NEEDED?

Before answering the first question, we must decide what we require of the Health and Medical Services in general. (See Chapter I.)

We must know, broadly, what the existing Medical Service is like. (See Chapter II.)

We can then judge whether the Service, on its present basis, is likely to meet the need, or whether a State Medical Service is essential. (See Chapter III.)

Chapter I WHAT MEDICAL SERVICES DO WE NEED?

Britain’s Health Aim

The aim of the nation’s Health policy can be nothing less than the utmost possible fitness of body and mind for all the people. Full health; We cannot afford to aim at anything less than that; for full health is the greatest asset of an individual, and a healthy population is the greatest asset of a nation.

Health and Government

To achieve this aim we need as good a Medical Service as possible. We need much more than that, however. We need social action to create the conditions under which the healthy needs of the whole people can be satisfied. In truth, there is hardly any activity of government which does not affect health, directly or indirectly. If, through a sound social and economic policy, we can master poverty, we shall thereby do much to eliminate ill-health; for poverty is still the greatest single cause of ill-health. If, by good government, we secure for all good conditions of work, with full employment, and with ample opportunity for leisure and exercise; if, through our public services, the citizen can obtain well-built and well-placed houses, with sanitation, water, clean and plentiful milk and other nourishing food, clean air and as much sunlight as possible, and freedom from injurious noise; then the health of the nation will benefit far more from these causes than from much doctoring. If our economic and social conditions are such that no removable barriers stand in the way of happy parenthood and healthy childhood, then we may reasonably hope that the population, instead of diminishing sharply and progressively, will be kept replenished by a sufficiency of children, well-born and well-nurtured.

The full health that we aim at is to a great extent a consequence of good government.

No agency less universal in its authority than Government can secure for the whole people the conditions necessary for health; and no ill-health in any part of the population can be a matter of indifference to the people’s Government.

The Medical Service that we Need

Besides the various Services which affect health indirectly, we need the direct aid of a Medical Service. That Service should be:

  • Planned as a whole, so that there are no gaps in it;
  • Preventive as well as curative. It must be equipped for preventing every avoidable damage to the intricate working of body and mind, and for promoting the full flowering of every man’s and woman’s physical and mental strength; it must be positive as well as negative, helping those who are fit to keep fit, and those who are nearly fit to become fully fit. In addition, the Medical Service must provide for the cure of disease, the treatment of accidents, the care of the sick, the relief of suffering, the rehabilitation of the convalescent, maternity care and the medical treatment of children, etc.
  • Complete, covering all kinds of treatment required. The Beveridge Report called for a comprehensive Health Service ensuring “that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it, domiciliary or institutional, general, specialist, or consultant, and will ensure also the provision of dental, ophthalmic, and surgical appliances, nursing and midwifery, and rehabilitation after accidents.” (Beveridge Report, 427) This has been accepted in principle by the Government. A service which is to provide “whatever medical treatment” the citizen may require must include the service of a good general practitioner; an all-round service of specialists; good hospitals with enough beds; a nursing service in hospital and, when necessary, in the home; midwifery and other maternity services; a complete infant welfare and school medical service; health visitors; welfare workers; home help to those who need it for medical reasons; and provision for obtaining surgical appliances, dentures, spectacles, etc.
  • Open to All, irrespective of means or social position. The Service must, as the Beveridge Report says, be available “for every citizen … without an economic barrier at any point to delay recourse to it.” Poverty must be no bar to health, no bar to a man’s right to life. There should be no lower limit of income, nor any upper income limit, for access to the benefits of the entire services.
  • Efficient and up to date. The service must be amply equipped and endowed for research. Medical research workers should be enabled to keep in closest touch with fellow-workers at home and abroad, and all the doctors should have every encouragement and facility for sharing in research. In particular, provision should be made for “team-work” by the doctors, and for bringing together the resources of modern medicine in conveniently distributed Centres.
  • Accessible to the public. It should be possible for a general practitioner to direct the public to a centre not too far from home where anyone could be examined by specialists and receive special treatment; and, if necessary, the doctor should be able to call in a specialist to the patient’s home.
  • Preserve confidence between doctor and patient. Good doctoring is a very individual business. Patients should be able to change their doctors if dissatisfied, and have a choice of an alternative.
  • Equitable for the Medical Profession. The Service must be so organised and paid as to afford a fair deal for the Medical Profession. The nation must tolerate no sweating or overwork of doctors, nurses, or other health workers. That involves having adequate specialist services, sufficient doctors, provision for the free time of health workers, and, amongst other things, a system of pensions for doctors and nurses who are past work. Whilst insisting that the Medical Service shall be available for “every citizen,” irrespective of capacity to pay, we must be sure that the burden of achieving this standard of equality does not fall on the shoulders of the most self-sacrificing members of a generous profession.

Lastly, the Medical Service should be so organised as to enable the medical profession to pull its weight effectively in all those tasks of democratic government which affect the nation’s health. More and more, in planning policy about food, housing, education, industry, etc., the nation will need the guidance of medical science.

Do you agree that this represents, broadly, the kind of Medical Service that the nation needs, as part of a comprehensive Health Service?

Chapter II OUR EXISTING MEDICAL SERVICE

Now, let us briefly review the nation’s existing Medical Service, and see whether it meets the needs outlined in the previous, chapter. We will preface this review by summarising Britain’s health record up to date.

Britain’s Health Record

Since the beginning of this century the health of Britain as a whole has substantially improved. The improvement has been partly due to the general advance of medical science, including the newer knowledge of nutrition; partly to Britain’s Medical Service; partly to the Social Services in general, including such recent developments as the issue of free or cheap milk, cod liver oil, and meals for school-children; and partly to other services, such as housing, which affect health indirectly.

When this century began, the health of a great part of the nation was very bad. For instance, as Sir John Orr has written, “At the beginning of the present century, in some industrial towns, more than half of the children in the poorer districts suffered from rickets to such an extent that those who recovered were left with permanent deformities of the skeleton.”

By the time the present war began, the chances of a child surviving to the age of 60 had greatly increased. There was a large reduction in deaths from tuberculosis. In particular, the infant mortality rate, which was due largely to faulty diet, had been halved.  The death-rate in maternity cases has declined in recent years, and in 1938 the death-rate for children less than one year old was only a third of what it had been in 1901, though the death-rate for children under one month old showed little improvement. “The children of to-day,” Sit John Orr writes, “are taller and of better physique than their parents were at the same age.” In a number of infectious diseases, such as diphtheria, the death-rate has been reduced in recent years to a remarkable extent.

We cannot assume, however, that reductions in the rate of mortality always correspond with an increase in positive health. We must recognise that the physical standard of a great part of the nation remains deplorably low. The annual loss of work, energy, and happiness through avoidable ill-health mounts up to a stupendous sum in comparison with what we spend on preventive medicine and medical research. The mass evacuation of children from our crowded cities to the smaller towns and the countryside during the present war has forced the people of Britain to realise, as never before, how shameful and wasteful are the conditions under which a great number of their countrymen and women are still condemned to live. When this war began the nation’s food policy was not based on the food requirements of the people as a whole, but reflected rather the interests of trade. Nor is the nation’s health policy nationally designed or nationally controlled to meet the health requirements of the whole nation.

The lower the family income falls, the lower, generally speaking, is the standard of health. The infant mortality rate has been reduced to some extent in all classes of society, but the richest class has benefited nearly twice as much as the great bulk of the nation from the new knowledge that has made this reduction possible. (R.M Titmuss, Birth, Poverty and Wealth). The infant mortality-rate among the working class is double what it is in the richest section of the population. In 1936 the infant mortality rate per 1000 live births in Glasgow was 109 (which exceeds the rate in Tokyo or Buenos Aires) In Gateshead it was 92, London, 66; Surrey, 42! Tuberculosis is twice as prevalent amongst the poor as amongst the well- to-do, and the average stature of the well-to-do is three or four inches greater than among the poor.

The lower standard of health amongst the poor is due mainly to surroundings, rather than heredity. Statistics show that, as might be expected, the industrial areas are much less healthy than the countryside, and that in the counties of Durham and Northumber­land the death-rate of children between one and two years is double the rate in the South-Eastern Counties outside the London area. We cannot do much to control heredity, but we can control our environment; and, if we will, we can have a health policy, as well as a food policy, based on the requirements of all the people.

The war has forced us to move in this direction. The food-rationing policy, for example, whatever its defects, has been such a move. We are now assured by the Minister of Food that the nation in general is better nourished on its war-time diet than it was before the war. What an indictment of pre-war policy this is. It means that the good resulting from improved distribution has out-weighed the injury resulting from the enforced reduction of the national food supply. Will the nation be content to ignore that lesson after the war? Or shall we insist, as to some extent we do insist in war-time, upon there being “bread for all before there is cake for any”?

So much for Britain’s health record. Now look at Britain’s health organisation.

The Control of the Health Services

Who plans and controls the nation’s Health Services? The answer is that a great many authorities are concerned, each controlling a bit, and that no one is in a position to make or direct a coherent plan of health services for the nation as a whole. One might expect that the Ministry of Health would be in a position to do this; but an outline of the powers now possessed by this Ministry will show that this is not the case.

Since 1929, the Ministry of Health has been charged with widely-increased respon­sibilities in England and Wales; but many important health services remain under other Government Departments, and great unofficial services such as the voluntary hospitals, the insurance companies, and all the doctors in private practice remain outside its control.

The Ministry has some measure of jurisdiction over some of the hospitals, but not all. This jurisdiction includes the special hospitals for infectious diseases, and the Poor Law infirmaries. The jurisdiction does not extend to the “voluntary” hospitals, which number about a third of the total. (For the development of special control over hospital accommodation during the war, see below)

The Ministry controls maternity and child-welfare, supervision of midwives, welfare of the blind. The School Medical Service is under the Board of Education, but with a Medical Officer common to both.

The Ministry of Health deals with housing, sanitation, water supply, river pollution, atmospheric pollution, and the regulation of food and drugs; but poisons are dealt with by the Home Office. The Medical Service in Factories is now the business of the Ministry of Labour, but Factory Inspectors are under the Home Office. Health in Mines comes under the Mines Department, Health in Shops under the Board of Trade, and Health in Prisons under the Home Office. The mental health services and the care of mental defectives are under the Board of Control.

Evidently, then, the direction of the nation’s Health Services is very divided. It is the result of a succession of legislative patches and does not make up a Comprehensive plan. It would be a mistake to assume that a system so evolved must work badly, or that it would necessarily work better if tidied up by a logically-minded theorist. But, in fact, the system does work very imperfectly, even without the added difficulties which war-time imposes. It often works very inconveniently for the patient. It does not allow the Ministry of Health to exercise a control wide enough to ensure an energetic, ccomprehensive, National Service for Health. The Ministry cannot make a rational plan for the economical use of the nation’s hospital service; it cannot adequately provide for a service of specialists to poor patients; it cannot ensure that the doctor’s service is expended where the need is greatest, since the Ministry’s control does not cover the doctor in private practice, and the doctors are largely dependent for their income upon paying patients. Above all, the Ministry, with so patchy a control, cannot do nearly enough to build up preventive medical services and to carry through a positive health policy based on a scientific assessment of the health requirements of the nation as a whole.

The Family Doctor

Turn now from the centre of our health defences, the Ministry of Health, to the front line of those defences—the family doctor, who receives fees from his patients. The system has rendered great service to the nation’s health, and the family doctor often serves as friend and adviser as well as general physician. Undoubtedly we shall continue to need a system of doctoring which preserves this relationship of confidence between the individual doctor and the patient.

The system as at present organised, however, is becoming increasingly unsatisfactory from the standpoint of the nation, of the patient, and of the doctor himself.

The Patient’s Standpoint

Consider the position first from the standpoint of the nation and of the individual patient:

(а)   What is needed (as we have seen) is a service of preventive as well as curative medicine. But the family doctor, under present conditions, is not in a position to render such service; he is bound to be a sickness-man rather than a health-man. Called in only when there is recognised ill-health, he has little chance of helping the fit to keep fit, or the near-to-fit to become quite fit.

Moreover, it is difficult for the family doctor, under present conditions, to keep in sufficiently close touch with others who are in a better position than he is to prevent ill-health. During the past 60 years the nation has developed a wide range of public health services, which are manned by a new class of public health officer; but the family doctor has little opportunity of keeping in contact with these officers who work alongside of him. The curative and the preventive health services are not closely associated as they should be.

(b) As we have already said, the nation needs a medical service which is comprehensive, covering all kinds of treatment that may be needed, and open to all, irrespective of capacity to pay. Here, again, we find that the system under which the family doctor now has to work cannot produce such a service.

The family doctor, by himself, cannot provide a comprehensive service. Medical science is becoming so vast a field that specialisation becomes increasingly necessary; the family doctor cannot be a specialist in everything. Medical diagnosis is becoming much more exact, but may often need the service of a specialist. Medical treatment is becoming much more efficient, with new apparatus at its command; but in doing so it becomes more expensive. The general practitioner, who probably has only a small surgery to work in cannot possibly bring together all these new resources of knowledge, skill, and apparatus for the service of the patient; only some kind of Health Centre, supported by the community, can do that.

(c) Nor can the family doctor, by himself, supply a service that is truly open to all, for very many of the people who need a doctor’s attention, especially housewives and young people; are still debarred by poverty from going to him. Poverty makes a huge gap in the nation’s health defences—a gap which not even the most devoted and self- sacrificing of doctor can fill by himself. To some extent this gap has been, narrowed by the generosity of doctors, who often waive or reduce their fees for their poorer patients. It is obviously undesirable that a burden which should be the nation’s should be borne in this way. To some extent, the gap is narrowed by the public provision of free medical services, such as treatment-for tuberculosis and for venereal disease, free of charge where necessary; it is narrowed also by the Poor Law medical service, which makes some pro­vision for the treatment of patients who are technically paupers. To a substantial extent also the gap is narrowed by the National Health Insurance Scheme, by which insured persons can secure certain medical attention and treatment from their panel doctor. But still the gap between medical needs and medical service remains a wide one. It is particularly injurious in the case of children, who. are not covered by the Insurance Scheme, and for whom the School Medical Service does not yet provide an adequate service. No mere tinkering with the system will close this gap. If we want a Medical Service which is open to all, comprehensive, preventive as well as curative, and based on relations of confidence between doctor and patient, we shall have to make some radical change in the present system of organising and paying for the service of home doctors.

(d) These are not the only weaknesses of the existing system of family doctoring, from the standpoint of the nation and the individual patient. The service is not nearly as efficient as it should be, within its present limits.

For one thing, the training of a medical student is so long and costly that doctors are recruited from too narrow a section of the population. A full medical education lasts at least five years and costs about £1,500. Scholarships and prizes, and in Scotland the Carnegie Trust, afford some relief, but in effect there is a very stiff entrance fee for this profession, which restricts recruitment to about one-sixth of the population. Here, surely, is a waste of ability which the nation cannot well afford. The accident of wealth should not be allowed to play this decisive part in the selection of doctors. Ability should be the only test.

A still more serious weakness is that doctoring is not, and cannot be, allocated in accordance with the real need of the population. Having no fixed salary or pension, doctors naturally tend to congregate where they are likely to make a good income, rather than in those fields where the need for doctoring is greatest. No public authority can now say to the doctor: “You are wanted in Durham or in the Rhondda Valley, rather than in Harley Street.” Wealthy private patients can pay the piper; and so to a great extent they can call the tune, even though this results in wasteful distribution of medical services which the whole nation needs to share.

The Doctor’s Standpoint

We have considered the present system of private doctoring from the standpoint of the nation and of the patient. There remains the question:. Is the system satisfactory from the doctor’s standpoint?

There is an increasing recognition in the. medical profession that it is very unsatis­factory. The conscientious doctor wants to be able to serve effectively in preventing ill-health; but he knows, better than, any layman, that at present, he cannot do this. He cannot even keep in touch adequately with the preventive work of the public health services. The doctor wants to see his patients supplied with whatever kind of treatment they need: but he cannot himself supply that treatment. He wants to spend his skill as a healer on those who most need it, regardless of their capacity to pay; but,: however generous his intention, having no assured income or pension, he is hampered in giving such service. The existing system.is not producing nearly enough doctors for the nation’s needs, and it makes no provision for the doctor to be “off duty; so the general practitioner is apt to be perpetually overworked. That is very bad for him, and also for his patients.

There is only one way in which these difficulties can be removed and that is by providing for “teamwork” between doctors, better contact between general practitioners and specialists, and fuller access to all the resources of modern medicine. That leads to the conclusion that, in the doctor’s interest as well as that of the patient, there must be well-equipped Health Centres throughout the country as part of a National Service for Health, and that the doctors should be whole-time, salaried officers of that Service.

National Health Insurance

We come now to the National Health Insurance Scheme, which was provided as u means of mitigating some of the defects of our private medical service which have just been noted.

The Scheme applies, broadly speaking, to all persons who work under an employer’s direction and whose salary is less than £420 a year (formerly £250). The insured persons are entitled to a certain amount of free doctoring by a specified doctor “on the panel ” and to a certain amount of drugs and medical, necessities. In addition, insured persons

can qualify for receipt of financial assistance during a period of incapacity. The Scheme entitles the doctor to a capitation fee for each person registered as being on his panel.

The Scheme has done a good deal to mitigate the defects of the old, wholly unorganised, medical system.

(а) It is not designed, however, for the prevention of ill-health but only for its cure. A doctor, when in panel practice, is in no better position for preventing ill-health than he is when acting as a private family doctor.

(b) The Scheme does not provide a comprehensive service, covering all kinds of treat­ment that may be needed. What is demanded of the panel doctor himself is no more than the elementary standard of doctoring which any and every general practitioner can provide.

Patients often complain that the panel doctor’s attention is perfunctory. This would not be surprising, for the panel doctor is not employed full time on this part of his practice, and he can hardly help feeling the pull of other, more lucrative, employment.

A very important deficiency in the service is that it does not entitle the insured person to hospital treatment, or to the service of specialists.

(c) The Panel Service, by its nature, is not open to all. It does not include the higher- paid, salaried worker, nor those who work on their own account, nor the dependents of those insured. More than half of the population is not covered by the Scheme; and, as we have indicated, even those who are included are not fully provided for.

(d) A further defect of the Panel System is that it does not provide sufficient guarantee for the efficiency of the doctors employed. A fact too little realised is that practices are bought and sold by doctors, and that anyone can buy a practice if he has a minimum qualification, and if he possesses, or can borrow, the requisite capital. The general public lacks the knowledge for appraising the quality of his service and his efficiency is not in fact subject to any adequate public control. If he has a manner which ingratiates him with his clients; he can retain and even increase his practice, even though his technical competence may be very low.

(e) Lastly, the scheme bears hardly on the doctor who desires freedom from financial anxiety coupled with freedom to do the best work of which he is capable. He cannot speak freely, bluntly, as a healer, or as a guardian of good health, if he has always to be thinking of pleasing enough patients to swell the list on his panel.

In short, the National Insurance System, for all its merits, does not meet more than a section of the nation’s need.

Hospitals

The nation’s hospital system is a curious medley. It includes some 2,000 public hospitals and some 1,000 so-called “voluntary” hospitals of various types. The public institutions are under the control of Local Authorities, democratically elected; the voluntary hospitals are responsible only to their own individual governing bodies. The public hospitals are paid for almost entirely out of rates and taxes, whereas the voluntary hospitals finance themselves as best they can by private endowment, by appeals to private charity, and by payments for services rendered.

All the medical schools in the country (except one) have grown up in association with some large voluntary hospital. It is in these hospitals that a large part of the nation’s medical research work is done:

(1) The Voluntary Hospitals have rendered great service, and have been maintained by devoted effort, much of it unpaid. Much of the medical work in these hospitals is done by “honorary staff,” who receive no monetary payment, but who may thus gain prestige and reputation; generally it is those who can afford to take this road who find their way to Harley Street and to highly-paid consultant practices.

The voluntary hospitals have to wage a perpetual fight for funds. Their income from charitable sources had increased before the present war, but not fast enough to meet their needs; and nearly a third of them were in debt. During the war, their financial position has been temporarily eased as a result of the State’s Emergency Medical Service, which is referred to below.

(2) The Public Hospitals were mainly built in the 19th century as Poor Law Hospitals or Institutions, or for infectious diseases. Many are still Poor Law Hospitals, controlled by Public Assistance Authorities. Others have been taken over by the Public Health Committees of County and County Borough Authorities, as Municipal Hospitals. Some of the public hospitals have been developed in recent years to a high, standard of efficiency by Municipal Authorities.

The public hospitals provide nearly three-quarters of all the available beds in the country, including nearly all the beds for infectious diseases, most of those for tuberculosis, and many for maternity cases.

The Ministry of Health exercises only partial control over the policy of these hospitals.

