Category Archives: NHS history

Fabian Tract no 160

THE final aim of Socialism includes the socialization of the national wealth. But before coming to close quarters with this great problem we have to recognize that a large amount of spade work, of a nature less dazzling, perhaps, than direct Socialist propaganda, but not less necessary, must take the shape of organiz­ing for social purposes those services called the professions, which contain a large proportion of the intellectual and trained members of the community, by whose efforts, even though hitherto only to a small degree secured for public ends, the cause of social reform has been so consistently helped forward. It is certain that long before the democracy is ready to undertake its widest responsi­bilities the educational profession will have to be organized in its service, and the nationalization of the medical service should be considered a prior step to that of the great routine industries. Working for Socialism along these lines we have the advantage of securing the sympathy and active help of a larger section of the population than any mere industrial propaganda would bring to our aid. The provision of good secondary schools by the County Council, for instance, has begun already to bring home to the poorer middle classes the economy and efficiency of State action. The application of the principles of Socialism to the profession of medicine would be another powerful demonstration of the sanity of our ideals to working and middle classes alike, and would put into the hands of the Socialists the most powerful weapon they could possess. There exists in rela­tion to this branch of Socialist effort an abundance of those forces which make for a radical transformation of structure and function. There is widespread discontent with the present system, both inside and outside the profession; there is a crying need for economic co­ordination, for collective and individual efficiency; and reforming zeal is likely to be none the less active, because no one will seriously lose by the change, while both the profession and the public welfare will stand to gain.

It may be necessary at the outset to remind the layman that the present system—or want of system—in the medical service is but a temporary phase in its history. There have been three stages in medical progress. First, the mysterious when the practitioner was found in the garb of the medicine man, the druid, and the witch, leading up to the ecclesiastical, which led to a medico-theological sway in Europe throughout the Middle Ages, when the recognized medical work was performed by the monks. The second stage may be described as the commercial or guild system, which developed with the downfall of the monasteries, when the function of the healing art was assumed by the smiths and barbers, as servants of the monks; and later the establishment of apothecaries, surgeons, and physicians, who were organized into guilds, and who sold their ser­vices to those who could pay for them. The growth of science combined with the natural repugnance towards selling professional service to the person in need, and the beginnings of a State medical service, have ushered in the third stage, which may be called the professional. At all times there has been a mingling of these main features, but the growing feeling that medical service cannot be appraised in terms of cash: the disability on suing for fees volun­tarily accepted by Fellows of the Royal College of Physicians: the suppression of ordinary advertisement: the tacit recognition of only one medical status in the eyes of the law: the gradual rise of a medical civil service: the professional ban placed on the patenting of remedies discovered by the individual: are all signs that the third stage is well upon us. In fact, one of the most distinguished physicians of to-day (Sir R. Douglas Powell) recently declared: “The healing of the sick was never a business. It was in early times attached to religious rites, and more or less sanctified as a divine calling. Hippocrates, St. Luke, Christ himself were examples. The monasteries in the Middle Ages were the great, centres of medical treatment: to each or to most of them, were attached infirmaries. The great hospitals —St. Bartholomew’s, St. Thomas’s, Bethlehem—were priories in the twelfth and thirteenth centuries, and were only secularized at the time of the Reformation. The practical result was that any money equivalent for medical services had from all time been more or less of the nature of an offering, an offering to the gods at one time, an offering to the servants of the gods at another, and still offering, honoraria, voluntary offerings rather than exacted payments.”

The best description of the blending of the commercial with the professional man is given us by Thackeray: “Early in the Regency of George the Magnificent there lived in a small town in the heart of England, called Clavering, a gentleman whose name was Pendennis. There were those alive who remembered having seen his name upon a board, which was surmounted by a gilt pestle and mortar, over the door of a very humble little shop in the city of Bath, whence Mr. Pendennis exercised the profession of apothecary and surgeon, and where he not only attended sick gentlemen in their sick rooms and ladies at the most interesting periods of their lives, but would condescend to sell a brown paper plaster to a farmer’s wife across the counter or to vend tooth brushes, hair powder, and ladies’ perfumery.”