(3) During the war the Government has exercised partial control over all hospitals of any size, so as to operate the Emergency Medical Service Scheme which had been roughly planned before the war. Under this Scheme, beds were reserved in each hospital for “E.M.S.” cases, such as civilian war casualties and patients from the Forces. The Government has paid for the beds thus reserved. The Scheme has resulted in some grouping of hospitals and in the division of the country into a dozen large areas for administrative purposes. Some such Scheme has been indispensable for war purposes, but the existing Scheme could not meet post-war needs. It is without any adequate democratic control and without plan; it is largely controlled by representatives of the voluntary hospitals; and any attempt to make permanent the arrangements which were imposed for war-time purposes would be resented by the authorities in charge of public hospitals.

One of the defects of the hospital system as now organised is that the Voluntary Hospitals do not, generally speaking, provide beds for chronic cases, among which the majority are old people; so that the Local Authorities have to find accommodation for almost all such cases.

Reviewing the Hospital Service as a whole, it must be said that it lacks co­ordination; it lacks such provision for comprehensive planning as would ensure the location of hospitals where they are most needed and their use for the purposes most required in the national interest; it often lacks adequate provision for prompt and efficient treatment (There is, for instance, a great shortage of beds for the treatment of rheumatic diseases); and it also lacks a comprehensive system of financing which would eliminate the present scramble for charity, and would make possible a long-term programme of development.

Maternity and Infant Welfare

An efficient, co-ordinated service for mothers and for infant welfare is a national necessity, as was shown by the terribly high death-rate of mothers and infants before 1918. The Public Health Act, 1936 (which incorporates the Maternity and Child Welfare Act of 1918), permits Local Authorities to provide Ante-natal Centres for looking after expectant mothers, and Centres for infant welfare. The Midwives Act, 1936, requires Local Authorities to secure the provision of an efficient service of midwives. In practice, some Local Authorities do a lot, others very little. The agencies dealing with maternity in London, for example, are numerous and uncoordinated. A uniform maternity service, nationally planned and locally administered, is urgently needed.

School Medical Service

A School Medical Service is a logical corollary of making school attendance com­pulsory, if only because a child in poor health cannot get full benefit from education. It was not until 1907, however, that this fact was recognised by the beginning of a School Medical Service.

At present, this Service provides for free medical inspection of every elementary school child at least three times between the age of entering and leaving school; but sufficient time for a thorough and complete examination is rarely available. Local Authorities provide treatment for school-children’s minor ailments, practically free of charge. There is also some provision for treatment of teeth, eyes, nose, and throat, etc., but this is still very inadequate in some localities, especially as regards dental treatment, and some payment has to be made by the parents, save in special cases. Increasing provision has been made for supply of milk, cod liver oil, etc., and this has had a valuable effect on the children’s general health. Before the war there was provision on a small scale of cheap meals for children at school, and this has been extended during the war, where school equipment permits; but even now the scheme provides for only one-fifth of the children. Finally, the benefits of the National Health Insurance Scheme have lately been extended to cover employed children who have left school but are not yet 16.

Thus, we can say that the foundations of a School Medical Service have been laid. But evidently the service greatly needs expansion. All too often in the past, this expansion has been cramped by the demand for economy by Local Authority Com­mittees; so that poverty has remained a bar to health just at the time of life when the foundations of health are being laid. (The old are voters, the young are not!) Let us remember, for the future, when dealing with Health Services for the young, that in no field of medicine is “economy” more likely to prove “false economy.”

Permissive Health Legislation

Much of Britain’s existing health legislation is “permissive.” Local Authorities are allowed to provide certain services, but may fail to do so. This applies, for instance, to the maternity service: much would be gained if the more backward Local Authorities would exercise the powers permitted so as to bring up their service for maternity to a standard comparable with that achieved by the more progressive authorities. The “permissive” laws ought in such cases to be changed into obligations.

Moreover, in some cases the powers of Local Authorities are limited in such a way as to make an efficient, comprehensive service impossible. Thus, Local Authorities can provide domiciliary treatment in the case of paupers but not for others. In the well- equipped cities children who are well enough to attend clinics can get first-class treatment for dental, eye, rheumatic, throat, and-ear troubles, etc., but if the child happens to be too ill to attend the clinic, the school medical service can do no more, and the parent can only call in and pay for a private doctor. Such anomalies ought to be cleared away by an “all-in” service.

Summary of Conclusions

The foregoing chapter has sought to show that the nation’s existing medical service, good though it is in many respects, is ill-planned and far from adequate for the needs of the nation as a whole. Further it is contended that there is need for more control at the centre; the Ministry of Health should be in a position to plan the lay-out of the nation’s hospitals, doctoring, etc, according to the nation’s need. The family doctor’s position is unsatisfactory; in particular, more “team-work” is needed, and the efficient doctor should have an economic security which the present system cannot give. Whilst the defects of the old system of private doctoring have been mitigated by the National Health Insurance Scheme, they have not been removed; and the Scheme does not provide a medical service which is comprehensive or open to all, or well-equipped for the prevention of ill-health. Moreover, the hospital system is an unplanned medley of public and voluntary institutions, without any unified control, and with many financial embarrassments. Certain services in particular, such as the provision for care of mothers before, during, and after child-birth, and the School Medical Service, are in special need of expansion.

How are these needs to be supplied? How are these defects to be remedied?

Chapter III WHY A STATE MEDICAL SERVICE IS NECESSARY

Having considered what kind of medical service is required and what the existing service is like, we can now answer the first of our two questions: “Is a State Medical Service Necessary?”

A Central Health Authority

We have seen that there is need for a Central Authority, empowered to plan the lay-out of the National Health Services, including the medical service, on the basis of a scientific assessment of the needs of the whole nation, and to see that the plan is carried into effect. We have seen, too, that this need is not now being met; the Ministry of Health lacks the power to pull the medical service into shape as a coherent whole.

The conclusion surely is that a Central Authority responsible to Parliament, must be given the powers appropriate to the central organ of a comprehensive National Service for Health. That Authority must be in a position, for instance, to weld together the separate sections of our hospital system into in economically-planned service. Just as the Ministry of War directs the strategic placing of the Home Forces for defence against invasion, so this Central Authority should be able to plan the strategic disposition of the nation’s defences against ill-health.

Local Health Authorities

The Central Authority, however, should not attempt to run the whole machinery. That would mean certain breakdown. Wide powers must be left to Local Authorities; it is they who must be responsible for the detailed administration of the service. That administration must be organised in units of convenient size; it must bring together all the necessary services at convenient Health Centres; and it must be elastic, allowing for considerable diversity of treatment. At present Local Authorities are not in a position to do all this; they cannot construct a comprehensive scheme which will govern the policy of voluntary as well as public hospitals; they cannot bring together a team of general practitioners at a series of Health Centres, or provide a full service of specialists to patients who need them. Nor can the necessary powers, with the necessary democratic control, be obtained except as part of a comprehensive National Health Service.

Doctors

The same conclusion emerges when we consider how the nation can obtain the services it most needs from the doctors, whilst affording to the doctors all the considera­tion that it owes to them? Unless the doctor has a salary, and a prospect of pension, which frees him from economic dependence upon paying patients, he cannot devote his full energy to the prevention as well as to the cure of ill-health. Unless the com­munity provides that economic security, it cannot direct where the doctor’s work would best be used in the national interest. Only a salaried medical Staff, as part of a National Health Service, can meet the need.

National Health Insurance

It is sometimes suggested that the nation’s need can be simply met by extending the National Health Insurance Scheme. That is a mistake, as will be seen if the principles of Health Insurance are compared with the principles of a nation-wide Health Service such as is here proposed. The essence of any commercial insurance scheme, properly so-called, is that the insurer has to cover risks which he can calculate within a narrow margin of error; the premiums payable by the insured must be determined in advance and must be paid regularly; the insurance payments offered must be limited in amount and the treatment must be limited in character, and these benefits must be confined strictly to those who have paid the premium or are covered by it.

On the other hand, the essence of a nation-wide Health Service is that it covers risks to health which cannot be exactly computed; that the benefits it offers must include every kind of treatment needed by the patient, and must provide that treatment for as long as the doctor thinks necessary in the patient’s interest; and that no one should be debarred from these vital services by poverty or any other cause. It was agreed at the outset that the Health Service which the nation needs must be preventive as well as curative, comprehensive, and open to all. That means that we are calling for something different in kind from an Insurance Scheme. We want the whole nation to be the insurer, and the. whole nation to be the insured. What we want does not involve a mass of paper work, or filling-in of forms, or competitive offers of this and that special benefit as the reward for an increased premium. What we want, in short, is a compre­hensive service for the health of the whole nation, provided by the nation, for the nation.

Hospitals

One more example must suffice.

We have seen that the hospital system has grown up haphazard and without adequate co-ordination. We have estimated that in some respects the hospitals are much below the standard of efficiency and equipment that should now be required. It is clear that the voluntary hospitals have to base their policy upon the uncertain outcome of a com­petition for charity, and are subject to no public control. How is it possible, without some unified planning and control, to build up a hospital service that is well adjusted to the need of the nation as a whole? Surely the conclusion must be that public and voluntary hospitals alike must be brought within a National Health Service on equitable terms.

SUMMARY OF CONCLUSIONS

We said in the first chapter that the nation needs a Medical Service which is planned as a whole; we have seen that no authority is now in a position to make such a plan or to see that it is carried out;

We said that the Service should be preventive as well as curative; but we have seen that neither the system of paid private doctoring nor the National Health Insurance Scheme is in a position to deal adequately with the problems of prevention of ill-health. Only a salaried State Medical Service can do so.

We said that the Service should be complete, covering all kinds of treatment required; we have seen that it is far from complete and can only be made complete by State action.

We said that the Service must be open to all, so that poverty shall be no bar to health; and we have seen that this provision for the nation as a whole can only be made by the nation as a whole.

We said that the Service must be efficient and up to date, providing for “team-work” and for convenient concentration of medical resources; but we have found that only the community can achieve this, by means of a health system which allows for a planned disposition of hospitals, doctors, etc.

We said that the system must offer a fair deal to doctor and patient alike; but we found that only a system of whole-time, salaried, and pensionable doctoring would meet these requirements.

We said that in the interests of true economy certain Services, such as the School Medical Service and the various Services connected with maternity and infancy, need expansion; only the community can provide for this expansion.

So it comes to this:

Do you, as a citizen, want a Medical Service that is planned and directed in accordance with the needs of the nation as a whole; or do you think that we had better muddle along with the present system, distorted as it is by the influence of private profit?

Do you not agree with the Labour Party that the Medical Service should be developed, as rapidly as conditions permit, into a State Medical Service, as part of a comprehensive National Service for Health?

PART II  A STATE MEDICAL SERVICE

Assuming that a State Medical Service is needed, how should it be organised? What services should at render? Could the nation afford it?

Here, in brief, is the Labour Party’s answer.

Chapter IV LABOUR’S PLAN FOR A STATE MEDICAL SERVICE

The nation’s most precious asset—its health—is to be insured by the entire nation. So the nation must have, amongst other services, a State Medical Service which is sensibly planned so as to make the very best use of all the nation’s medical resources for the benefit of all.

Organisation

There must, therefore, be some Central Health Authority, competent to plan the Health Services as a whole, including the Medical Service, subject to the general control of Parliament, and competent to see that the plan is carried out, with due allowance for the diversity of local conditions.

There must also be some kind of Regional Authority, for the more detailed planning of the medical service and for its administration.

Besides this, there must be local units, under the general administration of the Regional Authority. Some of these operational units should be large enough to allow for the concentration of medical equipment and specialists at convenient centres, others should be small enough to make the service easily accessible to everyone who needs it.

The Ministry of Health

The Central Authority can only be the Ministry of Health. No other Authority has the Ministry’s accumulated knowledge of national health conditions; nor could any organisation less nation-wide in scope be held responsible to Parliament. In a matter which so vitally concerns the whole nation, it is Parliament, representing the whole nation, which must have ultimate control.

What has been said of the Ministry of Health applies, in the case of Scotland, to the Scottish Department of Health.

The powers of the Ministry will need revision, however. On the one hand, its powers should be extended to cover all the Health Services, including those now controlled by other Departments, such as the School Medical Service and the health service in factories; for technical reasons the medical services of the Armed Forces should be excepted. On the other hand, the Ministry of Health should be relieved of respon­sibility for services which affect health only indirectly, and which involve large-scale organisation. (This principle is being adopted in the case of housing.).

The Minister, of Health should continue to be responsible to Parliament.

Regional Health Authorities

Labour’s Plan for the reform of Local Government (see the Labour Party’s pamphlet, “The Future of Local Government”) recommends that the country should be divided into Regions, each having a Regional Authority for certain purposes of Local Govern­ment; and that these Authorities (unlike the regional organisation during the war) should be democratically elected. The Party also proposes that, for health purposes, each of these elected Regional Authorities should appoint a Health Committee for its Region. Under these Regional Health Committees there should be appropriate sub­committees.

Divisional Hospitals

(1) Within each Region there should be a series of Divisional Hospitals, associated with Divisional Health Centres.

The divisional unit must be large enough to justify a big, fully-equipped hospital, and the concentration of specialists of every type. It has been found by experience that an economic size for such units is one which includes a population of about 100,000 persons and requires a hospital of about 1,000 beds. In some cases it may be convenient to have larger “operational units,” with, say, 250,000 population and several Divisional Hospitals.

The Divisional Hospitals should be large and fully equipped, with from 600 to 1,200 beds; they should include departments for X-rays, for rehabilitation of patients whose powers have been temporarily damaged by ill-health or accident, and for other kinds of special treatment.

These should be General Hospitals, treating all kinds of cases except infectious cases or mental disease of certain kinds, apart from these exceptions, “special” hospitals should be eliminated. The system should provide for a certain amount of specialisation in the following way: The General Hospitals should be associated in groups, so that only one hospital out of a group of three or four would admit, say, skin cases, or eye cases; perhaps only one hospital in each Region would undertake rare specialised treatment such as plastic surgery or brain surgery. Thus, whilst in the main the Divisional Hospitals would be General Hospitals, specialised units would be included in them.

(2) For this reorganisation, the nation will need all, and more than all, the efficient hospitals that there are at present—both public and “voluntary.” All those that come up to standard and can be fitted into the scheme should be brought within a coherent plan—a plan that is reasonably elastic and constantly brought up to date. This means that voluntary, as well as public hospitals, must be brought into the National Scheme, on terms which will satisfy the nation’s sense of equity.

The Labour Party therefore proposes that the Government should lay upon Local Authorities the duty of securing a comprehensive hospital service, based on a coherent but adaptable plan, each plan covering a large area—a “Region.” All hospitals within the area, whether public or voluntary, general or special, should be required to come into and conform to this plan, undertaking only the type of work which is allotted to them in the plan. The standard of efficiency, and the conditions of service and staff should become the same for all, and all should be subject to inspection by inspectors responsible to the Ministry of Health. The voluntary hospitals should be required to admit all patients in accordance with a unified system of admission covering the whole hospital service.

A simple method of achieving the goal of a unified hospital system would be as follows. The voluntary hospitals might receive financial assistance in respect of the cases referred to them by Local Authorities, and the Local Authorities would become entitled to a share of representation and control on the Governing Board of the hospital which is proportionate to the services rendered to the patients thus referred. The effect of this scheme would be to ensure that before long the voluntary hospitals will come under the control of the Local Authorities, and that the conditions of service and staff in all the hospitals will become standardised. Thus we should have at last a unified hospital system, laid out on a rational plan, each section of the plan covering a sufficiently large area for efficient working.

(3) The staffing of Divisional Hospitals should be of the highest possible standard. A hospital of the size indicated would need a staff of about 50 doctors of various types. Specialists would see cases referred to them at the hospital, and should also be available for consultations at the Health Centres or in the patients’ homes. The specialists’ service should be so organised by the Divisional Hospital and the Divisional Health Centre in co-operation as to be available at short notice at all times.

It is important that the doctors working in the Home Doctor Service should be able to keep in close touch not only with the cases which they have themselves sent to the hospital, but also with the hospital’s general work.

Divisional Health Centres

The Government should require Local Authorities to establish Divisional and Local Health Centres as soon as conditions permit, and should offer grants for this purpose, sufficient to cover a large, proportion of the cost. Each Divisional Centre should, where practicable, be close to a Divisional. Hospital. Its equipment should provide for the widest possible range of services, including those that cannot always be provided at Local Centres.

There should be a laboratory adequate for the service of the Divisional Hospital and Health Centre, and it should be staffed and equipped on a scale sufficient to allow for research. The clinical pathologist in charge of a laboratory should co-operate with the whole staff of the division, including the doctors in general practice, so as to facilitate research work throughout the area.

Local Health Centres

In each divisional area there should be four or more Local Health Centres, each linked with the Divisional Health Centre, and each served by from eight to twelve general practitioners. In rural areas, these Local Health Centres may have to be much more numerous in proportion to the population, and may have a much smaller number of doctors—perhaps only one or two.

At these Centres patients would obtain the service of their home doctor; and through him they could draw upon a complete service of specialists at, or from, the Divisional Centre or Hospital. The Local Health Centres would also organise the services of midwives, home nurses, home helps, health visitors, and social welfare workers.

Health Records

One of the great advantages of a unified medical service, with Health Centres as proposed, would be that complete records of the health of all the people could be kept. The Health Centres, Local and Divisional, should have an appropriate clerical staff; and the clerical work should include the keeping of health records. The records would be available, in strict confidence, to all doctors in the unit who may require them, and would be sent to the Health Centre of any other area to which the individual may move.

The value of such continuous recording of the medical history of each individual, in health and in sickness, need hardly be emphasised. Suppose, for instance, that a boy is examined in the school medical inspection. Is it not obvious that the record of that inspection should be available in confidence to the doctor who may afterwards see the boy at the Health Centre, or at home? Presently, the boy may go away to some other part of the country, and may there need a doctor’s attention. Would it not be sensible that that doctor should have access, without difficulty, to the boy’s medical history? If the boy had to go into hospital, would it not be useful that the doctor in charge, during convalescence should have knowledge of the record of his case whilst in hospital and before he went there?

Only an organised, unified Medical Service, with an adequate clerical staff, can provide such a system of records.

Specialist Services

One of the developments most needed to make the nation’s Medical Service compre­hensive is the provision of a service of specialists, available to all who need it. The plan outlined above will afford by far the best means of organising such a Service. (Some Local Authorities now find it convenient and economical to employ full-time specialists who divide their time between the clinics and the municipal hospitals. The existing law allows a local doctor to call in a specialist to a patient’s home, charging the cost to the Local Authority; but this applies only to maternity cases.)

Home Doctors

The general practitioner, or “home doctor,” is the first line of the nation’s health defences; and he must always retain that position. The confidential relation between doctor and patient is an indispensable part of a satisfactory health service. It is becoming apparent, however, that the present system of organising and paying for the doctors’ services has become increasingly unsatisfactory from the standpoint of the nation, of the patient, and of the doctor himself. The patient is not getting a service that is preventive, comprehensive, open to all, and fully efficient. In particular, the nation’s resources of doctoring are ill distributed, and the doctor’s conditions of employ­ment do not adequately protect his own health, or his freedom as a guardian of health.

In the Labour Party’s opinion, therefore, it is necessary that the medical profession should be organised as a national, full-time, salaried, pensionable service.

Doctors and nurses, as well as the rest of the medical profession, should have fixed hours of service; though in the doctor’s case an emergency may of course arise which will upset his normal time-table.

The service must be national, i.e., supplied and paid for out of taxes and rates. We cannot have a Medical Service which covers all the medical needs of all the people unless all the people contribute to the cost, and unless the doctoring can be distributed in accordance with the needs of all the people.

The service should be full time. Suppose that it were not full time, but that the doctor was partly employed in private practice. Either his service for the State would be just as thorough and conscientious as his service when treating fee-paying patients as a private doctor, or else his standard would differ. If patients could get his full attention, however, without paying a fee during half the day, they would hardly go to him during those hours when a fee would be charged. It would be intolerable that his service as a State doctor should be less adequate than the service rendered for private fees.

National Service for Health is a service honourable enough for any recruit; it should be a service well enough paid and protected to meet the needs of every doctor in a democratic Britain.

The service should be salaried and pensionable. The State should make equitable provision for the security of tenure and superannuation rights of all the members of the State Medical Service; and it will be necessary for reasons of equity to devise a scheme of compensation for the value of doctors’ practices in which doctors have invested capital. Only when the doctor is thus paid will it be possible to set him free to do his best work in the wide field of preventive, as well as curative, medicine. Only so will it be possible to ensure that the service of doctors is distributed in accordance with a disinterested estimate of the nation’s needs. Only so will it be possible to protect the doctor against the overwork which is often the consequence of his own devotion to his great task as a healer.

It may be that for a while some doctors will wish to be left out of the State Scheme, and remain dependent upon private practice. The nation should make the service so efficient and complete that no patient could desire a better and every doctor will wish to serve in it.