At the time here described, and for many years after, there was connected with medicine competition enough to please the most enthusiastic member of the Manchester School. Many corporate bodies had been granted special rights with regard to the conferring of licences to practise medicine—societies of apothecaries, colleges of surgeons and physicians, and several universities in different parts of the kingdom possessed these powers, and the competition for the licentiates’ fees resulted in an alarming reduction of the standard of qualification. There was no reciprocity between the licensing authori­ties, and at the same time no effective authority to put down illegality. Hence there were many spurious diplomas arid licences, and numerous quacks both inside and outside the profession, while, at the same time, an ignorant public possessed no means of distinguishing the good from the bad; qualified men were frequently only persons who had “walked the hospitals” for a few months, and had finally bought a diploma from a body that knew well that if not granted it would be easily purchased elsewhere. But competition reigned also among the qualified, arid the effect of this on not very scientific doctors is described by George Eliot in the persons of the practi­tioners of Milby: “Mr. Pilgrim looked with great tolerance on all shades of religious opinion that did not include a belief in cures by miracle.” “Pratt elegantly referred all diseases to debility, and, with a proper contempt for symptomatic treatment, went to the root of the matter with port wine and bark. Pilgrim was persuaded that the evil principle in the human system was plethora, and he made war against it with cupping, blistering and cathartics.”

This state of chaos continued well into the middle of the nine­teenth century, but was being undermined mainly by two influences: First, the immense advance of science in relation to medical practice, and second, the movement, led on the one hand by Wakley of the Lancet, and on the other by Sir J. Simon, Medical Officer to the Privy Council, which aimed at the establishment of medicine on a State basis. The two forces making for reform may be described as (1) State interference or control, and (2) State organization.

State Interference.

The first great step towards the co-ordination of the medical profession and its control by the State was taken in 1858 by the passing of the Medical Act of that year, followed in 1876 by the Act admitting women to qualification for the register. This measure of 1858 was carried primarily in the interests of the public, although the profession has reaped its reward also. Its main purpose was to enable persons to distinguish between qualified and unqualified practitioners. Mr. S. H. Walpole, the Home Secretary of the time, and the chief supporter of the Bill, stated expressly that it was not intended to prevent the public from consulting whomsoever it wished —whether qualified or unqualified—and that any advantage that might accrue to the profession was quite secondary to the main object of the Bill, viz., the protection of the public from fraud. Under its provisions was created, as an offshoot of the Privy Council, that body which is becoming daily of greater importance in all matters affecting the relations between the medical profession and the public—the General Medical Council: This is a statutory body including representatives of the profession, but principally charged with its regulation and control for purposes of public protection.

At the present: time it is composed of thirty-four members, five representing the Privy Council, five the profession, and twenty-four the educational bodies. It is not even incumbent upon (although generally the practice of) the educational bodies and the Privy Council to select medical men as representatives. The functions of the General Medical Council are as follows: (1) The keeping of a register to enable “qualified men to be distinguished from unqualified; (2) the controlling of medical education and the raising of its standard by preventing down-grade competition between the educational bodies (with this end in view it carries out a systematic and careful inspec­tion of all medical examinations); (3) to act as a professional court of justice and remove from the register the names of those convicted of crime or of “infamous conduct in a professional respect,” such as covering,” canvassing,” the employment of unqualified assistants, etc.; and (4) the drawing up of a pharmacopoeia.

The General Medical Council is the authority which brings the community into touch with the profession, and gives it an enlightened means of control. Its creation is an admission of professional rights, it is true; but much more does it lay down the principle that the medical service exists for the public interest, and should be ad­ministered, controlled, and governed with that idea. It is a recog­nition of medicine as a trade union, and also of the need for adequate control by the community of such a powerful organization. By the creation of the General Medical Council we have laid the foundation for that State organization of the medical service which it will be the work of the future to carry out.

Great as was the advance made by the Act of 1858, strengthened later by the Dentists’ Act of 1878, and the Amending Act of 1886, yet all authorities are agreed that the work of co-ordination and organization has only just commenced. There are too many varying examinations which alike qualify for the register, though their value differs widely. There is great overlapping of educational institutions in single areas such as London. There is scandalous underpayment of professional teachers in connection with medical education. Finally, the relation between the charity-supported hospitals, and the medical schools is not clearly defined, and is far from satisfactory. It is not surprising, then, that amendments of the Acts of 1858 to 1886 are contemplated by Bills now before Parliament, promoted by the British Medical and British Dental, Associations, the former of which aims at (1), the reduction of the personnel of the General Medical Council and an addition to its representative character; (2) the institution of one State examination for entrance to the pro­fession, and (3) the legal prohibition of practice, by any but qualified men; while the Dentists’ Bill aims at prohibition of unqualified practice. It, will thus be seen that from the profession, itself there is a widely voiced demand for further State interference, and for a more uniform system; and it is for the public to see that the general interests of society are at the same time carefully safeguarded. In view of the measures relating to medical matters that are likely to come up for solution during the next few. years, it is well to realize that the probity and efficiency of the medical service is of the utmost importance to all classes. Socialism has had most effective support from scientific members of a profession whose whole tendency is towards reform, whose daily study makes for an equalized conception of human nature, and who are taking an increasing interest in Socialist propaganda. The influence of quackery, with its secret remedies, its advertisement, its ignorant audacity, and its intense commercialism, is essentially anti-social; and the widespread use of patent medicines must be regarded as a form of exploitation of the ignorant and weak, as hateful and injurious as that represented by the individual appropriation of rent and interest. The denunciation of the qualified man is no part of Socialist propaganda. He does not necessarily represent the reforming element in society, nor does he enter his profession for propagandist reasons, but, as a rule, he compares very favourably with his fellow citizens in the matter of humanity, enlightenment and sympathy.

State Organization

We have glanced at the chief step which the community has taken towards controlling the profession from without; it remains for us to consider to what degree its organization directly as a State service has already been carried out. In order to make this clearer, let us review the present constitution of the whole profession. There are at present (1911) 40,642 registered practitioners, who may be classified as follows:

London 6,415
Provincial England 17,721
Wales 1,336
Scotland 3,958
Ireland 2,724
Resident Abroad 5,188
The Services 3,300

Few people realize to what a large extent the medical service is already socialized. The Army and Navy and Indian Services account for 3,300 practitioners, excluding a numerous and ever growing Colonial Service. In addition there are the full time public health officers, to the number of about 400 in England and Scotland; the medical staff of the Local Government Board and the Board of Education; the prison surgeons; medical inspectors under the Fac­tory Acts; medical visitors in lunacy; poor law medical officers; the medical staff of the Metropolitan Asylums Board; medical officers of lunatic asylums; and school doctors.

These services represent the growing needs of an organized com­munity; most of them are of recent origin, and all are increasing in numbers from year to year. But they do not represent the whole scope of publicly controlled medical work. A large amount of official duty is also done by practitioners who, to the number of 1,423 in Great Britain, add to their own practice the duties of medical officer of health, the 4,000 poor law doctors, the Post Office medical officers, certifying factory surgeons, medical advisers under the Workmen’s Compensation Act. It will not be denied that the combination of public functions with private practice is viewed with a growing distrust, which will end in forcing more and more of the official work into the hands of the whole time man, a change that would be easily accomplished by means of co-operation between different local government areas, and one which would greatly improve the administration, as it should raise the standard of the officials affected. In any case, a large and growing proportion of medical practitioners is already removed from the sphere of com­petitive practice. This proportion is working as a civil service under such conditions as any Socialist would approve of, nor can it be doubted that the public services compare favorably with any branch of the profession. Their popularity is proved by the great competition there is for such posts as happen to become vacant or are created for fresh necessities. Removed from the petty worries of fee collecting (a kind of tax gathering which is in no way con­nected with medicine, and which to the average medical man is wholly distasteful), there is ample opportunity for scientific work over and above the routine duties; and that such opportunity is taken advantage of, the records of the Local Government Board and the annual reports of the medical officers of health will clearly prove.

State Insurance

There is taking place at the present moment a movement for the. partial nationalization of the medical profession which, according to many, is likely to surpass all the steps that have hitherto been taken in that direction, viz., the Scheme of Compulsory National Insurance against Sickness and Invalidity. If this bill become law, nearly half the medical work of the nation will henceforth be. paid for in part out of public funds administered for that purpose through the agency of the trade unions, the friendly societies, and the Post Office. This will, no doubt, commence in the form of a vast system of well paid club medical work, but as its scope extends to a wider circle of persons and the State continues to buy control through its increasing contributions, it is likely that an ever increasing number of private practitioners, becoming freed from competitive practice, will find the advantages of regular salaries, with emancipation from the many calls to gratuitous work, amply compensate them for the gamble for success which medical practice has too often been in the past. The organization of a majority of medical men in the different localities again, will bring the possibility of arranging for hours of duty, will obviate the scandal of the twenty-four day for the doctor and make for complete organization with ultimate nationalization.

The Private Practitioner

The bulk of medical men, however, are still private practitioners, either consultants or in general practice, and it remains to analyze the conditions under which their work is carried out so that we may find out to what degree Socialist opinions and social development will modify them. The medical student spends his five or six years, at the hospital or medical school, passes his final examination, registers his name, and, if he chooses to be a consultant—for which money as well as brains will be necessary—he gets a series of hospital appointments and bides his time. If he select general practice he buys or starts such a practice in a chosen locality and waits for work. He has been for years devoting himself to scientific study, too much influenced by the approaching examination, it is true, yet largely dis­interested. He now finds himself in a new world: he has to compete for patients with others in the same calling. His work and ways are now appraised by persons who are in no way qualified to discern the best man. The public judge of the qualities they can appreciate, and, needless to say, the prize of practice too often goes to the man whose manner, establishment, social intercourse, religion, amusements, motor-car, etc., most favorably impress his would-be patients. Up to the time of starting, all his work was subject to professional valuation. Now he is thrown on the mercy of public opinion—often the opinion of the very persons whose diseases he is called upon to treat, and from whom he may, or may not, get that mysterious reputation implied in the epithet “clever.”