Midwives

The service of midwives should be organised through the Local Health Centres, and the midwives should form a team with the obstetrical doctors. Much of their work will be in the homes of mothers, but they must also be in close touch with the Maternity Section of the Divisional Hospital.

Health Visitors

Health visitors should be available at the Health Centre and in the home. They should become a strong link between the family and the medical staff of the Health Centre. In particular, they should be concerned with protecting the health of infants, and with education in the preservation and development of full health for all in the home.

Social Welfare Workers

In any Health Service, trained social workers have an important place, especially so long as surroundings—such as bad housing—contribute so largely as they do in our in­dustrial towns to the production of disease. Such workers should be able to contribute substantially to the improvement of “environmental” conditions affecting health.

Home Helps

Home helps are at present available in some areas to assist mothers with new-born infants. This system should be developed so that home help can be provided in homes where the mothers have been removed to hospital, or are prevented by whatever cause from attending to home and family.

Nurses of the Home Nursing Service

Local Authorities should be required to establish a complete Home Nursing Service in every locality. The nurses should work with the medical staff of the Health Centres, and the admirable personnel now employed in the District Nursing Service should be taken over by the Local Authorities and increased where necessary.

Hospital Nursing Service

Hitherto, the nursing profession has commonly been grossly underpaid and over-worked. It is only recently that a major effort has been made to remedy this by State action. Those who have ever been in hospital know how much their comfort has depended upon the nurses’ unfailing care, no matter how irritable and unhappy the patient may sometimes have felt. It is then that one has realised something of the strain under which the nurses have to live. The community would be blindly ungrateful and very foolish if it did not ensure a fair deal for nurses in regard to working conditions, salaries, pensions, and training.

School Medical Service

At present the School Medical Service is very inadequate, and, as already noted in Chapter II, little medical service is available for school-children without cost to the parents. The Labour Party holds strongly that free treatment in the School Medical Service should be instituted without delay. If a child requires treatment and is not being attended by the family doctor at home, the School Authorities should send the child to the Health Centre or Hospital, for treatment free of charge to the parent.

There should be at least four medical inspections of school-children during school life, instead of the standard of three inspections as at present, (when the school-leaving age is raised the number of inspections should be increased) and these should be thorough, instead of being summary and superficial, as is too commonly the case now.

In addition, there should be annual inspections of teeth, sight, and hearing. Twice a| year all school children should be weighed and measured. A special inspection should be made not only after a child has developed definite symptoms of illness but whenever the child’s physical and mental progress is found to be below normal.

Maternity Service

The care of mothers and infants has long been organised as a separate service. In developing this service, so as to fill its essential place in a State Medical Service, the experience of the existing schemes will of course be a necessary foundation.

Here, in brief, is the Labour Party’s Plan for a complete National Maternity Service. It is assumed that the aim of the service will be the safety and comfort of the mother and baby; that all personnel concerned must be fully capable for their job, and should co-operate closely, before, during, and after the confinement; and that all the services should be co-ordinated under the Regional Health Committee.

(1) Ante-Natal Service

There should be ante-natal supervision of all expectant mothers, and, when necessary, treatment. For this purpose, ante-natal clinics are essential and should become an important part of the work of the Local Health Centres. Patients should (as now) be encouraged to attend the clinic, both for medical examination and for advice and help as to preparations for their confinement (such as the early booking of a midwife or hospital bed). The clinics should be staffed from the Maternity Department of the Divi­sional Hospital. The Dental Service at the Health Centre should be available for the treatment of expectant mothers.

Health visitors will also be attached to the Centre, and will be in a position, through their normal visits to patients’ homes, to ensure that the advice given to mothers at the clinic is understood and carried out. The health visitor will also be able to advise whether the mother’s home conditions are, or can be made, suitable for her confinement, or whether this should take place in hospital. (In general, all first confinements, and all confinements which are likely to show some departure from the normal, should take place in hospital.) If the staff of health visitors is adequate and competent, and if the other services are manifestly of a high standard, the health visitor should be able to allay un­necessary anxiety and to persuade the mothers to make full use of the services offered.

(2) Confinements

(а) Home Cases

Every effort must be made to ensure the efficient working of the Midwives Act, 1936, with the direct appointment of qualified and competent midwives by the Local Super­vising Authority. This service should be organised from the Health Centre.

Sterilised maternity outfits should be available for all mothers. A uniformly good set should be provided and regarded as part of the necessary equipment of the midwife.

Ample provision for domestic assistance must be ensured. The Local Authority should have a service of suitable women for employment as “home helps,” a regular salary being paid for full-time work. Domestic assistance should be available for special cases during pregnancy, and for a longer period than two weeks after the confinement, whenever necessary.

(b) Hospital Cases

The hospital provision for maternity cases must be adequate, and must include beds for emergency cases of all kinds. The patients should remain in hospital for not less than the minimum period of 14 days. It is desirable that there should be small wards of not more than four beds. Proper isolation accommodation must be provided, with all precautions against puerperal infection.

Whether the confinement is in hospital or in the patient’s home, labour should be made as painless as possible; provision must be made for anaesthesia. In hospital this is easy; at home, methods which the midwife can use should be developed and taught.

(3) Post-Natal Services

As far as possible all patients should be seen after childbirth by the same staff as were responsible during the ante-natal care and at the birth. At least one full examination of the patient should be made, and advice should be available at the Health Centre. It is important that further home help should be provided when required, and that there should be convalescent homes to which mothers can be sent after childbirth for periods of rest if necessary.

Tuberculosis

Among the diseases connected with poverty, none is more deadly than tuberculosis. Wherever we find poverty, poor food, over-crowding, over-work, lack of good air, there we find a high tuberculosis rate.

Between the wars, the death-rate from tuberculosis in England and Wales was reduced by more than half, but even so the deaths in 1938 amounted to 26,000. With the out­break of the present war this improvement was sharply reversed, especially in Scotland. The Government have taken one important step to deal with this, by providing for cheap and rapid X-ray examination, so as to identify the disease while it is still amenable to treatment. But this provision for improved diagnosis will not have its proper effect unless certain other conditions are satisfied. There must be adequate subsistence allowances for a patient’s family during his or her absence; otherwise the patient will be tempted to postpone until too late the opportunity—which is also a social duty—of undergoing the treatment even at a time when he may still be feeling well. The same applies to the provision of home help. There must be adequate staff and accommodation in hospitals and sanatoria, so that patients are not kept waiting. Further, when the patient is convalescent, there should be provision for “rehabilitation,” with suitable work, both for infectious and non-infectious cases. In all these respects, new developments are needed, as part of the State’s comprehensive Medical Service.

Industrial Health Service

A very important part of the National Health Service will be the provision of preven­tive, as well as curative, health services in industry, especially in factories. At present, factory legislation only prescribes minimum standards as to health, safety and welfare con­ditions in the factories. There are not nearly enough official Factory Medical Inspectors. Industrial Medical Officers are now employed in large factories; but they are paid by the employer, which unduly weakens their position, and which may give rise to pro­fessional difficulties as to the confidential relationship between doctor and patient. A large development of the work of Factory Inspectors and Medical Officers is required, to prevent occupational maladies, to improve factory conditions and amenities, etc. In particular, Medical Officers should be in a position to advise freely on measures needed to prevent ill-health and over-strain, especially in dangerous occupations, and to recommend improvements in the statutory standards for health, safety and welfare.

The industrial health service is of course a specialised service, but needs to be inter­woven and co-ordinated with the National Health Service as a whole. The work of industrial Medical Officers should be fitted in with that of the Inspectors, so as to provide a complete service of health, safety and welfare by a team, comprising the Factory Inspector, and the doctor, industrial nurse, welfare workers, and the worker themselves.

Mental Health Services

Much needs to be done about the Mental Health Services, i.e., those concerned with mental illness, neurotic illness, and mental defect.

If the reform of these services is to be carried through with the necessary energy, public opinion must become more awake to the importance of the subject, and more enlightened about mental sickness and suffering.  In 1938 the number of persons in England and Wales notified as being under care for mental disorder was 158,723.  In addition there were 89,904 mentally defective patients in institutions and under statutory care. The net cost for mental hospitals and certified institutions was £11 ½ million.

Whilst there is now a growing realisation of the influence of mental factors on the health and happiness of every citizen, there is still an unfortunate tendency to regard mental illness as shameful, and as leading inevitably to long residence in a mental hospital. In consequence, patients and their relatives are reluctant to seek advice in the early stages of mental illness, when the prospect for recovery is good provided that modern forms of treatment are applied.

The amount of incapacity and suffering due to neurotic illness (which is often associated with some physical cause) is still much too little realised; very many of the neurotic patients seen by general practitioners could be cured if suitable treatment were available.

As for mental deficiency, permanent retention in an institution is necessary in many cases, at least in the present state of medical knowledge; but a good many of the less backward cases, given suitable training and after-care, are capable of becoming useful members of the community.

The main reform needed is that the Mental Services should be incorporated in the National Health Service. The close connection between mental and physical health is becoming clearer and patients and health workers alike would benefit from more interchange of knowledge and service between the mental and other sections of the Health Service.

One much-needed reform is the reduction of the size of the very large mental hospitals, and especially the reduction of the size of wards. At present, such wards not uncommonly provide for 80 to 100 patients; 25 would be a reasonable maximum. Too many mental hospitals are simply institutions where custodial care is given but where modern treatment and proper classification of patients is not available, owing to shortage and unsuitability of staff, equipment, and funds.

Little provision is made for in-patient treatment of neuroses in civilians; and, whilst most cities now have out-patient clinics for psychological cases and child-guidance clinics, these are totally insufficient for present needs.

It is important that there should be wards in large general hospitals, staffed by suitably trained doctors and nurses, for treatment of neurotic cases and the early stages of mental illness. This will help to ensure that those needing in-patient treatment will seek it early, undeterred by the stigma attaching to the word “mental”; it will help also to ensure fullest co-operation between workers in the physical and psychological fields.

In industrial health, specialists in psychology can help in many ways, e.g., by suggesting suitable work for children leaving school, by correcting conditions of work liable to cause nervous strain, and by ensuring, with the help; of social Workers; that people who have recovered from some mental trouble, do not, on returning to work, go into jobs of a kind likely to make the trouble recur.

Treatment in an institution is often necessary for mental cases. But segregation of such patients has its dangers, as the law recognises; and the statutory provision for the visiting of such patients by competent laymen is a humane safeguard which should be maintained and developed.

It must be recognised that such reforms, involving reorganisation, new building, and increased staff, will need more expenditure. But in these as in other Health Services, preventive medicine and early treatment is a true economy, and the humane and efficient care and cure of the sick is a responsibility that the community dare not evade.

Finance of the Scheme

How should the finance of a comprehensive National Medical Service be organised? The Labour Party considers that the necessary expenditure should be drawn:

  • Partly from national taxation, expended directly by the Ministry of Health (e.g., for the National Health inspectorate);
  • Partly from national taxation; allocated by the Ministry of Health to Regional Authorities in the form of percentage grants;
  • Partly from rates payable to Regional Authorities.

The Ministry of Health should allocate to each Regional Authority a grant amounting to a percentage of its approved health expenditure; the object being

  • To provide a Health Service which is preventive, comprehensive, open to all, and efficient as judged by national standards
  • To even out the present inequalities of standard between different areas.

The Ministry of Health should be empowered to exercise “powers of default” in the event of continued failure by a Regional Authority to carry out its functions as a Health Authority in accordance with the principles and standards nationally laid down.

CAN WE AFFORD IT?

The need for a comprehensive Medical Service is literally a “vital” need. We have given solid reasons why that need can only be met by a State Medical Service, nationally planned, locally administered, and financed out of public funds. There remains the crucial question: “Can we afford it?”

One might answer with truth that we cannot afford not to afford a service so necessary for life; but no such facile answer should satisfy us; or, indeed, could satisfy a Chancellor of the Exchequer. Before asserting that the nation should undertake to foot this bill, we must have an adequate idea of the cost of the present service and of the reorganised service.

Pre-war Cost of Existing Service

Before the war Great Britain spent on the treatment of the sick about £140,000,000. £45,000,000 of this went in doctors’ and dentists’ fees, £40,000,000 on public and voluntary hospitals, and £25,000,000 on medicines. Besides this £140,000,000 for treatment of the sick, there was an expenditure of some £8,000,000 on certain preventive medical services, such as the School Medical Service and the Maternity Service.

These figures do not include certain items difficult to assess, such as fees to nursing homes. Nor, it should be noted, do they include cash benefits paid under the insurance schemes; for these should properly figure as part of the loss resulting from ill-health rather than as part of the bill for medical treatment.

The Cost of Ill-health

About £32,000,000 was paid in cash benefits under the insurance schemes in cases of sickness or disablement. The economic loss through stoppage of work by ill-health represents, roughly, a further £120,000,000.

Thus, we may say that the loss resulting from ill-health, together with the cost of the medical services, came to over £300,000,000 a year.

Post-war Cost of Existing Service

After this war, the cost of treatment of the sick, if the medical service were to remain organised as at present, would probably be somewhat higher than before the war, owing to some increase of prices, the need for rebuilding hospital accommodation, and other developments. Let us put the figure at £155,000,000 instead of the £140,000,000 spent before the war. Presumably, also, the cost of the School Medical Service and Maternity Service will increase. It appears then, that, if the Medical Service remains organised as at present, we may expect to pay about £165,000,000 for a service which, as we have seen, will be neither comprehensive nor open to all.

Cost of a Comprehensive Service

The cost of a comprehensive service for the treatment of the sick (not including cash benefits) was carefully examined in the Beveridge Report. The figure was arrived at in consultation with the Ministry of Health and Department of Health for Scotland, so it can be regarded as the most expert estimate we can get at present. It is meant to cover “comprehensive health and rehabilitation services for prevention and cure of disease and restoration of capacity for work, available to all members of the community.” The figure is £170,000,000 a year.

The Report proposes that this cost, should be defrayed out of public funds, subject to a grant-in-aid of £40,000,000 from the Social Insurance Fund.

It will be noted that this figure of £170,000,000 is very close to what we shall be spending on the existing service after the war—about £165,000,000; but the Beveridge estimate is to cover a much wider service.

It must not be assumed that we could not have a more complete service for the same money, if the system were reorganised by the State. The pre-war expenditure of £140,000,000 on treatment of the sick has been carefully analysed by the Socialist Medical Association and by Dr. Stark Murray. They estimate that, if the service were replanned as a State Medical Service, we could get far more than we now get for £140,000,000. For instance, we could increase our hospital accommodation by 25 per cent, and spend £7,000,000 a year on medical research instead of some £400,000 as at present; and we could have the full service of 40,000 doctors, 14,000 dentists, 24,000 pharmacists, etc.

Even if the Beveridge figure of £170,000,000 were to be somewhat exceeded, the burden would still be a light one, having regard to the importance of the need and the size of the national income. That income has been increasing, remember, at the rate of about 1 ½ per cent, annually; there is no reason to anticipate that such an increase will not be resumed soon after the war.

The money we spend on health is not money poured down the drain or blown into space; much of it is productive, since it buys not only release from the frustration and pain of ill-health, but also fulness of life, new strength for new endeavour. At any given time we have in this country about 800,000 people who cannot work owing to ill-health. If, through the State’s new service of preventive medicine and rehabilitation of the disabled, one quarter of this number can be restored to fitness for work, the value of the extra capacity for work by the 200,000 people will amount to something like £60,000,000 a year.

So it comes to this. We shall be spending approximately £170,000,000 a year on the existing service, with all its defects. For about the same money, we could have a com­prehensive service, economically planned and open to all.. Which is the more economical investment? The Labour Party has no doubt as to the answer. In the interests of the nation’s health, vigour, and happiness; in the interests of true economy; in the interests of the medical profession as well as the interests of the sick, the Labour Party appeals to every citizen to support this great reform—the organisation of a National Service for Health.

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April, 1943  
Reprinted September, 1943.  

 

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A discussion document prepared by a sub-committee for the S.M.A. Central Council

Published by The Socialist Medical Association 13 Prince of Wales Terrace, London, W.8 6d.

It is not necessary to be a socialist to realise that the National Health Service is being strangulated by lack of money. A vast sum is required to develop its potential into a service capable of utilising the increasing possibilities of modem techniques and discoveries for the treatment and prevention of disease. Money is required to train sufficient doctors, nurses, technical and administrative staff; to build and equip hospitals and health centres; to launch an effective occupational health service; to finance home welfare services, and so on. As socialists we must continue to campaign for right priorities in our national expenditure.

We know well enough that socialism is impossible so long as the basic principles of capitalism remain untouched. Whilst the class structure in our society persists, our health programme pays little more than lip-service to the idea of equal opportunities for all. We must be prepared to watch and attack practices which prevent the National Health Service living up to its original ideals. In no other feature is this danger so marked as in the phenomenon of the hospital waiting lists.

We set out here to ask whether hospital waiting lists are really necessary? Could they be abolished? In what way does private practice effect the waiting lists ?

Types of Waiting Lists

Hospital waiting times are of three types:
(1) the time out-patients wait to see consultants;
(2) the waiting time for a first appointment for an out-patient;
(3) the waiting time for admission.

These times vary throughout the country, from region to region, hospital to hospital, speciality and consultant. The first, the wait in out-patient departments, has been almost eliminated in well-organised hospitals; in others patients must resign themselves to a half-day or even a whole day spent on each visit. Many refuse to attend at all but request their general practitioner to arrange a private consultation —if they can afford it! Clearly, if the waiting time were cut down, money would not flow so readily to consultants, and one wonders whether the greatest effort is always made to organise an efficient appointment system which would eliminate waiting.

In many parts of the country patients wait weeks or even months for a first out-patient appointment, and sometimes months and even years for a bed. These waiting times and the reputation they have created are together responsible for a great part of the demand upon the private sector and private insurance schemes. Consequently the efficiency of the non-paying services is threatened and patients must suffer even longer waits, whilst those seen privately “jump the queues”, often not even into pay-beds.

The Evils Caused by Waiting Lists

The evils which these waiting times cause are even more widespread than would at first appear. The most serious, of course, is the medical aspect. Possibly vital time is lost awaiting the out-patient appointment and again awaiting admission, when early attention might at least facilitate treatment, at most prevent death. The psychological effect of waiting is difficult to assess but probably greater than is usually estimated. In this respect it is unlikely that any disease should be classed as “not urgent”. Likewise waiting lists may cause hospital patients to believe that those with money to pay receive not only quicker but also better attention.
Many “minor” complaints which could be easily cured in hospital are no longer referred at all. A conscientious general practitioner knows that by sending these patients he would only swell the waiting lists. Also it might in fact add to his patients’ distress to know that treatment could be given but is not possible “at present”. So numbers of people throughout the country, in addition to those actually counted on the waiting lists, are condemned to carry on in unnecessary discomfort. We may find, in addition, a very awkward situation created by the demand for legal abortions in departments already carrying a heavy waiting list.

Not the least of the evils is the stress on the hospital staff. It is usually lay staff who must bear the brunt of enquiries from anxious general practitioners, patients and relatives, and who are obliged to operate a system which they know to be unfair and suspect to be avoidable. Without the waiting lists many administrative workers would be freed for other duties. Medical staff, too, are often dis¬tressed to have to turn away patients whom they would admit if a bed were available. From time to time the newspapers make the most of inquest reports which cast blame on casualty officers for failing to admit patients who subsequently die. In fact, hospital doctors are faced day after day with decisions which depend primarily on lack of beds and not on medical necessities.

The Causes and Prevention of Waiting Lists

These are some of the evils of the system. What are the causes and prevention? No one can deny the difference which more money spent on the Service would make. More beds, more operating theatres, more staff, new and better equipped hospitals—all these are needed. But the growth of private practice and private insurance schemes are vested interests which depend for their existence on the maintenance of waiting lists. Most of the “private patients” of today would gladly accept National Health Service treatment if waiting lists were abolished. But because of the interests vested in them waiting lists may be kept longer than is necessary, even with our existing resources.

How can hospitals be run more efficiently without much additional cost, and how can patient-turnover be speeded without detriment to the patient?

Computer statistics make it easy to estimate average duration of hospital stays for varying diseases, and whilst obviously no hard lines can be drawn, it is clearly possible to pinpoint hospitals where bed- usage falls far below average. When beds are empty because of lack of nurses it is almost certain that matron belongs to the “old school” where “discipline” is a first priority. Many hospitals still insist on resident nurses although adjacent flats or other accommodation would give greater freedom. Enough encouragement is not yet given to married nurses to return to work because there are still matrons who refuse part-time workers or who will not allow off-duty times compatible with family life. Male nurse recruitment and promotion is not yet sufficiently encouraged.

Improvement of organisation in every sphere of hospital work through consultation by all grades of staff can greatly increase efficiency. Surveys have shown that high staff turnover produces low patient turnover! Thus good staff relationships, for instance through Joint Staff Consultative Committees, are essential.