Whatever competition may do for trade, it has nothing but a thoroughly bad influence on professional work. It often brings rewards to the least worthy; it tends to drive down fees below a level compatible with efficiency, as is shown by the sixpenny and shilling dispensary practices. It tends to crush out that fraternal feeling that should always exist in such a service as medicine; it undermines that co-operation which is of great importance in practice, both to patient and doctor; and it places an educated man at the mercy of each individual member of an unenlightened public, on whose ailments he is made dependent for his living. There is a further blot on the present chaotic condition of the medical profes­sion, namely, the fact that when the student starts in practice—unless he is one of the favored minority who happens to get a hospital appointment—he surely, if slowly, loses touch with the more methodical and scientific side of his profession, and stands in danger of drifting into a routine manner of looking at things, from which even the occasional opportunity of post-graduate lectures and the excellent medical periodicals cannot save him, if his practice is a small one; while if his clientele grows to fairly large proportions, sheer fatigue, emphasized by the continuous nature of his work and the pressure on his time, acts equally effectively.

In the matter of over-work, all branches of the medical and allied professions are worse off than any other calling, and the results are shown in the high mortality among doctors, ranging above all others, except the three somewhat closely related occupations of wine merchants, innkeepers, and cabdrivers. (Mulhall’s “Dictionary of Statistics,” 4th edition, p. 181, and “Vital Statistics”, by Win. Farr, 1885 edition, p. 401) There is no more useless waste of valuable human life and energy than that which competitive commercialism has attached in the form of day and night work to the practice of medicine, and there is just as good a case for legal interference in this matter as in any of those instances in which Acts of Parliament have regulated the hours of labour. The medical men do not like the arrangement; it is injurious to the public interest in that it may lead to individual disaster just as surely as the over­employment of a signalman or engine-driver may lead to a collision, and yet nothing is done because we regard commercialism as in­evitable.

Other Hardships of the Competitive System

Slowly the evils of competition are revealing themselves to the profession, but there are certain other hardships which are more obvious. The first of these to be noted is the constant tendency on the part of the public to impose on the physician or surgeon in the matter of gratuitous work. A well-known surgeon (J.F. Fuller FRCS) has said: “The well-to-do philanthropist is so moved by the sight of suffering that he is impelled to ask the doctor to cure it gratis.” Practically all hospital appointments (except those under the control of the State) are unpaid, and although the eclat of a position on the staff of a large city hospital is in some ways its own reward, yet there are endless posts held in connection with small provincial hospitals, orphanages, epileptic colonies, etc., etc., which bring to the holder of them neither the reward of education nor any professional distinction, and which are filled without fee by the long-suffering profession. Then, again, there are countless reports and certificates (some of which, such as the death certificates, are matters of com­pulsion), which the doctor is asked to sign, and for which he is unpaid; and there are those who, regarding his calling as a noble one, consider that, it would be demeaned by the settlement of their quarterly or half yearly accounts, which for social reasons it is almost impossible for the creditor to recover in the legal manner. No body of men is more imposed upon in these ways, and if ever a doctor asks for his fee in advance, or refuses to get up at night to attend a case without the assurance that it will be forthcoming, he is regarded by the public almost in the light of a criminal.

Hospital Competition (“Abuse”)

There is another factor that tells heavily against the average medical man, especially in the poor and populous localities, that is, hospital competition—or “abuse,” as it is called. The immense increase in free hospital, of assisted dispensary treatment is making this more and more serious. Although some hospitals—notably the London—are trying to carry out a selective process with regard to their patients’, the temptation for statistical and educational reasons is all in the direction of encouraging them to come. It is hard for a democratically minded doctor to refuse hospital treatment to an interesting case whose income is £5 a week, and take under his care an alcoholic dyspeptic whose average wage is £1. The impossibility of any effective selection of patients according to appearance and wages, is apparent to anyone who thinks. If you put up a barrier of appearance, you exclude the tidy and penurious clerk, and include the skilled artizan, whose comfortable circumstances make him care­less as to his appearance. If, on the other hand, you erect a maximum wage barrier, then you admit a bachelor with twenty-five shillings a week, and exclude a married man with a family of five who earns thirty shillings. The most superficial observer knows, in fact, that there are thousands of the small shopkeeper or poor professional class who need free hospital treatment just as much as those imaginary persons for whom hospitals are intended, and yet who would be excluded as unfit. That this competition, is really serious is shown by the growth in the number of patients annually treated in the London hospitals: These were, according to Sir H. Burdett:

1895 …        …       …        …   1,753,611 patients.