Some hospitals send short notice for admission to patients who have been waiting months or years and finally may be prevented from coming in because of absence, family commitments, treatment elsewhere, or even death. A preliminary letter could save this waste in bed-occupancy. Some consultants clearly make less use of beds than younger ones with more modern ideas, and, although criticism is not usually possible, the use of statistics should make adjustments easier.

We have knowledge of consultants who bar the appointment of new consultants to their hospitals although they are overworked and have long waiting lists, and it is hard to believe that this is for any reason other than the fear of competition for their private patients. Regional Boards must insist on the appointment of new full-time consultants where needed. When appointed part-time, consultants can see private patients in the remaining time. There are special income-tax concessions which at present favour part-time consultants and which could easily be amended by the Chancellor of the Exchequer. Efficiency in hospitals would be increased by having full-time consultants only and the private patient system would not be perpetuated.

The method of allocating a fixed number of beds in a ward to individual consultants (known as “the firm”) must go. Increasing use is being made in up-to-date hospitals of the principle of “progressive patient care”. Staff and equipment are concentrated in a special ward for patients requiring “intensive care”. When less attention is required the patient can be moved to another ward less fully equipped for “intermediate care”, and finally when ambulant moved again for “self care”. This method is both economical on staff and beneficial for patients who no longer need lie in beds adjacent to those desperately ill or coming round from anaesthetics.
The visiting hour is now frequently regarded as a necessary evil by the authorities. It is possible that, instead, use could be made of relatives visiting; for instance, assisting in feeding or other duties. In addition to relieving the nurses this could help to teach the relatives how to cope on the patient’s return home. A change of heart and habit might first be needed, however!

Some hospitals already have computer analysis of daily activities and it becomes apparent even in efficient hospitals that a very great improvement in bed-occupancy and use is possible. Nurses and theatres can be more economically deployed, the type of case for admission more carefully selected, and many tests can be performed prior to admisison both to the benefit of the patients and the economy of bed-occupancy.

Treatment outside Hospital Wards

More general use should be made of the “day-patient” method of dealing with minor operations. In some hospitals this method has long proved successful, and again statistical evidence should be supplied in pressing more hospitals to adopt such procedures. An efficient ambulance service is a pre-requisite to such methods of treatment.

Indeed, we believe that the best attack for the elimination of waiting lists would be a programme for better facilities and use of out-patient departments for investigation and treatment, and “open access” arrangements to general practitioners for use of X-Ray, laboratory tests, etc., thereby saving consultants’ and patients’ time. Since lists for out-patient attendance remain generally static it is reasonable to believe that these improvements could greatly reduce, if not eliminate lists altogether.

The better use of Health Centres as well as of out-patient departments must also be borne in mind. Many consultants would welcome the opportunity of closer co-operation with general practitioners. In suitable areas consultant sessions at Health Centres could eliminate the need for hospital out-patient attendance entirely for some patients. The presence at Health Centres of district nurses and other ancillary staff could make possible more and more treatments at home—not, we maintain, as a make-do method but as a desirable step forward into the future. We commend the greater use of statistics in the field of general practice, which will reveal for the first time the natural course of disease and make possible the knowledge of the most efficient, desirable and economic forms of treatment.

Another attack in the same direction could be a reduction of bed- occupancy for patients for whom hostels and half-way houses serve equally well. After recovery from operations there is frequently no need for full hospital treatment although the patient may not be ready for home, or the home may be unsuitable. Use could perhaps be made of existing buildings for this pre-convalescent type of patient. Such accommodation could also serve patients requiring treatment of a special nature such as radiotherapy, but who live too far away to travel daily to hospital. Good nursing and medical care might be required, but less intensive than at hospital.

Local Authority Services

Many hospital beds could be vacated earlier if local authorities supplied home services which would enable patients ready for discharge to be cared for adequately. Home helps must be better paid so that supply meets demand. Night home helps would make possible more home nursing for patients anxious to be at home. Expensive though this may sound it is cheaper than the cost of hospital accommodation. Meals-on-wheels, laundry, supply of equipment are all supposed to be available but would need to be more easily attainable throughout the country.

Who benefits from Private Practice?

The consultant who accepts the fee benefits financially. The insurance companies thrive. The hospital does not benefit because the actual money paid for accommodation goes back to the Exchequer. The benefit to the private patient himself is of very doubtful value. Apart from the fact that he avoids waiting times he has very few genuine advantages. On the contrary, the best treatment may well be more difficult to attain for the private patient than for the ordinary hospital patient. It is important to realise the truth of this because private practice flourishes on the myth that better service for payment is available.

Modern medicine needs expensive modern equipment and requires team-work by medical, nursing, and ancillary staff. Isolation in private wards prevents the advantages already mentioned of progressive patient care. The consultant in charge of the paying patient is, of course, paid for his services, but every additional doctor he might call in for advice is also entitled to a fee. The consideration as to whether the patient can afford this additional expense and whether it is wise to bring in another, perhaps “rival”, consultant plays its part in treating paying patients. Payment should be made for X-Rays, laboratory tests, physiotherapy, and so on. The National Health Service patient has access to all these more readily than the paying patient.

Very few consultants would honestly deny that the best way to treat a patient is to be free from all considerations of money. It is strange that this principle is accepted readily for university teaching. Even the medical professors in Teaching Hospitals are freed from “the burden” of private practice. What is acknowledged as best for progressive university teaching can surely be seen to be best for medical care, both in respect to hospital and the general practitioner service. No university lecturer suggests that he will give better lectures if his students paid him individually or that he would hold special private sessions for “paying students”. In this context payment sounds ludicrous.

Patients attending Teaching Hospitals should realise that “lack of privacy” caused by medical student teaching can be to their own advantage. Consultants teaching students must explore every channel for reaching the right diagnosis and instituting the best treatment. Consultation in isolation as in private practice can lose this advantage.

Awareness of these facts is essential if the public is to attack the pernicious evils which seriously undermine the efficiency of the Health Service.

What can be done?

(1) The Minister can agree to appoint only full-time consultants in future.
(2) The Chancellor of the Exchequer can arrange that tax concessions favour full-time practice. Payment of tax-free private insurances should not be permitted as a “fringe benefit”.
(3) The general public can bring pressure to bear against any unfair practice. Question such statements, whoever makes them, as “Your case is urgent, you will have to wait . . . months as an ordinary patient, but you can come in at once if you pay.” All urgent cases should be admitted urgently regardless of pay, and the statement is often an effort to obtain more paying patients. In many hospitals pay-beds are not full and legally should not be reserved if urgent cases are waiting.
(4) Complaints can be made by individuals, or better still, through organisations such as Trade Unions.
(5) Complaints can be made at all levels, i.e., Hospital Secretaries, Regional Hospital Boards, Member of Parliament, Minister of Health.
(6) Precise facts must be given; no fear should be entertained about giving names. Reprisals are not one of the weapons in use in the Health Service.
Finally, either as individuals or as organisations join the Socialist Medical Association who will continue to fight on your behalf.
For we maintain that, as long as there are waiting lists, private practice will grow, and as long as private practice flourishes, waiting lists will persist. The ring must be broken.

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No date. Probably around 1970.

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3 challenges to the NHS on its 70th birthday.

NHS embodies a set of key principles and values which are increasingly under attack. In an age of austerity, with widening social and economic inequality, and increasing intergenerational division, I argue that these principles are more relevant and necessary than ever. In this talk for a meeting of the East Dartmoor Labour Party, I look at threats to three of the underpinning principles of the NHS, and considers how we might respond . . .

  1. NHS celebrates its 70th birthday on 4 July. Timely to look at the challenges it faces, why it is important to be aware of these, and consider how we might respond.

  2. Founded after the WW2 as a key component of Beveridge’s war on the 5 giants (idleness, squalor, want, ignorance, and disease) the HS continues to occupy a unique place in the British psyche. It embodied and continues to embody a set of principles and values: universality, collective citizenship, fairness, social and redistributive justice. It was established as a publicly funded; publicly provided, universal service, free at the point of use.

5 giants

  1. NHS was part of a social vision which connects health, housing, education, and employment – we know empirically how health is influenced by each of these – so in that sense challenges to the NHS now are in my view part of a broader neoliberal assault on the entirety of that vision.

  2. Throughout the 50s, 60s, and 70s that vision broadly held good. That is not too say that we should be too misty-eyed about these times: financial problems still occurred, waiting lists were too long, and the delivery of services on a universal basis was problematic.

  3. It was in the late 80s and 90s that the underpinning principles began to be challenged. The 1990 Act separated for the first-time provision of services from planning (purchasing) and the assessment of need. Under the banner of modernisation later reforms introduced more fully the language and behaviour of the market. The consequences were:

  • Entry of new providers into healthcare
  • Redefinition of patients as consumers who wanted to express choice
  • The business of contracting was invented, a performance management industry (star ratings, performance targets) created
  • Regulatory agencies established
  • Repetitive, disruptive cycles of organisational change begun (FTs,PCT,CCGs)
  • All under the control of New Public Management.
  1. This policy direction culminated in the Health and Social Care Act (2012). Directly this absolved the Secretary of State (SoS) of accountability for the NHS, allowed the passage into law of a set of secondary legislation which opened the door for private health insurance schemes, top-up payment schemes, co-payments, and by the introduction of the “any qualified provider” test, heightened the possibility of private sector involvement through the application of competition law to the commissioning of care.

  2. HSCA was translated into a vision for the NHS through the Five Year Forward View, which further changed the NHS by creating 44 Sustainability and Transformation Plan geographical footprints for future service design – which in turn are the basis for new care models such as Accountable Care Systems, Accountable Care Organisations, and Integrated Care Organisations.

  3. If this is the policy background – let us turn to the key challenges now. My argument is that the current direction of policy is a clear and present danger to the NHS and the principles behind its establishment: and 3 principles in particular: publicly-provided service; universality; publicly-funded.

  4. Firstly, public-provision. Consider the growing insertion of private providers within the NHS, and philosophy of marketisation. NHS funding on the private sector has grown from £2.1bn in 2006 to £9bn in 2016. From the early experiments to the most recent examples, a considerable body of evidence has accumulated about private provision which, in summary, shows:

  • A market system has created huge transaction costs for the NHS (estimated to cost £4.5bn)
  • The inability of regulators to assure patient safety within a profit-motivated private sector (Ian Patterson as the example)
  • The significant diversion of funds away from patient care, for example the PFI scheme (Barts Trust pays £127m, pa, until 2049 for its PFI scheme; Central Manchester pays 10% of its annual clinical revenue to the PFI scheme)
  • That patients want high quality local services, not artificial choice
  • Loss of trust as providers game the targets and avoid accountability
  • And that, as with banks in 2008, whilst profit is privatised for shareholders, the risk when providers fail (Carillion) or withdrawn (Circle) is borne entirely by the state.

Despite all this evidence, the national policy response has been to ignore it, and to pursue ever more enthusiastically an irrational, ideologically-driven, zombie policy of privatisation. Thus, we now see new, novel forms of privatisation. In general practice, PUSH Doctor, Doctor at Hand, Babylon and Simply Health are growing
threats to primary care.  In community health, Virgin is now a major provider, with over 400 contracts, including here in Devon where it is bidding to extend its control over childrens’ services. And in the acute sector, separate firms are being established to employ hospital staff, whilst land sales are key to hospital financial recovery plans. In summary, the implementation of market reforms has transformed the NHS from a single healthcare system to a complex conglomeration of public and private providers under the umbrella of the NHS brand.

  1. The second challenge is to the universality of service provision. – the notion that services are broadly the same in Buckfastleigh as in Birmingham. STPs have been explicitly established to solve national problems on a local basis. Direct responsibility has been given to them to make local choices – choices which have primacy over national ones. Looking again at the evidence we see that STPs and CCGs are accentuating local variation through 6 processes, Deflection, Delay, Denial, Selection, Deterrence, and Dilution.

GP referral management schemes delay, defer and deflect patients from secondary care; the explicit exclusion of certain groups (smokers, the obese) denies care; blaming patients for presenting inappropriately deters the future expression of need; the tightening of referral criteria (hip replacements; IVF, continuing care) selects patients, and increasing funding variation in community nursing dilutes quality.

Through these processes geographic variation is being magnified, and the principle of universality undermined. Rather than making transparent the boundaries of care and seeking national agreement on acceptable variation. STPs are developing and implementing their own criteria and policies, the effects of which compound variation and institutionalise the postcode lottery of care.

  1. The third challenge is funding. At this point speakers generally reveal a graph showing historical NHS expenditure trends, and the debate is framed by international comparisons (relevant or not), anecdotes about efficiency and waste, and discussion about the meaning of the figures and timescales. There is inevitably reference to “infinite” demand.

I’d like to approach it differently. We are constantly told by the rhetoric of austerity that money is tight, that demand is rising (those old people keep living longer and longer), and that difficult choices have to be made.

I want to challenge that. For me, that narrative is about the government trying to locate this funding crisis within the minds of taxpayers and to get them to accept their interpretation of the problem and, also, to be part of the solution by agreeing to new funding alternatives, such as top-up payments, co-payments, by accepting restrictions on access to care for immigrants, or the obese, or by agreeing to use more private healthcare. Moreover, the funding crisis in the NHS is constructed as a purely financial one, predicated upon convincing people that the austere response is the only possible one. Underpinned by notions of staff ineffectiveness and inefficiency, this creates a narrative strong enough to compromise the principle of treatment being free at the point of use.

An alternative narrative is that we are (according to Liam Fox no less) the 5 th largest economy in the world: that 78% of people consistently rate health spending as a priority, and 67% would pay more tax for the NHS. Current health spending has increased (4.1% of GDP in 1978 to 7.2% in 2016; but going down to 6.8% in 2019) but even the promises made by Tony Blair to equal European average spending, have been, in this context, modest. Am I alone in thinking we can and should do better?

The challenge is to resist the dominant narrative that it is a service that can’t be afforded, that the only solutions lie in private care and insurance; that demand rises inexorably, or that a cross-party Royal Commission, or a hypothecated tax, is needed to sort this all out. It can be afforded – it is a question of political will.

  1. I’ve identified 3 challenges to the principles of the NHS: to universality; to its public provision; and to its national funding. It is often questioned whether the principles, established in 1948, of social justice, collective citizenship, and an active, assertive role for the state are still relevant today. For me, in an age of austerity, with widening economic and social inequality, and increasing inter-generational division, these principles seem more relevant and necessary than ever.

  2. How can we respond individually and collectively to the challenges?

A) NHS Reinstatement Bill is being debated in Parliament on 11 July, sponsored by Eleanor Smith. The Bill re-establishes statutory health bodies with responsibility for health and underlines accountability to local people. It reinstates the national accountability of the SoS. Further, it abolishes marketisation, commercial contracting, and
centralises PFI debts. This bill should be widely supported.

B) Local action is key to disseminating the message about what is happening within our health service. There are active campaign groups across the country including the Keep our NHS Public  and the NHS 999 campaigns, and local NHS SOS campaigns here in Devon.

C) Real stories, patient experience stories are valuable material on the doorstep when campaigning about the NHS. Its is important to challenge the myth that “there is no money for the NHS,” or that it cannot be afforded, and real examples of the damage that has been done to the NHS, by talking about patient care stories can help
here.

D) Finally, those who understand best the changes that have occurred with the NHS are often those who work within it. Talking to local practice and community staff, going to see hospital staff, is an effective way of learning about what is happening, and building allies and future supporters.

 

 

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In the year that celebrates the 70th anniversary of the ‘national treasure’ that is the National Health Service, this meeting of the Manchester Medical Society is more than timely. The origins of the NHS are rooted in the fight for social justice which runs not only in Manchester, Liverpool and the NorthWest but across the industrial and commercial north of the country. Next year here in Manchester, we will be commemorating the bi-centenary of the Peterloo Massacre in which 15 people, including one John Ashton, protesting about the poor social conditions and lack of suffrage, were slaughtered in a cavalry charge. This was a defining moment in the development of our democracy, the extension of suffrage and in due course to the extension of public services for the whole population.

On 5 July 1948, Aneurin Bevan, Minister of Health and midwife of the NHS inaugurated its first hospital, The Park, in Davyhulme in Trafford; and today, as we speak, former Health Minister and now elected Mayor of Greater Manchester, Andy Burnham is leading the charge for devolution and integration in partnership with the borough councils of this major conurbation. Along the M62 in Liverpool, William Henry Duncan, the country’s first full-time Medical Officer of Health pioneered a dynamic Victorian town hall based public health movement. His work has in recent years inspired a renaissance of public health going far beyond this region, a renaissance of importance when we come to looking at what the future holds in the next 70 years, not least with the long overdue move to devolution of government in arguably the most centralised country in Europe.

This talk will be in two parts. In the first, I will draw on my recent Lancet article of Nicholas Timmins’ formidable review of the first 70 years of the NHS to set the scene and identify some key challenges [1Ashton JRSeven decades of fighting the five giants: a work in progress. Lancet. 390 (10111): e47e48; 2017. DOI:10.1016/S0140-6736(17)32913-6[Crossref][Google Scholar]]. These challenges must be addressed if our grandchildren are to be able to benefit from the NHS and the Welfare State in their later years. In the second part, I will lay out my own conclusions based on a lifetime within the NHS and my experiences of trying to ensure that a balanced approach to prevention, treatment and care underpin the pursuit of social justice within a whole systems set of arrangements and characterised by visionary local leadership.

On 1 December 1942, queues stretched from his Majesty’s Stationery Office along High Holborn in London. By lunchtime all copies of Sir William Beveridge’s ground breaking report, Social Insurance and Allied Services  had been sold. It was much the same story elsewhere. In Liverpool, my father secured the two volume report that today takes pride of place in my study. Beveridge’s report sits alongside work by others who have guided me in my career: Brian Abel Smith, Douglas Black, Ann Cartwright, Karen Dunnell, Margot Jeffries, Jerry Morris, Richard Titmuss, Peter Townsend and many others associated with the London School of Economics and the London School of Hygiene and Tropical Medicine.

In the introduction to his report, Beveridge enunciated three principles that provided a framework for all that was to follow. First, in supporting the importance of learning from past experience, he spelled out that sectional interests (of doctors), should not be allowed to stand in the way of what was ‘a revolutionary moment in world history….a time for revolutions, not for patching’. Second, he was clear that social insurance – the focus of his terms of reference from Prime Minister Winston Churchill – was only one part of a comprehensive policy of social progress, before going on to declaim his most famous and Bunyonesque passage:

It is one part only of an attack upon five giant evils:

(1) upon the physical Want with which it is directly concerned
(2) upon Disease which often causes that Want and brings other troubles in its train
(3) upon Ignorance which no democracy can afford among its citizens
(4) upon Squalor …
(5) and upon Idleness which destroys wealth and corrupts men.

Finally, the principle of cooperation between the state and the individual was made explicit.

…..the state in organising security should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual…

Details of the Beveridge plan were broadcast throughout the day by the BBC in more than 20 languages. Copies of the report were dropped into France and circulated among the troops. Later, they were used by the Workers’ Educational Association in theatres of war as educational material that was subsequently held to have contributed to the election of the Labour government in 1945.

For many people, like my father, an insulin – dependent diabetic on low income with a growing family, the security offered by the prospects of comprehensive social security, including access to health care, was transformative. To academics at the London School of Economics and the London School of Hygiene and Tropical Medicine, the Beveridge Report was a bible for post-war reconstruction and an opportunity to put their intellectual muscle to work for the common good. They were to occupy an influential place in government policy – making that would last some 30 years before the Thatcherite revolution of the 1980s. The subsequent fashion for market – based solutions at all costs in the corridors of Whitehall swept away the consensus of solidarity that had emerged from pre-war hardships and the dark days of the fight against fascism in the Second World War.

By the time Nicholas Timmins published the first edition of The Five Giants: A Biography of the Welfare State [1995] that consensus was more than frayed at the edges after 11 years of Thatcherism and the rise of rampant free marketeers. As summed up by Julian le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics, the welfare state had been hit first by an ‘economic hurricane’ and later by ‘an ideological blizzard’. The demographic challenge was still to come. The ambition of the war-time generation to build a better future for their children was under attack in a cold climate. In returning to the fray with his new edition of ‘The Five Giants’, Timmins has taken on the monumental task of not only bringing his earlier work up to date but also of synthesising some 70 years of social policy in the UK, covering some of the most complex and interlocking areas that between them account for two-thirds of government expenditure.

Timmins describes his magnum opus as lying somewhere between ‘1066 and All That’ and Gibbon’s ‘Decline and Fall of the Roman Empire’. In agreeing with this assessment, I would add Salman Rushdie’s ‘Midnight’s Children’. Rushdie’s novel, in tackling the theme of India’s transition from British colonialism to independence through the use of magic realism, touches inadvertently on the surreal nature of many of the Shakespearean plots, subplots, and recurring themes to be found in ‘The Five Giants’. Through his device of a spiral treatment of health and social services, education, social security, housing and employment, Timmins provides a perceptive and comprehensive analysis of the British welfare state. I have long held that nobody should be allowed near the National Health Service who has not at least studied Richard Titmuss’ introductory lectures on social administration, written in the post-war period; to that essential bibliography, I would add this second edition by Nick Timmins.

Reading Timmins’ book I felt at times like a dying man with the whole of my life passing before me: hard times and rationing, mum counting every penny, national dried milk and welfare orange, the death of King George VI and the Coronation of Queen Elizabeth II, primary school in Liverpool with more than 40 children in a class in prefabricated huts, school milk and dinners, 6 weeks in Alder Hey Children’s Hospital with suspected meningitis, passing the 11+ examination while my brother failed it and was consigned to an underfunded and undervalued secondary modern school, constant interaction with the NHS for my dad’s diabetes, the discovery of the teenager during the Beatle years, and getting into medical school with a full grant. Then later as a doctor in the 1970s at the tail end of paternalism with ex-colonial administrators and later after the Griffiths Report of a new breed of general managers on huge salaries and flash cars, watching the slow descent of the UK into crisis followed by the rise of monetarism and oscillating nostrums that sapped the energy, without leading to sustainable change in the NHS.

This social history is all documented in Timmins’ truly remarkable book.

He chronicles the battles between different world views, veering between soap opera and epic, with ideology frequently trumping evidence; shallow rhetoric and narrow managerialism in place of authentic leadership, an increasing infatuation with keeping ministers happy in the Westminster bubble, a loss of focus on serving the people and being accountable to them, not least after the abolition of the Regional and District Health Authorities.

Nevertheless, at its heart the flame was kept alive, an enduring ambition to provide social security and freedom from fear for the whole population – for the many, not the few. Nick Timmins lays bare many of the underlying paradoxes, contradictions, and recurring challenges that underpin the muddling through so characteristic of UK Government social policy. He exposes the bankruptcy of politicians who seek short-term advantage at the expense of stability, progress and authentic leadership. Timmins’ blow-by-blow account of former Secretary of State for Health Andrew Lansley’s destructive and fragmentary NHS re-organisation, the orgasm of re-organisation heaped on re-organisation in an ever more frantic crescendo, captures the biggest threat to the NHS since 1948.

Years ago, in another life as a psychiatrist, I had as a patient a young man who was crippled with an obsessive compulsive disorder manifested by elaborate rituals. One day he told me that he had a plan to expunge his problem once and for all by acting out the ultimate in rituals in a local park. A few days later he returned to see me in great distress; he was half way through his ritual when he forgot what to do next. This image came into my mind most vividly at the height of Andrew Lansley’s structuralist madness.

Flawed Victorian notions such as ‘the undeserving and the deserving poor’, the principles of ‘lesser eligibility’ under which it was necessary to be completely destitute before receiving state help, and ‘the workhouse test’ make an unwelcome re-appearance in UK Government social policy dressed in new clothes (the virtual workhouse of Ken Loaches recent shocking film ‘I Daniel Blake’). In an age where we are functioning in a global economy, policies that will only reach part of the population prevent all citizens from reaching their full potential and put the national economy at a disadvantage.

The search for a unified system of tax and benefits continues. Centralisation proceeds apace dressed up as citizen empowerment. Thomas Gradgrind, Charles Dickens unfeeling character in ‘Hard Times is alive and well and living in the Treasury or the Department of Work and Pensions where knowing the price of everything and the value of nothing appears to be a prerequisite for promotion.

But not all politicians are bad guys. Tessa Jowell understood public health as Sarah Wollaston does today, but we are sadly lacking in the kind of leadership which is needed to take us forward to a new era that is fit for purpose. Timmins holds that George Godber and Liam Donaldson have been England’s best Chief Medical Officers. (I would add Donald Acheson) The civil servants in the Department of Health have often been dealt a poor hand in having to deal with contradictory political demands. Having worked closely with Duncan Nichol in our Mersey days I can attest to Duncan’s imagination and support for creative innovation and Simon Stevens is doing his best to unravel the mess that Lansley left behind. At the very beginning Churchill supported Beveridge, whilst the ambivalence of The British Medical Association was worthy of a contortionist.

And in the end many of the questions about how to provide population – based security out of general taxation remain, the ideological and the demographic. Of these, the demographic should be the most straight forward, and the Health Service must adapt to the needs of an increasingly elderly population – after all we have had over 30 years of knowing what was coming! The interdependence of the five giants is just as great today as it ever was. If we are to use our resources to optimal effect for the whole population, we need that interdependency to be understood by those charged with serving the public; we need citizens who understand it too. Timmins book provides a basis for that curriculum and is essential reading for all would-be public sector leaders.

In the second half of this talk, I will describe my conclusions about the agenda for such leaders that can carry us forward for the next 70 years.

So with Nick Timmins and ‘The Five Giants’ in mind we might ask ‘So what is the question that the constant tinkering is supposed to answer?’ The incessant reorganisation and obsession with structure to the detriment of function; the flirtations with privatisation and our fixation on the grossly unfair arrangements that are to be found in the USA where even the Health Maintenance Organisations such as Kaiser Permanente only cover employees; the constant threat of the introduction of regressive health insurance as an alternative to a system funded out of progressive taxation where there is pooling of risk. Meanwhile, we choose to ignore the experience of other countries, such as Finland, which have long since achieved the necessary transformational changes, within modest budgets, to put themselves on a sustainable path.

The starting point is how to optimise the health and well-being of the whole population, equitably, through a system of social security and welfare provision funded out of general taxation. It is daily apparent that essential services, services that make for a productive and healthy population [water and sanitation, energy, mass transit, education, housing and health] are too important to be left to the market, something that Richard Titmuss would have argued passionately 50 years ago. Ironically, we have been here before, as the recent demise of Carillion should remind us. Over 100 years ago the main utilities, including the gasworks and tramways were taken into municipal ownership, as later were coal mines, iron and steel and the railways because as essential services they could not survive without effective public interest oversight. In the fashionable dash to market-based purism that followed in recent decades, the public has become increasingly aware that the most obvious impact of privatisation has typically been the addition of around 10% to bills to satisfy the expectations of shareholders, without adding to the satisfaction of consumers. Health Services are no different, as the huge increase in transaction costs in the NHS over the past 30 years demonstrates. The distress of patients, workers and families that follows market failure from care homes to hospital construction is a price that the public is increasingly not prepared to pay. The burden imposed by the Private Finance Initiative is now seen for what it is: short sighted and obscene. Where were the voices of restraint at the seats of power when those decisions were being made? And those such as Alison Pollock who raised the alarm were ridiculed, vilified and disparaged.

If we ask why the NHS and similar systems in other countries arose in the first place, we find that an ethical impulse was often secondary to the imperatives of Empire and Industry, not to mention the actual survival of elites. In Germany, the ethical argument was made by Neumann in 1847 ‘The State argues that its responsibility is to protect people’s property rights. For most people the only property which they possess is their health; therefore the State has a responsibility to protect people’s health’. So much for the ‘Nanny State’. In fact, it was Bismarck, who, fearing revolution among the young men drawn into the cities by rapid urbanisation in 1848, the year of revolution in Europe, and fearing the spectre of the guillotine from France, implemented reforms in social welfare. In this country the extension of primary education in 1870 was motivated by the realisation that we were falling behind Germany and our European competitors. The consequence of finding that 40% of working class recruits to fight in South Africa in 1899–1902 were unfit for military service led to concerns about ‘how the country could maintain an Imperial Race and contain Germany’ and a comprehensive programme of action was proposed which included:

(1) A continuing anthropometric survey
(2) Registration of still births
(3) Studies of infant mortality
(4) Centres for maternal instruction
(5) Day nurseries
(6) Registration and supervision of working pregnant women
(7) Free school meals and medical inspection
(8) Physical training for children, training in hygiene and mother craft
(9) Prohibition of tobacco sales to children
(10) Education on the evils of drink
(11) Medical on entry to work
(12) Studies of the prevalence and effects of syphilis
(13) Extension of the Health Visiting Service

I don’t know about you but I am ashamed at the state of many of these essential public health services or their equivalent today, despite having had a National Public Health Agency now for six years. These late Victorian and Edwardian measures owe a great deal to Lloyd George who then built on them with his health insurance scheme in 1911, a scheme which resembles that of the American Health Maintenance Organisations which we seem to be so infatuated with despite them mostly being restricted to employees and their families. The great breakthrough with the NHS in 1948, three years after the death of Lloyd George’ was extending cover to the whole population, ‘equal access for equal need, free at the time of use and funded out of general taxation.’ The momentum that lay behind the consensus for the implementation of Beveridge was borne of shared hardship during the economic recession of the 1930s and in the Second World War fronts at home and abroad which transcended social class, although not the front between hospital medicine and general practice, private practice in London and medical practice in the rest of the country. In the event, it has been estimated that GPs doubled their pay in 1948 once bad debts had been taken into account. We have seen time and again how enduring is the public commitment to the NHS as a treasured national institution despite the fanatical determination of those on the political right for privatisation, returning time and time again like space invaders unwilling to learn from experience.

When the NHS was established in 1948, the public health picture was on the cusp of change. Infectious diseases, in particular those of childhood were in rapid decline as a result of improvements in living conditions, nutrition and the advent of comprehensive programmes of immunisation. Maternal and infant mortality rates were still high, certainly in comparison with today and life expectancy was a good deal shorter than now. The remarkable transition to a burden of disease characterised by non-communicable conditions and mental health problems was over 20 years away. However, the manifestations of unmet need were soon making an appearance, notably in relation to dental and optical care. As the pharmaceutical revolution proceeded along with a model of care dominated by hospitals, general practice was neglected and public health, temporarily consigned to the history books. In 1974, the arrangements that had placed the UK at the forefront of public health internationally, led by a Medical Officer of Health from the town hall were laid to rest, marking the high point of this chapter of hospital hegemony. Almost immediately, commentators began to argue the case for a renaissance of public health and for a reorientation of thinking, policy, organisation and practice. In 1976, Birmingham Social Medicine Professor Thomas Mckeown, demonstrated the fallacy that modern medicine had been responsible for the dramatic improvements in mortality rates over the previous 100 plus years; rather, most of the reduction in deaths from tuberculosis, bronchitis, pneumonia, whooping cough, and food and water-borne disease had already occurred before effective immunisation or treatment was available. Progress in these areas had probably had much more to do with smaller family size, improved environmental and housing conditions with advances in hygiene and the improved availability of cheap and safe food. Around the same time researchers such as Ann Cartwright, Peter Townsend and South Wales GP, Julian Tudor Hart began to point to the existence of an ‘Inverse Care Law’ in which the most highly trained doctors were to be found in the most privileged parts of the country and those with the worst health were least able to access high quality health care.

Tragically, over 40 years later and despite much hot air and lip service, we have failed to grasp the nettle, even when provided with the logical narrative and increased funding by Sir Derek Wanless. In 2004, Sir Derek persuaded the then Chancellor of the Exchequer, Gordon Brown to cough up significant extra funding for the NHS on the basis that it should be spent on resourcing a fundamental NHS reorientation to one of full public engagement and an upstream focus on prevention. In the event, the money disappeared into the Private Finance Initiative and a massive increase in clinical salaries. Every time dedicated funding has been identified for public health and prevention it has been diverted into balancing the hospital books. For me, the ‘Choosing Health’ monies, which I never saw, as Director of Public Health, was the epitome of the bad faith which emanated from Richmond House to be implemented at the local level. If I had a penny for every time I was told that we would get round to prevention once we had sorted out the hospitals I would be a rich man. And since the creation of Public Health England, another national body has failed to protect the frontline public health budget, standing by whilst the invidiously placed local authorities have diverted funding away from public health programmes such as family planning and sexual health to balance the books for social care.

Since McKeown published his analysis and others fleshed out our understanding of contemporary patterns of health and disease there has been no excuse for failure to transform our organised efforts and arrangements to optimise population health. This year we will celebrate 40 years of the AlmaAta Declaration made in Kazakhstan in 1978 and which underpinned the World Health Organisation Strategy of Health for all by the year 2000, adopted by the World Health Organisation in 1981. Health Services grounded in a whole population, whole system approach, the reorientation of health care towards primary and community care and upstream to prevention, tackling inequalities in health, full public engagement and partnership working and policies that support health within supportive environments; later this year in Alma Ata [now Almaty] these same principles will be revalidated. Finland is one of those countries that was listening when the Declaration was made. A Primary Care Act was passed which defined once and for all the proportion of capital spending to be dedicated to comprehensive primary and community health care. It included networks of modern community health beds, such as modern cottage hospitals linked to state of the art health centres across the country, a progression of high-quality community mental health facilities and general practitioners playing a key role at the front end of hospitals ensuring appropriate admissions. On a trip to the Finnish county of Karelia, with health service managers from Cumbria and Lancashire, where over 40 years ago Pekka Puska led a pioneering whole county approach to the prevention of coronary deaths, we heard of the systematic work that had skilled up the local population to manage common health conditions for themselves and resulted in a reduction in general practice consultations of between 20 and 30%; the Finnish Government itself was no hostage to commercial interests or allegations of ‘the nanny state’ and had been prepared to use the tools available to it in the form of legislation and taxation to create an environment that really did make ‘healthy choices the easy choices’. On that same trip to a country that in the early 1970s had had a notoriously bad diet, devoid of fresh fruit and vegetables, we visited a factory canteen where the workers were tucking in to an appetising selection of luncheon salads.

While this was going on in Finland and some other countries, in this country we were on a treadmill of structural reorganisation. In my 13 years as Regional Medical Officer, we underwent six – one every two years. Just as I had finished building up a team I had to start all over again. When I left the regional job in 2006 I commented that if I had wished to be a removals worker I would have joined Pickfords. I like to think that, together with colleagues here in the North West, we did make an impact in developing the New Public Health, not least in emulating what we could from Karelia with regard to heart disease and non-communicable disease in the absence of systematic government support; and certainly with teenage pregnancy and abortion, HIV and AIDS against central government opposition or apathy, but with the covert support of Chief Medical Officer, Sir Donald Acheson. How different it looks today with the present incumbents in Richmond House and Public Health England; a central team with little interest in public health and a lack of public health leadership in Public Health England, together with an unwillingness to challenge government, whilst neglecting the withering on the vine of local and regional public health since the transfer back to local authorities, now under the cosh of austerity and the centralisation of expertise and funding into a vanity project, a quasi-public health hospital in Harlow.

The Board of Public Health England is chaired by Sir Derek Myers, the former chief executive of Kensington borough council, where the disastrous Grenfell tower fire occurred last year, the Board itself having been recently recast as an advisory rather than an executive Board. In June last year the Guardian reported that Shelter Chairman Sir Derek and trustee Tony Rice had resigned because of concern over the organisation’s muted response to the Grenfell Tower fire. So what is needed to keep the faith with that noble generation that returned from war and with a bankrupt country delivered a National Health Service that the cynics and those with contrary vested interests said was impossible?

The manifesto to get us back on track and deliver equitable health and well-being to the population within affordable resources has five components which I will briefly outline:

(1) A clear vision. This vision is not rocket science and has been around since Thomas Mckeown and the Alma Ata Declaration 40 years ago. It is a vision of a whole system that tackles the 5 Giants, is rooted in public health and strong primary care which is a partnership with the population it serves. Community-Orientated Primary Care with its roots in Peckham in the 1930s, its adolescence in Johannesburg in the 1950s and a range of documented and persuasive experiments since, not least in Jerusalem, South Wales and Finland show the way. The integration of a whole population approach with the skills of epidemiology and public health alongside clinical and social care and a health literate public has to be the future, especially in the digital age. The combination of an anthropologically Place-based approach and Community Orientated Primary Care is a powerful one. The commercial determinants of health and disease must be confronted by both independent voices for public health and governments for whom the population’s health is more important than commercial interests.
(2) A convincing narrative. The failure of neither government nor managerial leadership to provide a convincing narrative of the future that we need is a disgrace. Much of it has been implicit but the repeated reorganisations and ill thought through dalliance with the private sector has happened because of the failure to describe the future and take people on a transformational journey. When Sir Derek Wanless published his report I managed to get a personal submission into Prime Minister Blair’s Christmas red box which brought together much of the argument presented in this talk and urged him to take a different path. The complacency of his reply shocked me and we have all lived through what has happened subsequently. In particular, I had suggested that he make use of his Directors of Public Health to argue the logical case for change in order to give the politicians the evidence-based justification to see it through. If anything today Directors of Public Health have been even more marginalised when they could be important allies.
(3) Authentic leadership. When Sir Roy Griffiths suggested that Florence Nightingale would be hard pressed to find a satisfactory answer to the question of who was in charge of our hospitals in 1983, the answer was seen to lie with general management. 35 years later it has failed to deliver. Too often, very highly, not to say excessively paid NHS chief executives have failed to provide either leadership or delivery to their communities and have failed to take responsibility when things have gone wrong, often finishing up with national honours en route. In part, their recruitment and training is to blame, and the move to greater clinical management is to be welcomed, but we are still producing chief executives and finance directors who are trained in silos with a narrow range of skills when it would be better for them to be trained in regional multi-agency staff colleges that included future leaders from all the health and social care professions, public health, the voluntary sector, the police, the media, academia and political life to list a few. That there can be chief executives from a range of backgrounds including finance who are unable to make sense of health outcome data or be on top of safeguarding and clinical risk management is unacceptable. As Director of Public Health I battled without success over many years to have health items and health data given the same prominence on Monday morning top team agendas as finance data.
(4) Full public engagement. The medical model of health services that was inherited from the private sector is not fit for purpose. As George Bernard Shaw put it ‘All professions are conspiracies against the laity’ and medicine is no exception. The nature of a profession is that of putting up one’s plate in the high street and seeing those customers who can afford to pay. It is not fundamentally about either a population focus with equity at its heart or empowerment but is about giving away small pieces of expertise in exchange for payment, not wishing to take the bread from its own mouth. The result is the creation of dependency and inappropriate demand that is not in the public interest and results in the deskilling of the workforce. This applies in the relationship between primary and secondary care where innovation of intervention and expertise has tended to remain hospital bound long after it could have been disseminated. Compare the situation with the motor car industry where expensive expertise is to be found in research and development followed by large scale, high quality and economic delivery. We have begun to realise that such a model can apply to long term conditions as well as to surgery. The modern equivalent of the Home Medical Encyclopedia, which my parents depended on before the NHS, is the internet backed up by proper school education in the classroom, by the full range of accessible allied health professionals and by peer led expert patient groups. In public health, there is now mainstream interest in Asset Based Community Development in which individuals and communities are seen as being half full rather than half empty dependent always on professionals coming along to fix them in a state of childlike dependency. It’s time the NHS and its leaders cottoned on.
(5) Adequate resources. Resources in the sense of money are usually the first item to be discussed in relation to the National Health Service. However, the way we frame the questions at the moment there can never be enough money. If we turn things on their head and build a system built on healthy public policies, full citizen engagement and a public health grounded clinical system money is the final question and it is about what it takes to make the system work. In a sense Simon Stevens has been trying to pursue this approach with the five Year Forward View, the programme of Vanguards (incidentally a Trotskyist notion of the leaders having all the answers), and the Sustainability and Transformation Plans which whilst well-meaning have slipped into the Richmond House default position of top down planning in nowadays smoke free, darkened rooms.

These five major components of the change we need must be backed up by a proper population evidence base, appropriate capacity and capability, and arrangements, curriculae and institutions that are fit for purpose. In turn, this has significant implications for our understanding of the values and cultures of a wide range of professional groups, their ability to work collegiately across agencies and as equals with members of the public. It would help if politicians had proper induction into the issues along with the officers who they must work with and if there was clear water between the public and private services and self-interest. But the most important element is co-productive, ethical and challenging leadership at all levels and across the whole system.

Here, in Manchester and in the North generally where there is increasing anger at the failure of our centralised national system of government to deliver, not only on the NHS but with tackling all five Giants and beyond Devolution can bring hope. Andy Burnham and Steve Rotherham, the great cities and counties working together as Leaders of Place can use soft and convening power with an outward focus to transform life for millions. They can push the boundaries free from the fossilised processes that hold us back and provide accountable voices for local people; early examples of the momentum for change that is building include homelessness, environmental sustainability, the need for a living wage and the obscenity of very high pay and inequality. Mayor Bloomberg in New York has given us a flavour of the potential of an elected mayor in championing public health and I have personally witnessed the power and influence of 1000 such first citizens committing themselves in cities across Latin America.

I have had the privilege of working with the World Health Organisation Healthy Cities initiative, which now involves over 1400 cities worldwide, for the past 32 years. Next month  February 2018) in Copenhagen there will be a summit of elected city and metropolitan mayors from around the world marking a new phase of political leadership at the city level. The focus will be on six P’s:People, Place and Participation; Peace, Prosperity and the Planet. Beveridge’s five Giants are now a global threat; by working together not just here in Manchester but in concert around the world we can keep the faith with those who gave us the NHS on 5th July 1948.