1902 …        …       …        …   2,098,905 patients

The same authority concludes that, in spite of the fact that each visit to the hospital, with the journey and the waiting, took five to six hours, counting the whole population of London, one out of every two persons gets free medical advice, while thirty years ago the figure was one in every four. The same condition, only less acute, holds good in the provinces, as the following table shows:

  • In Portsmouth 1 out of 14 people received free medical relief
  • In Cardiff 1 out of 7.1
  • In Glasgow 1 out of 5.3
  • In Manchester 1 out of 3.5
  • In Liverpool 1 out of 3.4
  • In Birmingham 1 out of 3.2
  • In Brighton 1 out of 3.1
  • In Bristol 1 out of 2.9
  • In Edinburgh 1 out of 2.8
  • In London 1 out of 2.2
  • In Newcastle 1 out of 1.9
  • In Dublin 1 out of 1.3

This means that the proportion of cases to the population is as stated; but one person may be counted as several cases or may attend several, hospitals in the course of a year.

This question is being further complicated by the fact that work­ing men are becoming collective subscribers to hospitals in urban areas, and it is not unreasonable to suppose that they will fall into the same error as members, of the middle class;, in considering that a donation entitles them to free treatment: Whatever may be said with regard to out-patients, there is no doubt whatever that the in­patients. belong to a large extent to a class above the necessitous poor; and one is not surprised that sick members of the middle and lower middle classes should use all their ingenuity to get admitted to a hospital when they cannot; afford the best treatment at home. Nor is this surprising when it is remembered that modern medical treatment implies the use of expensive apparatus, such as those used for the X Rays, for bacteriological diagnosis, etc., as well as all the necessities of modern aseptic surgery. With the growth of hos­pitals there is an increasing opportunity of education for those on the staff, making them a more dangerous: competitive class in the eyes of the majority of their colleagues, while at the same time that efficiency is gained, in the treatment of patients who would normally fall to the share of the poorer practitioners.

Hospital competition as a source of discontent is supplemented by that of the optician, who poaches, in the preserves of the oph­thalmic surgeon; the chemist; who prescribes as well as dispenses remedies, and even does minor surgery; the herbalist and all kinds of quack healers as well as patent medicine vendors, who make the lives of the less fortunate members of the profession a story of respectable penury: Circulated a few weeks ago among the members of the Marylebone Branch of the British Medical Association was a pamphlet, written by one of the victims of this competition. He says, addressing his more fortunate West End brethren: “We do not ‘hunger and thirst’ after your righteousness; our needs are food, clothing, house rent, and wherewithal to pay our taxes, or for our house, or carriage, or motor, or even a new bicycle. This is our ‘economic’ question, to be worked out on the basis of ‘advice and medicine for sixpence,’ ‘a visit for one shilling,’ ‘a labour for ten shillings.’ We cannot afford Westminster or Charterhouse for our sons, but even we struggling doctors must educate our daughters. In short, it is the old schoolboy heading: ‘Edendum est vivere.’ This is our economic need. Change places with us for one week. Come away from your carriages and motor cars, your butlers and retinues of servants, your houses furnished like palaces. Forget, your shooting lodges and fishing lettings and come to ‘poverty, hunger, and dirt,’ where ‘women’s lives are wearing out’ and the men are weaving their shrouds. Come to the factories and the coal mines. Live sandwiched in between a butcher and a pawnbroker, and feel that they both are more independent than you are.”

The only inaccuracy of this picture is the exaggerated idea of financial success, which, according to the writer, Marylebone offers to its professional population, If we are to, believe writers such as the late Sir James Paget and others, we are forced to the conclusion, in the words of a well known surgeon, (Dr. J.F.Fuller) that “in London the position of the young consultant is tragic in the extreme.”

“The Battle of the Clubs.”

There is one other evil resulting from the present circumstances of the medical man that must be noted, because it has caused a very great outcry in the profession, —namely, the sweating of doctors by the working classes organized as friendly societies and burial clubs. Such organizations represent the attempts of the people to obtain collective medical service at a small weekly rate per member. This has represented a new form of collective bargaining. On the one hand a single medical, man, and on the other an organized, ready­made clientele. Under these circumstances, the individual profes­sional man has been powerless to escape overwork and gross under­payment. Tempted by a fixed nucleus of salary, or the threat of seeing a stranger called in to do his work, the unfortunate individual has been driven to accept the most unfavorable terms, and has been at the same time subject to that kind of treatment which the aggrieved always receive at the hands of the aggressor.

Two shillings to five shillings per member per annum is a common sum for the doctor to receive, the average fee for each attendance working out at 10.60d.; in the case of one club a fee of 10d. per member per year was received by the club doctor. Attempts have been made by the doctors to combine against this kind of thing, but, for obvious reasons, with only partial success. When local men have combined successfully a man from a neighboring town has been imported, and in some instances, where this has failed, a sub­stitute has been tempted away from the remoter parts of Ireland. This sweating of medical men and the way they are treated by clubs (trade union and otherwise) is similar, except that it is worse, to blacklegging in industrial trades, and shows that the working classes have still, a good deal to learn in the matter of meting out fair conditions to their employees.

False Remedies.

Of course, remedies for the above-mentioned grievances are being constantly suggested by those who see the evil, or feel the pinch, but most of them are based upon the idea that the present order is from everlasting to everlasting, and often the treatment suggested is of the most, futile and symptomatic kind. The suggestion, for instance, of cutting down hospital attendance, as well as those other remedies mentioned already in connection with “hospital abuse,” dis­play a great ignorance of human nature, as well as a total incapacity to realize the grievances bound up with the general problem in the matter of medical attendance. It need only be said that for thirty years the cry of “hospital abuse” has been heard, and has been accompanied by a steady rise in the number seeking relief from hospitals. Co-operation between the general practitioner and the hospital has been suggested, with equal lack of insight into the problem. Combination among the profession is, from its very economic conditions, only partially possible, and, indeed, under present circumstances, anything like a thorough combination would be a public danger. Other palliatives might be named, but it is well before looking for a remedy, to bear in mind that any solution of the problem, to be satisfactory, must take into consideration the case of the public as well as the profession, and briefly to consider the hardships which result to the lay community from the present individualism in medicine.

Public Grievances

It will be seen at once that the most serious hardships resulting from the present system of medical service fall upon the middle classes. The small tradesman, for instance, when he happens to visit the local hospital, sees a finely equipped machinery for the cure of disease, staffed by the most able and scientific members of the pro­fession offered freely for the treatment of the poor, to which category he knows secretly that he belongs, but dares not acknowledge it for prudential reasons. He sees hospitals endowed and adapted for every purpose of treatment, with polished teak, floors, glazed tile walls, ample cubic space and ventilation, perfect operating theatres, well kept instruments, with a highly skilled and specialized staff’ of physicians, surgeons, ophthalmic surgeons, gynaecologists, dental surgeons, nurses, dispensers and, attendants, all ready and willing to receive the first member of the submerged fifth who happens to con­tract disease or meet with accident. He knows, too, that paupers in the large cities, and—to a greater degree than was the case formerly —throughout the provinces, are getting a care which is almost as good. While he has to call in his medical man, and to be treated (if seriously ill) in a room above his shop, which is, in no way suitable for prolonged treatment, and where wall-paper, carpet, curtains, want of proper ventilation, all make for a prolongation of his misery. If an operation be required he must have the man on the spot to per­form it, or pay a large fee to get a specialist from a neighboring city who knows that everything is against the patient whose only operating theatre is his own bedroom, or whose operating table is the one on which dinner is usually served! If the patient happens to be the bread-winner, he finds the procuring of efficient medical treatment, which implies each year, in place of physic, a growing need for skilled nursing and costly therapeutic appliances, a very costly affair, and that, too, at a time when he can least afford the money. If his illness becomes more serious, even though he cannot afford it, his family spend their last twenty pounds to call in one of the consultants who attended his general servant when she was in the hospital of the neighboring town. He knows, too, that in the matter of the best medical treatment the very rich, who can afford the expensive nursing home and the many appliances necessary for restoring health to the diseased, share these advantages with the poor, and he is apt to ask himself why he should not have his share of the good things. But with all the disadvantages mentioned above, there is another from which the poor patient is often delivered-—he alone does not employ his medical man and hence his treatment is likely to be unbiassed by those little concessions to a client which this relationship of employer and employed so often calls forth. If the poor man is alcoholic, is suffering from the need for occupation, is inclined to excesses of any kind, he is told so more plainly by his hospital doctor than is the aver­age patient in private practice. A further advantage of the hospital patient whether “out” or “in,” consists in the fact that he is treated at a sort of medical exchange, where there is co-operation between a staff numbering among them specialists of all kinds. I have seen two leading London surgeons consulting with two physicians of equal eminence over a poor old woman in a hospital ward. This kind of professional co-operation contrasts singularly with private practice on a competitive basis which always tends to shut the profession into water-tight compartments, and puts beyond the reach of all but the hospital patient that free, unbiassed and many-sided consultation which in serious illness is of so much importance. Only a complete re-organization of the profession will put proper specialist treatment within the reach of the middle-class man, and make his chance of recovery as good as that of the pauper in the State-managed hospital.