This was the Telford Memorial Lecture at Manchester Medical Society – 31st January 2018.

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Do you have a story of the NHS to share?  A new BBC documentary wants to hear from you!

Hospital in 1948

The People’s History of the NHS is a crowd-sourced history for the BBC in partnership with the University of Warwick, told through people’s treasured mementoes. Were you around when the NHS first started in 1948? Did you receive something you couldn’t have afforded before? Whether you were a member of staff or a patient, get in touch with your story.

To see what we have uncovered so far visit – www.peopleshistorynhs.org

To share your story, email peopleshistorynhs@7wonder.co.uk or call 020 3701 7599

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Volunteers needed for an exciting national public history project!

Are you interested in people?  Are you a good listener?  Would you like to play a part in creating a shared national story of the NHS?

NHS at 70 will capture the stories and artefacts of those who worked for and were cared for by this unique institution, creating a digital archive of NHS history.

  • We are looking for volunteers to develop oral history skills and collect stories about the NHS from members of the public in Greater Manchester.
  • You will receive professional oral history training, a chance to develop research skills and the opportunity to hear first-hand these remarkable stories from local communities.

The NHS 70th anniversary in 2018 is a perfect opportunity to celebrate its past and reflect on its present and future. Since 1948 the NHS has had a central place in everyday British life. Created to provide free and universal access to healthcare, it shapes the experiences of birth, life, health, sickness and death for the majority of the public and is also the UK’s largest employer.

NHS 1948 Informational Leaflet

NHS 1948 Informational Leaflet

We are supported by the Heritage Lottery Fund and partners include: Age UK, Mental Health Foundation, Rethink Mental Illness, Stroke Association, NHS England, NHS Confederation and the TUC.   

Contact us to get involved or find out more.

Email:  nhs70@manchester.ac.uk

Telephone:  0161 275 0560

@NHSat70

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How Labour built the NHS

On the 5th July 1948, a young girl was admitted to Park Hospital in Manchester, to be treated for a liver condition. Little did she know, she was at the focal point of a political and social revolution. Her name was Sylvia Beckingham and she was the first patient to be treated on the NHS. She would later recall:

Mr Bevan asked me if I understood the significance of the occasion and told me that it was a milestone in history – the most civilised step any country had ever taken. I had earwigged at adults’ conversations and I knew this was a great change that was coming about and that most people could hardly believe this was happening.

On his visit there that day, Nye Bevan described the birth of the NHS as “the most civilised step any country has ever taken.” Indeed, for Bevan, it was the culmination of a life-long struggle and vindication of a dream fostered in the deep squalor of the Tredegar slums. His journey started at just 13, when he began work as a miner, and by the age of 19 he was chairman of his miners’ lodge. As a rising political star, Bevan chaired the ‘Tredegar Medical Aid Society’ committee, which greatly shaped his outlook towards health inequalities.

In the medical aid society, members received healthcare in return for a financial contribution. During his tenure, membership was expanded to include non-miners, to the point that 95% of the town’s population became eligible to receive support. It was one of the first community health services and Bevan swore to export this model to the world.

He now had his blueprint and later explained: “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to ‘Tredegarise’ you.” The clamour for a state-run health service had certainly grown during the Second World War, when the volume of casualties had reduced the system towards bankruptcy. Back then, Britain’s 2,700 hospitals were run by charities and local councils. Only those in employment were entitled to treatment under the national insurance scheme in place.

The Beveridge Report of 1942 had outlined a vision for a national health service in order to slay the five giants: Want, Disease, Ignorance, Squalor, and Idleness. The report recommended a new system of social security and the paper had been a huge success. When the Allies finally made it to Berlin, a copy was found in Hitler’s bunker. The Nazi executive summary noted that it was ‘superior to the current German social insurance in almost all points.’

Labour’s commitment to a national health service was outlined in their ‘National Service for Health’ policy document of 1943. During the war, Labour had pushed the Tories for a consensual commitment to implement the Beveridge report’s findings. However, Churchill was absorbed in war strategy and ruled out any firm commitment on future planning until it was finished. A White Paper was published, but he spoke of Beveridge in private as ‘a windbag and a dreamer’. Churchill also had grave reservations about the motives of Bevan and Arthur Greenwood, who he believed wanted to subvert the wartime coalition.

When the Beveridge Report was brought before the Commons, the majority of Labour MPs voted for its immediate implementation. Although the government, of which Attlee was a key figure, had been against this, he cannily allowed a free vote on it. Labour became associated with the reforms, and the Tories were accused of being against them. Attlee had been in ‘permanent campaign mode’ through the war, preparing the ground for his stunning election victory, and earning the respect of the country with the Labour contribution to the war government. In 1945 Attlee became wary of the Tory commitment to the reforms and when Churchill asked him to keep the war cabinet in place for a transitional period, Attlee refused, citing the need to progress with change.

Before 1945, the role of Health Minister had been a relatively minor one, but for Nye Bevan it was the opportunity to alter society, and the first step towards socialism. He recognised that health was a key factor in social inequalities and needed to be tackled head on. “A free health service is pure socialism,” he announced, “and as such is opposed to the hedonism of capitalist society.” His assessment of health reform was underpinned by three key principles: to be free at the point of use; available to everyone with a need; and to be funded through general taxation. He later outlined his strategy for health “In Place of Fear,” in 1952.

When Bevan had published his Bill on the health service in 1946, one former chairman of the BMA described the proposals in dramatic terms:

I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to National Socialism as practised in Germany. The medical service there was early put under the dictatorship of a “medical fuhrer.” The Bill will establish the minister for health in that capacity.

Coming just months after the defeat of Hitler, the comparison to the Nazi’s could have been damaging. The comparison of Labour to the Nazi’s had been rejected at the ballot box a year earlier, when Churchill had compared the party to ‘some form of Gestapo’.

Between 1946 and 1948 the British Medical Association (BMA) campaigned vigorously, against the terms Bevan had offered the doctors. The right-wing national press was also opposed to the idea of an NHS. The popular right-wing tabloid The Daily Sketch claimed: “The State medical service is part of the Socialist plot to convert Great Britain into a National Socialist economy. The doctors’ stand is the first effective revolt of the professional classes against Socialist tyranny.”

The Tories voted against it 21 times and in one survey of doctors carried out in 1948, the BMA claimed that only 4,734 doctors out of the 45,148 polled, were in favour of an NHS. Churchill too was ferocious in his attack on Bevan. He told Bevan that unless he “changes his policy and methods and moves without the slightest delay, he will be as great a curse to his country in time of peace as he was a squalid nuisance in time of war.” The Tory amendment stated that it:

declines to give a Third Reading to a Bill which discourages voluntary effort and association; mutilates the structure of local government; dangerously increases ministerial power and patronage; appropriates trust funds and benefactions in contempt of the wishes of donors and subscribers; and undermines the freedom and independence of the medical profession to the detriment of the nation.

The Conservative commitment to the NHS has often been disputed by historians. In their 1945 manifesto they claimed: “The health services of the country will be made available to all citizens. Everyone will contribute to the cost, and no one will be denied the attention, the treatment or the appliances he requires because he cannot afford them.” Notably, there was no commitment to make the new health service free at the point of use, and given their opposition to Bevan’s proposal and past comparisons to the Nazi party, we can assume it would not have been as radical.

There was opposition within the Labour party too. Herbert Morrison felt that local councils were the bodies best equipped to run a health service, arguing that London had the best service in the country. However, on 26 July, 1946, the Third Reading of the Bill was carried by 261 votes to 113. The world was now watching Britain. The Chicago Tribune led with the headline ‘Pass National Health Service Bill in Britain – Doctors Fight Act That Covers All’. They went on to write ‘the Conservatives opposed the bill… seen as giving too much power to the Health Minister.’

The doctors still disliked the idea of becoming employees of the state, and would look to wield their power to prevent it coming to fruition. Doctors were in an extremely powerful position and the government would be forced to compromise. Once the Health Bill came before parliament in 1946, the BMA refused to negotiate.

Bevan took the battle to the streets. Conscious of the public appetite for change, he sought cabinet approval for a mass publicity campaign consisting of guide booklets, posters, and information films. When asked whether the negotiations would derail the implementation day, Bevan responded angrily “Why should the people wait any longer?”

He put more pressure on the BMA through a Parliamentary vote on “that the conditions under which all the professions concerned are invited to participate are generous and in full accord with their traditional freedom and dignity”. Bevan opened the debate with an attack on the BMA as a “small body of politically poisoned people” who had decided “to fight the Health Act itself and to stir up as much emotion as they can in the profession.”

Bevan resorted to “stuffing their mouths with gold.” – by allowing consultants to work inside the NHS, whilst remaining able to treat their lucrative private patients. Most doctors earned little from their hospital work and depended on the private patients to boost their income. Bevan would later claimed to be “blessed by the stupidity of my enemies”.

Faced with the threat of strike action, he conceded that GPs would retain the freedom to run their practices, the consultants were given a pay rise, and were also allowed to keep their private practices. Bevan also pushed up nurse wages in order to attract new recruits to the cause.

By July 1948, Aneurin Bevan had guided the National Health Service Act through Parliament. The government resolution was carried by 337 votes to 178. Bevan had won the backing of the PM, who supported the creation of 14 regional health authorities to oversee the service. On July 5 1948 the National Health Service took control of 480,000 hospital beds, 125,000 nurses and 5,000 consultants. When Nye Bevan arrived in Manchester to receive the keys from Lancashire County Council, the nurses formed a ‘guard of honour’ to greet him.

In the aftermath of the devastating world war, the UK showed the world that a universal health care system was possible. In pursuit of socialism, Labour had stumbled upon their crown jewel with the NHS: universal in nature, brought together through the collectivism and social solidarity of the people.

The iconic Davyhulme hospital where Bevan launched the NHS in 1948 lost its A&E unit in 2013, under the Tory reorganisation. What we wouldn’t give for some of that Bevanite boldness today.

This was first published on the British Politics and Policy blog

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On this day, 69 years ago, Aneurin Bevan founded Labour’s proudest achievement – the National Health Service, which was set up to provide universal healthcare for all, on the basis of need, free at the point of use.

Nearly 70 years on, and the NHS is still a precious institution, with over a million dedicated, hardworking staff. In government, Labour prioritised investment in our health service, bringing it back from the brink after 18 years of Tory neglect. Thanks to the last Labour government, over 100 new hospitals were built or refurbished; between 1997-2010 there were 89,000 more nurses, 44,000 more doctors and we had the lowest waiting times on record.

But after seven years of the Tories, our NHS is in crisis. There are now nearly four million people on the waiting list for treatment in England, well over a million more compared to when Labour left Government; over 2.5 million people waited too long in A&E last year and over half a million people were left stranded on hospital trolleys because they couldn’t get a bed on a hospital ward. Performance is declining across the board, and patients are being badly let down as a result of this Government’s mismanagement of the NHS. Hospital trusts racked up an £800m deficit last year, Clinical Commissioning Groups are being forced to ration care and treatments for some patients and are using funding set aside for children’s mental health to plug gaps in their budgets. The Tories have failed to address the funding pressures facing the NHS. Labour, on the other hand, promised an extra £37 billion for the NHS over the next five years in its manifesto, including much needed capital investment to modernise and repair hospitals and surgeries.

Our hardworking NHS staff dedicate their lives to putting patients first, working 24 hours a day, seven days a week, to make sure people get the best care possible from our health service. It is a scandal that this Tory government has refused to give our NHS workforce the pay rise they deserve – the prime minister herself told a nurse during the election campaign that there was no “magic money tree” to pay for an increase in wages for NHS staff. The Labour Party values those working in our NHS and recognises that, after seven years of austerity, staff deserve a pay rise. That’s why in Labour’s manifesto, we pledged to lift the one per cent pay cap, putting pay decisions back in the hands of independent pay review bodies.

Alarmingly, the Nursing and Midwifery Council this week revealed that we are now seeing more nurses and midwives leaving the profession than joining. At a time when there are 40,000 nursing vacancies across the UK, and a shortage of 3,500 midwives in England, this Tory government is making things even worse. The Tories’ decision to scrap NHS bursaries has led to a drop of 23 per cent nursing applications this year compared to last and yet they still refuse to scrap this disastrous policy. Labour firmly believes that investing in NHS staff for the future is vital, and that’s why we’d reverse the government’s damaging decision and restore nurse bursaries.

Today, the 69th birthday of the NHS is a cause for celebration of our treasured health service. But patients and the NHS are being badly let down by this Tory government. Labour will always fight to protect the NHS, ensuring that there are enough doctors and nurses to provide the care that patients need and we will always give the NHS the money it needs.

This was first published on Labour List

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atbaei via Getty Images
“NHS funding growth is much slower than the historic long term trend.”

“Real terms funding per person will go down in 2018/19 and 2019/20.”

“The public are concerned for its future.”

“There is likely to be continued pressure on waiting times for routine care and some providers’ waiting times will grow.”

The words above are not taken from a Labour press release or a critical speech in Parliament, but from a new NHS England Plan, Next Steps on the NHS Five Year Forward View, which was published this week.

The document confirms that the NHS does not expect to meet the A&E target, to see 95% of patients within 4 hours, which Jeremy Hunt described as being “critical for patient safety,” for at least the next year. It also sets out plans for another round of rationing of treatments and the abandoning of the 18 week waiting target for surgery.

The document, gloomy though it is, provides a realistic assessment of what is and isn’t achievable within the financial constraints that the NHS is operating in. Nor is it entirely without positives such as the welcome ambitions around cancer care and mental health, which Labour fully endorses, though the chasm between Government rhetoric and reality in these areas is huge.

It also very clearly does confirm once again that despite repeated assurances from Theresa May and Jeremy Hunt, the NHS has not been given the funding settlement that it asked for and patients will pay the price.

You would be right to expect that a frank assessment of the challenges facing the NHS, coupled with a plan for new governance arrangements and departure from nationally agreed targets would receive forensic scrutiny in Parliament. You would expect a detailed statement from the Health Secretary, followed by questions from MPs about why NHS funding has not kept up with demand and why a “critical” target will be missed for another year. You would expect an answer from Jeremy Hunt as to whether he considers the NHS Constitution is still actually a document that is binding on Government.

Unfortunately, this announcement came on the first day of the Easter recess, so there was no statement and no scrutiny. The Health Secretary who wants to deliver a 7 day NHS has also once again gone missing at a time when serious questions are being asked about his stewardship of the Department for Health.

The most striking thing about the new plan is the confirmation that not only did the 2012 Health and Social Care Act waste billions of pounds, it has also been an abject failure. The payment by results system is being quietly shelved, while there is a desperate rush to replicate the functions of the Strategic Health Authorities that the 2012 Act scrapped.

This second reorganisation is happening much less publically than the first one. Whilst there was some publicity surrounding Sustainability and Transformation Plans, there has been much less coverage of the Vanguards or the move towards Accountable Care Organisations which feature heavily in the new document. The Healthwatch guidance on ensuring that local people have their say recommends that organisations should “involve local people from the start in coming up with potential solutions.” Based upon this test, the exercise has already been an abject failure, while there are also question marks over whether changes on this scale could be open to legal challenge without further legislation. Will the abandoning by the Government of the 18 week waiting time target for treatment also lead to a legal challenge because the NHS Constitution has been broken?

However, possibly the most alarming prospect thrown up by this reorganisation is reference to the establishment of Accountable Care Organisations, which the plan says will lead to commissioners having “a contract with a single organisation for the great majority of health and care services and for population health in the area.” We will be seeking urgent confirmation that the ‘single organisation’ will be part of the public sector.

The concern is that this opens the door to huge contracts to private providers as the lack of a clear legal framework for these new commissioning arrangements makes a challenge likely if they are not given the same opportunity to bid as public sector bodies.

Finally, the statement “some organisations and geographies have historically been substantially overspending their fair shares of NHS funding” which “may mean explicitly scaling back spending on locally unaffordable services” will send a chill down the spine of anyone who works or is currently a patient in the NHS. They will know that services are already stretched to breaking point and this move to single out sections for further cuts could well push parts of the health service over the edge. We deserve better than the future strategy for the NHS being reduced to an exercise in expectations management.

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My name is Jenny Crane and I work on a Wellcome Trust project about the Cultural History of the NHS, looking at how the meanings of this key British institution have changed over time.  I also co-ordinate our engagement programme, the People’s History of the NHS, in which we collect memories, stories, and opinions from as many people as possible, to feed this in to shape our research work and outputs.

In terms of our engagement work, we have organised multiple physical events: with Museums, hospitals, art galleries, local history societies, and campaign groups.  Our upcoming events can be found here, please do join us!  We also try to extend the reach of our work through our public-facing website.  On the website, we write short articles about our findings, and have a ‘Virtual Museum of the NHS’ displaying pictures of NHS objects, from baby glasses and tags to portraits of Nye Bevan.  We also invite anyone to contribute to our website – it is free, quick and easy to sign up, and then myNHS members can see the memories which others have shared, and contribute their own.

So far, we have received 76 memories, many of which relate to campaigning around the NHS.  These submissions have really enriched my research into this area, and changed the nature of the questions which I’m asking of my archival materials.  Mostly from our responses I’ve been very struck by the variety of campaigning around the NHS – from the work of Leagues of Friends to raise money for new equipment, to marching and protest in various areas, and campaigns through letter-writing, petitions, and legal challenges.  The submissions have already started to give me some idea in to how NHS campaigning has changed over time – for example from multiple local groups to a more cohesive national movement, trying to mobilise collectively to defend the NHS as a whole, rather than local hospitals.  One submission suggested also that campaigning had moved to some extent from outside, protesting, as protesters had aged, and media and police come to manage such activism more.  Instead, the contributor argued, much campaigning was now done through letter-writing, Freedom of Information requests, petitions, and, of course, using the virtual space of the internet.  The extent to which the internet has been a good thing for campaigners – spreading the message, engaging new audiences, linking disparate groups together – or a bad thing – leading to lazy ‘clicktism’, dissuading political action – has been a regular debate in responses to my survey for NHS campaigners.

Another fascinating question raised by contributors is about the extent to which pro-NHS campaigning is radical, given that this Service has rated very highly in public opinion polls since its inception.  One member argued that this was radical, because promoting democratisation of the NHS placed campaigners up against large and powerful bodies – particularly the Trusts and the Clinical Commissioning Groups.  Another question raised is the extent to which NHS activism, or indeed activism in general, may be generational.  One of our submissions is from a campaigner who mobilised in 2010, because she saw changes being made to the NHS, and also in that year received papers from her father, defending the Service as early as the 1950s.  In one speech, made in 1955 to an American audience, the father argued against the idea in American media that a medical service run publicly was ‘both inexpedient and morally wrong’.  Rather, he argued, that the NHS cost a similar amount to the American health system, and yet was also ‘there for all’, reliant on the ‘venerable principle’ that everyone would contribute to the care of the sick.  His argument was both based on statistics and information, as a scientist, and on a moral call about entitlement and welfare: two strands which continue to be key to NHS campaigning together.

We’ve also received brilliant visual culture about campaigning through our website.   We have received for example pictures from Stroud Against the Cuts (see left) of their exhibition and campaign hub run in February 2017 in an empty shop on Stroud High Street.  We have also received photos of placards, t-shirts, and leaflets from Leeds Hospital Alert; a group founded in 1981 in response to Kenneth Clark’s proposal to allow hospitals to ‘opt-out’ of local authority control.

My research looks to understand different types of NHS activism; how these have changed over time, and when they have been successful, or not.  Looking at historical archives, I can see how campaign groups were received by media, politicians, think-tanks, and legal and medical professionals.  However, it is also invaluable to hear from campaigners themselves.  However involved you’ve been with NHS campaigning – whether you’ve just signed a petition once, or whether you’ve established a campaign group and led rallies – I am keen to hear your story.  By understanding these stories, I can better understand what the NHS means to people, and when and why and how people have, historically and today, made the shift from appreciation for this Service in to political action.

If you’d be happy to tell me more, please do consider contributing any photos or memories at our project website here.  It is free and simple to join up.  You can also email me directly at J.Crane.1@warwick.ac.uk, or fill out my short survey for NHS campaigners.

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On 27th February 2017, the Government debated an e-petition which had received 117,344 signatures through the Parliamentary website.  The petition noted that there are 193 attacks on NHS staff per day in England, and called for it to become a specific offence to attack a member of NHS staff, in line with legislation specifically prohibiting violence against police officers.  Following Parliamentary debate, the Ministry of Justice argued that ‘assaults again NHS staff are completely unacceptable’, but also that there were already sufficient offences which criminalised assault and violent behaviour.  The example of this recent petition raises broader historical questions – who has created petitions about the NHS over time?  Have these been effective, and in what ways?  How do such petitions fit in to a broader model of NHS-related campaigning?