There is one further disadvantage from the present system of practice which accrues to the middle-class public: namely, the fact that the power of life and death, the decision as to serious operation, or critical treatment, is too much confined to the judgment of the one—or at most two—medical men which the members of that class can afford to call in. It is high time that the public should appoint in its own interest Inspectors of Surgery, whose duty it would be to give an independent opinion, whenever possible, in cases of serious operations, both as to their advisability for the patient, and as to the competence of the surgeons to carry them out.

Transition

It is clear that a co-ordinated State service of medicine, in its widest aspect, is the only solution that offers itself to the student of sociology as in any way satisfactory, whether from the standpoint of the doctor or the patient. The sociologist has come to realize that that ideal will not be attained by any short cut; much public educa­tion will be required, both of Socialists and non-Socialists; certain departments of professional work will have to grow and others atrophy before the change will be complete. The important thing is to realize the phenomena of transition so that we may effect the change along the line of least resistance.

In this connection it should be our aim to increase the efficiency of the public departments, of medicine. We know that the 1,800 local sanitary authorities of England and Wales, together with the county councils, have among them about 1,500 medical officers of health, and that out of these only 350 (including those of London, the county councils, and county boroughs) are salaried “full-timers,” whilst about 400 are private practitioners to whom the health authority pays a stipend of from £3 to £30 per annum. Further, in Scotland the 313 local authorities have among them about 120 medical officers of health, of whom 40 devote all their time to their duties, whilst about 80 are engaged in private practice and receive salaries varying from £2 2s. to £200. All reformers should work for the appointment of one whole-time medical officer of health at least for each county Council. The larger cities and towns have appointed medical officers, and it is a public duty to see that their tenure of office is secure, and that they have ample qualified assist­ance. Large numbers of small boroughs and urban districts have at present only part-time officers, and these are paid salaries ridic­ulously inadequate. The policy here should be the appointment as opportunity offers of whole-time men, and the pooling of small urban and rural districts so as to make the work important enough and the salaries sufficient for a whole-time public health officer. Preventive medicine is bound to take a more important place in the future, as faith in cures is dwindling, and even the costly sanatoria for consumption are now regarded as doubtful palliatives which restore the consumptive to apparent health, only that he may die more quickly when he returns to his unhealthy occupation or ill-ventilated cottage. The individual demand for curative advice and medicine is likely to be largely replaced by a collective demand for information as to how to suppress or improve the callings and home conditions that kill and maim. Thus the centre of gravity of medi­cine will leave the curative and tend more, towards the side of preventive medicine. It is around the public health service that all the other branches of medicine will tend to group themselves, and this department has been steadily undergoing a change of function since its establishment by the Act of 1875. For twenty-five years it mainly dealt with the environment of the individual—refuse disposal, drainage, disinfection of houses, ventilation, air space, food adultera­tion, and kindred matters; recently the change has been in the direction of personal hygiene. The idea that accumulations of refuse can be injurious is supplemented by the conviction that ver­minous persons may similarly be destructive of social welfare. The public health officer now enters a realm which may be called that of preventive treatment. He draws up placards on the dangers of alcohol, the social risks of the spitting habit; he issues cards of advice for poor mothers as well as pamphlets to consumptives; he is entrusted with the supervision of midwives, whose disinfection may be enforced by him under certain circumstances; he administers the Cleansing of Persons Act,’- and may prescribe a bath for a vermin­ous person; he is commencing the inspection of school children, and has to arrange not only for advice to teachers and parents, but prescribes ointment and other media of treatment; he organizes a staff of health visitors to superintend the newly born, and is not in­frequently head of an infants’ milk depot. It will thus be seen that the medical officer of health is beginning to widen his boundaries, that prevention, in short, needs to be supplemented by a personal attention that is curative as well; in other words, the line of distinc­tion between prevention and cure is tending to disappear.