The first known petitions to Parliament date back as early as the fourteenth century, and petitions have emerged as a popular way for members of the public to try and influence Parliamentarians, particularly since the 1600s, initially about personal grievances and later seeking to change policy.  The historian Richard Huzzey has demonstrated that popular petitions in the late eighteenth century ‘transformed the fortunes of the anti-slavery cause, which had little prospect for political attention before them.’  Huzzey argues that these petitions were effective because of their reach (attracting signatures from as many as 1 in 5 adult men), and because political elites genuinely feared that they marked a sign of impending revolution.

The first petitions which I have found in relation to the National Health Service – and I’d be keen to hear if you know of earlier examples – were created in the 1960s and 1970s, usually by doctors as a tool during industrial dispute.  For example, in 1975 the Daily Mail reported that sixty ‘militant hospital doctors’ from Hillingdon Hospital had a petition signed by 600 patients to support their mass resignations (over the Government’s refusal to increase overtime pay).  An increasing number of petitions on every topic, including the NHS, were presented to Parliament in the early 1980s.  The House of Commons Information Office has attributed this to the emergence of several highly contested issues in debate at this time, many of which were related to health such as contraception, abortion, and embryo research.

This increase in the numbers of petitions also perhaps reflected a less deferential electorate, who were mobilising politically in a variety of ways, and concerned about the future of the welfare state under Thatcher’s reforms.  Certainly, NHS petitions were now created by members of the public, as well as NHS staff, and petitions began to challenge government cuts and the perceived privatisation of the NHS, both nationally and locally.  In December 1989, 4.5 million people signed a petition in defence of ambulance crews.  The physical content of these petitions filled 100 boxes, only 25 of which were allowed in to the House of Commons by the Speaker Barbara Weatherill.  Petitions were in part seen as a tool of specifically left-wing revival at this time: in 1991 Dr Clive Froggatt, of the Conservative Medical Society, argued that a petition created by the NHS Support Federation, calling for a halt to NHS reforms, was a barely concealed ‘political message…telling people to support Labour.’

From the mid-2000s, e-petition sites were created by the UK’s Parliaments and private –e-petition companies such as Change.org and 38 Degrees were founded.  Analysing the petitions on these websites allows us to look more closely at the relative popularity of the NHS as a topic of petitioning.  Considering the Government’s e-petition website (running from July 2015 – March 2017 so far), health issues are well-represented as a topic.  Of the top ten most popular petitions ever created on this website, the third most popular called to provide the meningitis B vaccine for all children, the seventh was a vote of no confidence in Jeremy Hunt, and the eighth called to lower the age of cervical screening to 16.

Looking at all petitions on this website, 1,852 out of 28,831 (6%) mention the NHS.  This seems significant.  Of these petitions, 40 received over 10,000 signatures, and thus a response from the government.  Nineteen of these petitions were about the treatment of specific diseases in the NHS – such as meningitis and cervical health – and one was about the firing of a particular member of staff.  These petitions, arguably, tell us more about concerns about the nation’s health than about NHS provision (although perhaps that preventative services are seen as part of the mandate of the NHS is also significant).  Nonetheless, half of these popular petitions – 20 – were about the NHS specifically and, like the petitions from the 1980s, the aims of these reflected a fear that the NHS was ‘in crisis’ due to cuts and privatisation wrought by a Conservative government.

Looking at the topics of popular petitions suggests a high level of public interest in the NHS and in health, which is played out on a national and a local level.  In terms of NHS campaigning, petitioning has been particularly prominent during periods of right-wing Government – the 1980s and 2010 to present – in which campaigners have sought to use petitions to criticise changing policy.  The extent to which petitions have been successful in this regard is difficult to assess.  Some petitions can be linked to change.  In 2007, Cancer Research UK presented a petition signed by over a quarter of a million people to Parliament, calling for cancer to be placed at the top of the Government agenda.  Soon after, the Government launched a new cancer plan for England.  In 2008, the British Medical Association presented a petition of 1.2 million signatures against the emergence of ‘polyclinics’, combining primary and secondary care.  The plans for such clinics were put on hold in 2010 by the new incoming Government.  The responses to the former petition, however, may have been merely rhetorical; or the changes wrought following both petitions, if real, could have been part of a new or changing government strategy anyway.

Something easy to find in newspaper archives and amongst campaigners is irritation and sadness that petitions do not affect change.  Prime Minister Margaret Thatcher did not even feel that it was politically necessary to meet the parents behind a petition to increase funding to Birmingham Children’s Hospital, simply telling the media that the NHS would not be given a ‘blank cheque’.  Campaigners in the 1980s and today suggest that various petitions against hospital closures meant that ‘barely an eyelid was batted’ (Daily Mail, 2002), and that the ‘voice of the people’ was ignored (The Times, 1994) or ‘very ineffective’ (own survey of NHS campaigners, 152 responses).  Nonetheless, however, despite this cynicism about the effect of surveys from both the political science literature and from campaigners themselves, we continue to create and sign surveys in mass numbers.

This may be for several reasons.  Perhaps those establishing surveys are inspired and hopeful, having noticed the success of some high-profile surveys (for example one which postponed the instatement of a new Road Tax in 2006, another which lead to an apology for the treatment of Alan Turing in 2009).  Research suggests that 19 out of 20 e-petitions (on the Downing Street petition website, 2006-9) were launched by individuals, rather than by groups or organisations – perhaps these individuals do not have the cynicism about petitions mentioned by the weary long-term campaigners above.  Petitions may also carry a higher function than merely calling for political change.  Some campaigners in my survey mention that promoting a petition is an easy way to bring members of the public into their groups, where they can also become involved with other forms of activism such as leafleting, discussion, and writing to MPs.  For others, signing a petition may enable them to feel like part of a particular ideological or moral community, or a way of perhaps may be a way in which they construct and understand their identity or position in society.

If you’ve ever signed a petition about the NHS, I’d be very interested to hear more.  Why, when, how did you do this, and what happened next?  Please do either comment below, respond to my survey for campaigners, or email me at j.crane.1@warwick.ac.uk (Jenny Crane).

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The National Health Service was established in 1948 to provide a comprehensive service designed to improve the physical and mental health of the population of the UK. The relevant legislation (National Health Service Act 1977) provides that services for the prevention, diagnosis and treatment of illnesses must be provided free unless a charge is expressly permitted by statute. The Beveridge report in 1942, which laid the foundations for the post war ‘welfare state’, stated that:

‘a health service providing full preventative treatment of every kind to every citizen without exception, without remuneration limit and without an economic barrier at any point is the ideal plan’.

In many ways, this underlying principle still governs the operation of the modern NHS, despite the strain which it has come under. Some of these pressures emanate from the Treasury or from the changed political landscape of the last two decades associated with the catch phrase ‘rolling back the state’. Some have come from within. Devolved responsibility for budgets, the drafting in of managers from the private sector and the involvement of private companies in the financial management of the health service have inevitably changed the climate in which funds are allocated. Increased running costs and expensive advances in medical treatment place pressure on NHS managers to find ways of generating income. Thus it is that Community Health Councils come to hear complaints concerning unreasonable, inequitable and sometimes illegal charges.

History of NHS Charges

At the outset of the NHS even Beveridge advocated the implementation of charges for ‘hotel’ expenses during hospital stays and contributions towards the costs of appliances such as dental and optical equipment. Since that time debates have persisted over whether and what charges should be levied.

Although the imposition of charges has often been justified as a measure to reduce wastage, much of the pressure for increasing revenue through this means arises not from any internal health policy logic but as an effect of wider political or economic agendas, particularly those driven by the Treasury. The need to prioritise defence spending (1951), win favour with international money markets (1968), comply with IMF loan conditions (1975-9) and generally control public expenditure (1979-97) have all been cited as reasons for increasing NHS charges3.

In many instances, charges have been extended as a concession to the Treasury to enable particular projects to be paid for. A onetime staunch opponent of charges, Richard Crossman, Secretary of State for Social Services in 1969 admitted that the introduction of optical and dental charges within the NHS was to fund school building projects.

Over the last two decades political pressures have not been sympathetic to the principle of basing service provision on need rather than cost. The wider political context has seen public services privatised across the board — Jean Shaoul, lecturer in accounting and finance at the University of Manchester, points out that in1999 57% of total government expenditure was spent on the purchase of goods and services, compared to only 28% in 1977. As privatisation has progressed, there have been growing pressures to recoup the cost of services from the user rather than out of government expenditure. Where this is not possible, means tested exemptions from user charges are preferred to universal subsidised provision. Thus in education, grants have been replaced by loans and tuition fees. In transport, provision has been privatised and fares increased. In housing, subsidies have been shifted from investment in bricks and mortar to (more stringently means-tested) housing benefit.

Yet despite this, the popularity of a free health service has always made the introduction of new or increased charges politically difficult. Thus in order to placate opponents of her plans for an internal market, Mrs Thatcher refused to introduce new charges for GP visits and hospital stays. (Nevertheless, prescription charges increased in real terms fivefold between 1979 — 1997).

For this reason the government is particularly keen to find ways of appearing to preserve the principle of free health care while drastically reducing its scope. One such technique has become increasingly important since the late 1980s. This is the process through which more and more functions formerly associated with NHS non-acute care — particularly of the elderly ­ have been transferred to local social services — enabling charges to be raised.

Social Care

Changes in the responsibilities of different public bodies for the provision of care are reflected in new and ambiguous terminologies: thus long-term care has increasingly come to be redefined as social care, and ‘personal care’ (chargeable) has come to be distinguished from ‘nursing care’ (free). As the Health Select Committee pointed out:

“The confusion is epitomised by the farcical question of whether a person needing a bath in the community should receive a `health’ bath or a ‘social’ bath — the first comes free, the second (in theory at least) has to be paid for on a means tested basis.”

The impact of this change is reflected in NHS bed numbers. Between 1979 and 2000 the number of beds in the NHS in England decreased from 480,000 to 189,000, while the number of beds in the independent nursing care sector, increased from 23,000 in 1983 to 193,000 in 2000.

The number of private residential care beds also increased, reaching 345,600 in 2000. The growth of this sector was initially fuelled by an uncapped social security budget in the late 1980s. This funding was then subjected to much sharper means testing in the NHS and Community Care Act 1990 and in subsequent legislation. Thus, formerly free NHS services became increasingly self-funded social services. It has been estimated that in 1995 40,000 pensioners were forced to sell their homes to pay for care. Under-funding by central government of local social services effectively forces councils to charge pensioners the full cost of their care if their capital exceeds the disregard limit. Even despite this a shortfall of social services beds remains. The result is that many elderly people cannot be discharged from hospital because they have nowhere to go.

The legality of these charges may be in some doubt. The ruling in ex parte Coughlan makes clear that even where an individual had been placed in a home by the local authority, responsibility for provision of nursing care stays with the NHS where the primary need is a health need. The assessment process carried out by social services and health bodies by which eligibility for ‘free continuing care’ is decided is not transparent or open, and not always rigorous. Patients have little say in decisions about where they go and who will pay for it. Support for this vulnerable group of people not easy to come by. A survey produced by the Pensioner’s Campaign Team in April 2001 suggests that only around 20% of social services departments employ patient advocates. After April 2002 assessment for continuing care will be integrated with assessment for nursing care under the Health and Social Care Act. Whether the new regime will improve matters remains to be seen.

Shortly after being elected in 1997, the Labour government set up a Royal Commission to consider the future financing and provision of long term care. This recommended that personal care provided in all settings should be made free at the point of delivery. The Government rejected this proposal. Provisions in the Health and Social Care Act 2000 remove the responsibility for the provision of nursing care from community care services, but limit its availability. The Act also extends the power of local authorities to recover charges for services by laying claim to the sale value of the homes of those receiving care. Despite the fact that this legislative change was introduced with the stated aim of improving the integration of health and social care services, the persistence of two very different funding regimes will ensure that the boundary between them remains hotly contested. 

Social and Health Consequences

If charges simply reduced wasteful overuse of health services across the spectrum of social classes, with no adverse health impact either for particular groups or for the general public, then they could be easily justifiable. Similarly, if the imposition of charges just acted to depress the use of ineffective treatments, they might be reasonable. Yet research has confirmed that such a blunt instrument will not achieve such smart results. In the 1970s the US think tank RAND carried out one of the most comprehensive investigations ever into the effect of user charges involving over 7000 participants. This established that charges reduced the uptake of both ineffective and effective treatments at the same rate. Charges were also found to have a disproportionately adverse effect on low income and vulnerable groups. These same points emerged strongly in a World Health Organisation (WHO) global survey of charges. WHO argued that such a ‘tax on illness’ often impacts adversely upon the control of infectious diseases and undermines preventative medicine while also producing inequality by deterring the poorest from using services.

Former Health Minister Gerald Malone claimed ‘there is no evidence to suggest that charges deter people from seeking the medication that they need”. This view has been shared by successive governments. Yet, if prescription charges were exclusively effective in reducing unnecessary usage, prescription redemption figures would show no differentiation between the financial status of individuals with similar clinical needs (horizontal equity). However, a 1993 study found that disproportionate numbers of patients (33%) who failed to redeem their prescriptions were liable for charges. A survey by ACHCEW in 1996 found that 58% of Community Health Councils (CHCs) had experience of patients failing to redeem prescriptions. This finding was supported by a poll conducted by. Kidderminster and District CHC in 1995, which established that 35% of people who are not eligible for free prescriptions sometimes fail to have their medication dispensed.

Low-income, but not-exempt, users are most disadvantaged by health service charges.

“A Citizen’s Advice Bureau in Northumberland reported a client with severe mental health problems who required three prescription items per month to control his condition. However his income from incapacity benefit left him 5 pence above the level at which he would have been entitled to free prescriptions. He could not afford the £18 per month prescription bill and therefore went without his drugs”

A recent report by the National Association of Citizen Advice Bureaux suggests that 28% of clients failed to get all or part of a prescription dispensed during the last year because of cost. According to the National Pharmaceutical Association “what can I leave out” is a common question asked of pharmacists.

There is no doubt that charges reduce uptake. Treatment figures fell by 25% following the introduction of the new dental charging regime in 1987. The introduction of charges for eye tests in 1989 had a similar effect, while the rise in prescription charges between 1979 and 1984 is estimated to have caused a 40% reduction in the number of chargeable prescriptions dispensed.

The Bristol Eye Hospital detected a fifth fewer cases of glaucoma following the introduction of eye test charges. Although the numbers have since increased, the BMA have estimated that within the introduction of charging, twenty million more tests would have taken place. Many will have lost the chance to have eye diseases such as glaucoma and retinoblastoma diagnosed early enough to be treated. in the case of glaucoma, eye deterioration proceeds slowly — at a rate of 3% per year. The full cost of this short term saving may not become known for some time.

Another instance where the introduction of charges may undermine longer term public health goals concerns the needs of those in their late fifties when ageing may begin to result in deteriorating teeth or eyes. If inadequate intervention occurs at this point the ramifications may undermine general health in old age. The Public Policy Research Unit explored some of the possibilities:

“What might follow, if for instance, people over 50 are deterred from dental treatment?

  • Less conservation of teeth
  • More older people will need dentures
  • More older people will avoid foods that can be difficult to manage with dentures such as high fibre foods, fruit and vegetables
  • The quality of nutrition will fall
  • Illnesses associated with poor nutrition will rise

  • Greater use of health services will follow, made worse because of the higher costs or treating older people who tend to need longer hospital stays

It is illogical to discourage people from receiving health care that might prevent the spread of infectious disease, detect a problem at an early stage, or prevent it arising in the first place. Critics contend that charges do just this.

Legislation

A Free Service?

The National Health Service Act 1977 (the Act) defines the scope of NHS services and provides the legal foundations for the duties and obligations of both the Secretary of State and health service bodies and professionals. Section 1(2) provides;

`services ….. shall be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed’ (emphasis added)

The powers of the Secretary of State to enact secondary legislation controlling charging tariffs are further defined in sections 77 to 82 and schedule 12 of the Act. Section 77 of the NHS Act states:

`Regulations may provide for the making and recovery…. of such charges as may be prescribed in respect of ….the supply under the Act ….of drugs, medicines or appliances (including replacement and repair of those appliances)’

Chargeable services include:

  • The supply of drugs, medicines and appliances under section 77.
  • Dental appliances such as dentures and optical appliances, for example glasses and contact lenses under section 78.

Other sections allow regulations to be introduced for the supply of more expensive supplies, the repair of appliances in certain specified circumstances and payment of travelling expenses.

These sections do not require the NHS to levy charges, but merely give the Secretary of State the option to introduce charges for these specific services.

Charging Regulations

Since 1977 a complex network of regulations and amendment regulations have been introduced establishing and revising charging mechanisms. New regulations, when enacted, may revoke or partially revoke previous regulations. The result is a lengthy ‘paper trail’ which is both difficult to understand and interpret. CHCs supporting complainants have reported that health service managers have sometimes been unable to identify the correct legal basis for charges.

At present regulations are in force providing charging arrangements for:

  • Dental treatment and appliances – NHS (Dental Charges) Regulations 1989

  • .Optical treatment and appliances – NHS (Optical Charges and Payments) Regulations 1997.

  • Drugs and appliances – NHS (Charges for Drugs and Appliances) Regulations 2000.

  • Wheelchairs – NHS (Wheelchair Charges) Regulations 1996.

  • Treatment to overseas visitors (Charges to Overseas Regulations 1989)

Dental Service

The provision of dental services is divided into two distinct service categories ­ treatment and appliances. The NHS (Dental Charges) Regulations 1989 detail the charging mechanisms and tariffs for both dental appliances (Regulation 2) and dental treatment (Regulation 3). However, neither ‘dental appliance’ nor ‘general dental services’ are defined within the regulations. This lack of clarity hampers interpretation of the legislation.

Dental appliances

Regulation 2 of the 1989 Regulations states:

‘A charge…..may be made and recovered under section 78(1A) of the Act in accordance with these regulations in respect of the supply under the Act of denture and bridges’.

Strangely, it appears that dentures and bridges are the only dental appliances that may legitimately be charged for under this section. However, other appliances, such as the provision of crowns may fall under the umbrella of ‘general dental services’ -and charges made under that section.

More expensive supplies

Under the NHS (Dental Charges) Regulations 1989 an individual may request the provision of appliances which are more expensive than the basic NHS variety. The extra cost to the dentist of both supplying and repairing the non-standard appliance may be recovered from the patient under Regulation 8 (1). Similar provisions do not exist for the provision of superior treatments.

Provision of more expensive supplies must be at the request of the patient being treated and signed request forms must be submitted’. There is, therefore, no scope for dental practitioners to charge for more expensive appliances without the express agreement of the person being supplied.

Repair and Replacement of Dental Appliances

A distinction is drawn between repair and replacement of appliances

‘Replacement’ is effectively the same as (new) ‘supply’. Therefore, whatever charges apply when an appliance is first provided will also apply if a replacement is required, (subject to certain exceptions listed in 5.3 below) Section 25(2) of the NHS Act 1980 widened the meaning of ‘replacement’ to encompass relining, adjusting and alteration of dentures.

‘Repairs’ are not included in the definition of supply, and the regulations do not make specific provision to charge for repairs. They should therefore be free, and Department of Health publications HC11 and HC13 do state that dentures and bridges must be repaired free of charge. However since “relining, adjusting and altering” of dentures may be charged for, it may in practice be difficult to say exactly when a given procedure constitutes an adjustment, and when a repair.

The patient may be charged for any repairs or replacement made necessary by an act or omission on their part. This applies even to individuals who would ordinarily be exempt from charges. Where a Health Authority considers an individual personally liable in this manner it may set up a sub­ committee, to hear oral evidence. The health authority is responsible for the ultimate decision, and it may reduce or discount the full bill if this would cause undue hardship.

General Dental Services

Although general dental services are not defined in the legislation, they are taken to include, check-ups, the provision of fillings, de-scaling, oral hygiene advice, the removal of teeth, work on roots and gums, the provision of crowns and anaesthesia.

Charging Tariffs

General dental services and regular appliances are provided without charge to exempt patients. The dentist is reimbursed the full cost of this treatment by the NHS.

The charging tariffs for both general dental treatment and appliances are laid out under Regulation 4 (as amended 1998) which states:

`the amount of the charge which may be recovered is 80% of the Statement Remuneration….being an amount not exceeding that which the Secretary of State considers to be the cost to the health service of the supply or provision’

The Statement of Dental Remuneration is a lengthy document laying down the amount the NHS will pay the dentist for specific treatments. It is published under regulation 19 of the NHS (General Dental Services) Regulations 1992 and is amended twice a year’. Non-exempt (paying) patients are charged 80% of the treatment amount. The NHS pays the balance. Where a course of treatment attracts charges in excess of an overall ceiling, also laid down in the Statement of Dental Remuneration, the NHS pays the excess in its entirety.

Exemptions

Regulation 3(2) of the NHS (Dental Charges) Regulations 1989 specifies both classes of service and classes of client exempt from charges.

Treatments exempt from Charges

Exempted treatments include: uncompleted occasional treatment; calling an additional practitioner to administer anaesthetics in an emergency; and replacing or repairing within twelve months any defective fillings, root fillings, inlays, pinlays or crowns (subject to certain exceptions). Where a patient sees a dentist out of hours in an emergency or is visited at home any additional costs will be exempt and treatment will be chargeable on the ordinary tariff’.

Exempted Persons

Regulation 3(2)(a) refers us to Schedule 12 of the NHS Act 1977, which contains details of persons exempted from dental charges.

Free treatment is available to

  • Under 18 year olds and 18 year olds in full time education.
  • Women who are pregnant at the commencement of treatment
  • A woman who has given birth within the previous twelve months.
  • Patients undergoing dental treatment necessitated by operative procedure used to combat invasive cancer’.

Additionally, individuals with low incomes or in receipt of benefits may also be entitled to a reduction or refund of dental charges. However, eligibility is dependent on strict criteria under the NHS low-income scheme. This severely restricts access to free or low cost dental treatment. Individuals of pensionable age do not automatically receive free dental care. This is inconsistent with the availability of free prescriptions for the over 60’s.

Ophthalmic Services

The provision of National Health Services is based on the presumption that services are provided free unless express mechanisms exist for the recovery of a charge. By contrast, the provision of ophthalmic services is based on the premise that

charges are levied except where specific exemptions apply.

Sight Tests

A duty to supply free tests only exists under certain specified categories. Originally, these categories were broad and encompassed the majority of the

population, however eligibility has repeatedly been narrowed. In 1989, 12,493 sight tests were carried out on the NHS but this figure fell to 5,280 in 1990 following a change in eligibility rules. At its 1997 AGM ACHCEW passed a resolution calling for the restoration of free eye tests, in particular for the elderly, on the grounds that they are a cost effective means of screening for illnesses. We therefore welcome the government’s subsequent decision to again make eye tests free eye for the over sixties’.

Currently free sight tests are available to individuals who are:

  • over sixty years old, or
  • under 16 years old, or
  • aged 16 — 18 and in full time education or under the care of the local authority, or
  • diagnosed diabetic, or
  • aged 40 or over and the immediate relation of a glaucoma sufferer”,or
  • in receipt of specific benefits (income support, income based Jobseeker’s Allowance, family credit or disability working allowance), or

  • eligible under the low income scheme, or

  • war/MOD pensioners where sight tests are necessitated by their pensionable disability” or
  • people with glasses with at least one complex lens.’

In addition, those patients who need eye tests to manage an eye condition are entitled to have them carried out free of charge. Such tests can be carried out in the hospital or on referral to a retail optician. However simply receiving advice from a hospital to seek a sight test will not secure a free test unless the individual is ordinarily exempt. Any ‘hospital’ sight test must be for the management of an optical condition”.

Contact Lenses / Glasses

Recovering the total cost of NHS optical appliances including glasses and contact lenses supplied on the NHS is permitted under section 77 in conjunction with schedule 12. Only an ‘eligible person’ in receipt of a valid voucher is entitled to receive optical appliances without charge or at a reduced rate. Section 8 (2) of the NHS (Optical Charges and Payment) Regulations 1997 provides:

‘An eligible person is a person who at the time of the supply of the optical appliance is any of the following 

  1. a child
  2. a person under the age of 19 years and receiving qualifying full-time education…

  3. a person whose resources are treated…as being less than his requirements’….

Additionally, under these regulations, individuals who require particularly strong lens or complex lens prescriptions are classed as eligible people.

The redemption value of the voucher is supposed to reflect the minimum cost of supplying the appliance that meets the patient’s clinical need. However, in practice it rarely meets the actual cost of spectacles, and in recent years the difference has been growing, with the result that people with vouchers have to pay increasing amounts towards the price of their optical appliances. The National Association of Citizen’s Advice Bureaux has suggested that opticians providing NHS treatment should be required to sell glasses within the value of NHS vouchers. Problems can also be caused by the limited range of frames and lenses available at the lower end of the cost spectrum. Uncomfortable or unattractive frames may deter individuals – especially children and young adults – from wearing their lenses. Opticians themselves have concerns that failure to wear prescribed lenses can cause deterioration in some optical and medical conditions. Those who want to buy more expensive lenses or frames simply pay the difference between the desired appliance and the face value of the voucher.

No assistance is available towards the purchase price of contact lens fluid, which makes contact lenses an expensive option for most eligible individuals. Individuals who use contact lenses but who are unable to afford the correct cleaning solutions are at increased risk of infections. ACHCEW considers that the unavailability of cleaning fluids on the NHS is a false economy if it results in increased NHS expenditure on treating eye infections.

Repair and Replacement

Assistance towards the costs of repair or replacement resulting from loss or damage is available only in the cases of appliances dispensed to a child. Other eligible individuals are only entitled to help with the cost of repair where the repair is required as a result of an illness. The Health Authority will first make ‘such enquiries as it considers relevant’ to ascertain the true cause of the damage. The cost of making such enquiries is almost certainly greater than the cost of repairing or replacing the appliance. Eligibility for help with the repair or replacement of optical appliances is particularly restricted, as health authorities are reluctant to fund repairs to appliances supplied under the voucher scheme.

The Medicines Act 1968 divides drugs into three categories, prescription only medicines, medicines that can only be dispensed by a pharmacist and general list medicines. Schedule 10 of the National Health Service (General Medical Services) Regulations 1992 stipulates which products are not available on prescription to patients. This list is regularly updated. Any item not available on prescription must be paid for over the counter at its full retail price.

The NHS (Charges for Drugs and Appliances) Regulations 2000 permit charges for the supply of pharmaceutical products supplied on prescription by chemists, doctors, health authorities, NHS trusts and Primary Care Trusts. The provisions governing the supply of drugs and medicines for each service provider are primarily the same. However, there are different restrictions and powers governing supplies by them.

The Regulations (as amended) state that a chemist, doctor, health authority or trust that provides pharmaceutical services to a patient shall make and recover a fee from each patient’. Each item of the prescription attracts the charge. Two separate fees may be payable where an appliance and a drug is prescribed, for example asthma drug plus inhaler or where a combination pack of drugs designed to make dosage easier is used. In resolution 4 at its AGM in 2000 ACHCEW criticised the inequality whereby

“a pre-packaged course (which) contains two separate types of tablet attracts two charges whereas a compound tablet attracts only one charge. We call upon the Government to review the exemptions urgently in order to make equity paramount.”

Regulation 2(3) limits these separate charges. Quantities of the same drug supplied in more than one container, multiple provision of the same appliance or parts of an appliance which are ordered on

Supply by Chemists

Regulation 3 deals with the supply of drugs and appliances by chemists.

Oxygen concentrators were originally supplied under these Regulations. A monthly fee, in line with prescription charges, was levied. This service was altered in 1992 when the provision of oxygen concentrators was removed from the charging regime. Oxygen concentrators are now supplied by commercial oxygen companies under contract with health service providers. Contractual terms often include charges for maintenance insurance, installation and monthly operational costs. The health service provider should meet these charges. In correspondence with ACHCEW in 1999, the NHS Executive confirmed that the provision of oxygen concentrators should be free of charge to all NHS patients.

Supply by Doctors

Doctors who provide pharmaceutical services may not charge for drugs or appliances required for immediate treatment or administered to the patient personally by the doctor. Injections and vaccinations available on the NHS attract no charge.

Doctors must also provide free pharmaceutical services to individuals resident in schools or institutions under certain circumstances. This provision is perhaps less significant than might be thought since many individuals resident in schools or other institutions will be already exempt from NHS charges on other grounds e.g. – age, income or medical disorder.

Supply by Health Authorities, Trusts and Primary Care Trusts

No charge can be recovered for the supply of drugs, medicines and appliances to a patient resident in hospital. However outpatients do pay the prescription charge. The precise moment of discharge thus assumes some importance: patients may find that they are given a prescription on leaving for items which might just as well have been provided and paid for by the hospital.

NHS bodies, providing a hospital outpatient service, may prescribe specific appliances that are not available from other pharmaceutical service providers. Schedule 1 of the NHS Regulation 1989 (as amended) states that charges may be recovered for the supply of surgical brassieres, abdominal supports, spinal supports, stock modacrylic wigs, partial human hair wigs, and full bespoke human hair wigs.

The level of charges for these appliances has been increased regularly since their introduction and prescription prices for wigs and fabric supports are surprisingly high. Even charges for surgical brassieres are at the top end of the price range for high street lingerie. Support tights, ordinarily unavailable on the NHS, may be supplied, where necessary, by a hospital. These too attract charges.

Exemptions from Prescription Charges

Some patients and some courses of treatment are not chargeable. Schedule 12 of the NHS Act 1977 details the circumstances where no charge may be recovered for the supply of pharmaceutical services and provides:

`No charge shall be made….in relation to the supply of drugs medicines and appliances in respect of;

  1. the supply of any drugs, medicine or appliance for a patient who is for the time being resident in hospital, or

  2. the supply of any drug or medicine for the treatment of venereal disease, or

  3. the supply of any appliance [other than those contraceptive in nature] for a person who is under 16 years of age or under 19 year of age and receiving full time qualifying education, or
  4. the replacement or repair of any appliance in consequence of a defect in the appliance as supplied.’

Regulation 6 of the NHS (Charges for Drugs and Appliances) Regulations 1989 (as amended) expands these exemptions to include people over 60 years of age; expectant mothers; women who have given birth in the last 12 months; those on income support, working family’s tax credit, or disability working allowance; war pensioners and individuals suffering from a variety of specified diseases.

The list of medical conditions, which entitles sufferers to free pharmaceutical services is very restricted. Those suffering from epilepsy and in need of continuous anti-convulsive therapy are exempt but individuals suffering from schizophrenia or paranoia are not. Similarly, individuals with insulin dependent diabetes are exempt but asthma sufferers must purchase their inhaler on prescription. Individuals who are HIV positive, exhibit a marked increase in the occurrence of medical conditions requiring treatment with pharmaceutical products, but neither AIDS nor HIV are included on the list of medical conditions that warrant exemption. The reasoning behind such anomalies is unclear, although generally those conditions warranting exemption tend to be less common and carry less social stigma than those where prescription charges apply. ACHCEW considers that the current restrictions on the types of illness which entitle sufferers to free prescriptions creates inequality between individuals with long term illnesses, and passed a resolution to this effect at its AGM in 2000.

Exemptions from charges for wigs, support tights, surgical bras and abdominal or spinal supports are only available to individuals who are under 16; under 19 and in full time education; in receipt of benefits or in possession of a valid exemption certificate detailing the supply of the specific appliance. Expectant mothers, new mothers, and those over 60 are not entitled to the same benefits.

Pre-payment certificates

Individuals who have long-term prescription needs, but who are ineligible for exemption from charges may incur. considerable cost over the course of their treatment. This is particularly problematic for patients using combination drug therapies who have to meet the charge for each item on their prescriptions.

In an attempt to spread the burden of prescription charges, a pre-payment scheme was introduced in the NHS (Charges for Drugs and Appliances) Regulations 1989. Under this scheme, individuals pay in advance and obtain a pre-payment certificate. Thereafter they do not have to pay prescription charges for the duration of the certificate. Certificates are available for four-month and twelve-month periods.

Medical / Surgical Services

Chargeable Equipment

Only equipment specified in the NHS (Charges for Drugs and Appliances) Regulations 2000 or the NHS Drugs Tariffs may be charged for. At present charges above the prescription rate can be made for elastic tights, spinal supports, abdominal supports and wigs. Further appliances available on the NHS but not listed in the drugs tariff must be supplied free of charge.

This includes orthopaedic equipment and prosthetic limbs. Many appliances, such as walking sticks, frames, and crutches are provided free on loan for the duration of the clinical need.

Wheelchairs

Wheelchairs are loaned to patients for as long as they are required. The NHS pays for maintenance and repair to be carried out by approved repairers. More expensive wheelchairs can be made available through a voucher scheme, which allows the patient to pay the difference between a NHS chair and their preferred model. The NHS (Wheelchair) Regulations 1996 extends this provision by authorising individuals to be charged for the additional costs which may be incurred in maintaining and repairing non-standard wheelchairs.

Deposits

Many hospitals operate schemes that require a deposit for the supply of walking aids and wheelchairs, on the basis that charges should reduce the number of appliances which become lost or damaged. However, such charges by way of a deposit are almost certainly unlawful. The NHS Executive, referring to a ‘deposit scheme’ proposed by Hastings and Rother NHS Trust, stated:

`if the item is medically required, it must be supplied without charge under the NHS, and such a charge would include the taking of a deposit.’

In subsequent communications the Department appears to have retreated slightly from this position. In a letter of the 30 April 1999 Mr N Turnbull, of the NHS Executive, stated that `NHS Trusts are independent and it is up to them to be satisfied of the legality of any arrangements they may have for providing walking aids on a temporary basis to people who are no longer hospital patients’

While ACHCEW recognises the need to reduce equipment damage and loss, hospitals can always seek compensation for this through the courts. The imposition of deposits is a charge and in many cases will affect the accessibility of care. Any charge not authorised by legislation is unlawful. Audiological Services

As noted above, charges may only be applied if statute and regulations allow. No regulations have been made to provide for charges for the provision of hearing aids supplied by the NHS. These must be supplied, repaired and maintained free of charge.

Unlike the schemes that govern provision of wheelchairs and dental appliances, there is no scope for the supply of superior hearing aids on payment of an extra amount by the patient. The NHS only provides standard models sufficient to meet the clinical needs of the patient. Those seeking more expensive models, for example models which are concealed within the ear, are obliged obtain them from private supplies and pay the full market price.

It is important that patients know about their right to free audiological equipment. Hospital NHS audiological services are often provided by private suppliers. Additionally, hospitals often rent space to private suppliers on their premises. Confusion may arise if patients are unable to distinguish between these services or are persuaded that a non-NHS hearing aid is needed to meet their clinical requirements.Appliances

Section 82 of the NHS Act 1977 allows regulations to be introduced permitting the NHS to recover the cost of repairing or replacing NHS appliances where the loss or damage arises from the patients’ carelessness.

Regulation 6 of the NHS (Charges for Appliances) Regulations 1974 provides for the recovery of costs incurred in repairing appliances damaged by the patient. This is a broad provision incorporating the cost of repairs to any appliance provided by the Secretary of State.

Under these regulations, any request for repair or replacement of a NHS appliance can be referred to the relevant Health Authority for investigation. If enquiries determine that the patient caused the loss or damage, a charge may be recovered.

Road Traffic Accidents

The Road Traffic Act 1988 permits NHS to levy charges for the treatment of road traffic accident victims. Procedures for recovering these charges were changed and simplified by the Road Traffic Accidents NHS Charges Act 1999. Previously hospitals claimed from insurance companies for the cost of treating people injured in road accidents, but the complicated administrative arrangements involved often resulted in the money not being collected. The new Act transferred responsibility for collection to the Compensation Recovery Unit acting on behalf of the Secretary of State. This unit redirects the money raised to the hospital where the accident victim was treated.

Insurance companies, not patients, are liable to pay these charges. When an accident victim makes a successful claim for compensation following an accident, the court will also require the insurer paying compensation to pay for the victim’s NHS care. Where the accident was caused by an uninsured or unidentifiable driver, the Motor Insurers’ Bureau becomes liable for these charges. The patient will have little or no role in this process.

Charges for Overseas Visitors

Regulation 2 of The NHS (Charges for Overseas Visitors) Regulations 1989 provides for charges to be levied on those overseas visitors who receive NHS medical care. Regulation 3 confers exemptions on various types of service, while regulations 4-7 allow exemptions for various types of visitor.

No charges will be recovered from any overseas visitor for:

  • Treatment at an accident and emergency department.
  • Treatment for a sexually transmitted disease (excluding HIV).
  • Diagnostic testing and associated counselling for HIV.
  • Treating an individual detained under the Mental Health Act 1983.
  • Treatment for a mental condition included in a probation order by a court.

All other NHS services (which do not attract charges to UK citizens) are provided without charge to any person:

  • Who has been resident in the UK for 12 months prior to treatment.
  • Who has come to the UK to take up employment or permanent residence.
  • Who is a national (and in some cases a resident) of the European Economic Areas or of countries with whom the UK has a reciprocal agreement, and where the need for treatment arose during the visit, (and in some cases where a person has been specifically referred for treatment).

  • Who is in the UK as a refugee, a prisoner, a diplomat or NATO service personnel.

 

Miscellaneous Charges

NHS Trusts are permitted to generate income so long as it does not interfere with their main function of providing health services to NHS patients. Charges for car parking, retail outlets, catering, and for the provision of occupational health services to local employers all fall into this category.

GPs, under their service contracts, are allowed to charge for a variety of non-NHS services. These include holiday vaccinations and private consultations. The BMA publishes recommended fees for these services but doctors are under no obligation to follow these scales. Similarly, hospitals often recover charges for the provision of side rooms and leisure facilities such as televisions.

However, attempts by GPs to levy charges for visits to patients in private nursing homes and suggestions made by ambulance trusts that they should be able to charge patients for non urgent transport, are not permissible under current legislation.

Sale of Goods and Services Legislation

The Sale of Goods Act 1979 and the Supply of Goods and Services Act 1982 are pieces of consumer protection legislation. They give consumers rights, for instance to claim damages for deficient goods and services. If patients are required to pay charges for NHS services, arguably they are consumers and should be entitled to the protection these laws afford. However, in the case of Pfizer v Minister of HeaIth (1965), it was held that services provided by health authorities under the authority of the Secretary of State are exempt from the provisions of Acts of Parliament unless those Acts specifically state that they apply to the Crown. Recent changes to the doctrine of crown immunity, the growing emphasis on the patient as consumer, and the decentralisation of the health service could lead a court today to take a different view.

Conclusion

The regulations governing charges are diffuse and difficult to understand. The range of charging regimes that apply confuses patients and health professionals alike.

The current government has committed itself to

“Undertake the biggest assault our country has ever seen on health disadvantage… to tackle health inequalities by improving the health of our nation overall and deliberately and determinedly raise the health of the poorest fastest

Yet apart from the welcome restoration of free sight tests for the over 60s, the only significant initiative to date undertaken by the government in relation to tackling the injustice of NHS charges has been to introduce a tougher sanctions regime for individuals found to have wrongly received free NHS treatment.

As an urgent first step the government needs to:

  • Remove eye tests and dental check-ups from the charging regime.

  • Significantly reduce prescription and dental charges.

  • Redesign exemption criteria and voucher schemes to reduce the hardship felt by those on long term medication.

While charging persists, action must be taken to simplify and make transparent the confusing mishmash of applicable rules:

  • Decisions about NHS charges should be brought into the public arena.
  • Charging policies must be firmly regulated at a national level to avoid geographical variations.
  • A major consolidation of the legislation must be carried out.

  • Patients should be told well in advance what charges can be levied and how much each treatment will be.

  • The inconsistencies in the exemption criteria need to be addressed to overcome the inequity whereby certain illnesses warrant free prescriptions while others do not, or certain ways of packaging treatments results in several prescription charges rather than one.

None of this would completely remedy the problems identified in this report. Charges markedly reduce take up by patients on low incomes and those who suffer long-term illness, and they undermine preventative public health. ACHCEW remains committed to the abolition of charging and the restoration of free universal health care.

 

 

Bibliography

ACHCEW [1996] NHS Charges — Do They Matter? Health Perspectives April 1996

DoH Publication [1998]. Advisors Guide to Help with Health Costs. HC13

DoH Publication [1996]. Are You Entitled to Help with Health Costs? HC11

NACAB [2001] Unhealthy Charges

Public Policy Research Unit [2000]. Thinking the Unthinkable Health Matters

NHS Executive [1999] Charges for Drugs, Appliances, Wigs and Fabric Supports. HSC 1999/063

NHS Executive [1998] Charges for Drugs, Appliances, Wigs and Fabric Supports. HSC 1998/16

NHS executive [1999] General Ophthalmic Services — Increase to the NHS Sight Test Fee for Ophthalmic Opticians and Ophthalmic Medical Practitioners. HSC 1999/068

NHS Executive [1999] General Ophthalmic Services — Increases in Spectacle Voucher Values, Changes in Definition. HSC 1999/051

Post Magazine [1998]. Bad Medicine from the NHS. 26 Nov 1998

Post Magazine [1998]. Insurance Industry Faces Battle over Law Reforms. 26 Nov 1998

Janice Robinson [2000] Reforming Long-Term Care finances: a continuing saga in Health Care UK, King’s Fund, Winter 2000

Smith L, Ghalamkari H [1998]. Can Prescription Charges be Justified? Pharmaceutical Journal vol. 260:531-534

Webster C [1988,1996]. The National Health Service. Oxford University Press

Produced by  Antonia Ford, Philip McLeish and Marion Chester  for the ASSOCIATION OF COMMUNITY HEALTH COUNCILS FOR ENGLAND & WALES

February 2002

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