The strengthening of the departments will be supplemented in another direction by the co-ordination of those State medical ser­vices which at present overlap and frequently are in conflict with one another. Take, for instance, the poor law medical service, which costs £5,000,000 a year and has a staff of 4,000 medical officers. With its restriction to persons proved to be destitute, its tardy application of treatment, with consequent waste of life and health to the nation, its failure to reach a large amount of illness even amongst the destitute themselves, its unconditioned grants of so-called medical relief, which inculcate no healthy habit in the recipients, it is clear that this service must be co-ordinated with public health administration. For it is the business of the latter service to seek out illness, to treat at the earliest possible moment, to remove injurious conditions; to apply specialized treatment, and, above all, to educate the public, with the end of preventing disease at its source. The mere “relief” of the individual must give way to a method of dealing with disease based upon wider social aims. The recommendations in favor of a unified medical service so ably put forward by the Minority of the Poor Law Commissioners, and supported by the responsible medical heads, of the great departments concerned, viz., the Local Government Boards of England and Wales, Scotland, and Ireland, and the Board of Education, mark one great step forward in the direction of a State medical service based on public health principles. In such a unified medical service, or­ganized in suitable districts, the existing medical officers of health, hospital superintendents, school doctors, district medical officers, workhouse and dispensary doctors, medical superintendents of poor law infirmaries, would find their appropriate places under the admin­istrative control of a county medical officer chosen for his experience and knowledge in this direction.

There are many public appointments which, to the advantage of the community, might be filled by medical men. As governors of prisons, for instance, they would generally be more suitable than military men, and their training adapts them for such posts as in­spectors of factories. When it is said that the profession is over­crowded—a statement which is only true of urban areas—it is for­gotten that there is abundant medical work waiting to be done before the community has utilized the energy that is at present being wasted.

The Ultimate Solution

However perfect may be the system of preventive medicine, it will always seem unfair to the average man that the only persons to get the very best treatment of a curative kind, should be the pauper, the lunatic, the criminal, and the millionaire. A growing sense of social justice will demand that the best medical service be placed within the reach of all and that implies a very high degree of excellence on the part of the qualified medical man, with an equal facility on the part of the patient for obtaining the most scientific appliances. Now the only way to put them within the reach of the many is to organize the medical service from the ambulance bearer to the consulting surgeon; and to keep that organization vital it must, in the case of the curative arts at least, be built around a public hospital. Every medical man must be connected with his hospital to the end of his career, i.e., his opportunities for scientific study must be constant. The Army and Navy are recognizing this need in the facilities offered to their officers for intermittent hospital study; and it is one of the fundamental reasons for nationalizing medicine. The maintenance of all hospitals out of Imperial and Local funds, and their management by the community, will be the first step towards educational efficiency in the profession. Under the provisions of the Public Health Act of 1875 ratepayers may provide themselves with hospitals of any kind. They are already supporting fever hospitals, asylums, sanatoria for tuberculous patients, and inebriates’ homes. With these institutions in their hands there are no arguments, left to oppose the abolition of all so-called charity in connection with the treatment of disease. Socialist finance will certainly reduce the number of millionaire donors, but it will regard the charge for hospital accommodation as a most necessary form of national insurance against sickness to impose on the people. If the cost of treatment is heavy at the outset this will only demonstrate more clearly the relative economy of prevention. The change, from charitable to publicly controlled hospitals will at once place medicine on a collectivist basis. The staffs will have to be paid just as the Metropolitan Asylums Board now pays its officers, and the, right of free treatment will determine the ultimate connection of all doctors with the hospitals of their respective districts. The extravagant charges of cruelty and wanton experimentation brought against hospital treatment and so often shown to be groundless on investigation, are, where true, due to the lack of public control and the social status of the patient. Both of these wrongs are characteristic of all present social institutions, and it is our duty to remedy them. By this, or some similar method of organization, we should not only remedy those evils of private practice which have already been referred to, but also obviate the hopeless waste of time involved in the waiting for a practice. The working hours of the profession could be regulated, and all its mem­bers kept in touch with scientific progress. Skill and capacity could then he made the criteria of success and promotion, while a certain freedom of choice with regard to their medical attendants would at the same time be left to the members of the public.

In a community where the health of the citizens was regarded as of equal importance with its trade statistics, the creation of a Ministry of Health would not long be delayed. This department of the Central Government would be assisted and advised by the General Medical Council, just as the Secretary for War is advised by the Army Council. The Minister of Health would be responsible to Parliament for the following departments: registration of births, diseases, and deaths; meteorology; coroners’ returns; central, and local sanitary and other medical work; adulteration reports; factory supervision and reports; veterinary supervision; prison and police inspection; the oversight: of all public sanitary works. In short, what is needed is a co-ordination of, the health functions, of the Local Government Board and a separation of those of its present activities which are alien to these. With regard to local administra­tion, each county borough or other large and populous district would have its health office, with a principal medical officer of health, having under him the various branches of preventive medicine, such as sanitary inspectors, health visitors, and school inspectors, and the organized hospitals and departments for medicine, surgery, midwifery, ophthalmology, dermatology, dentistry, etc. Each de­partment would have its senior medical officer, with a staff under him. There would be a visiting staff to see patients at their homes, an out-patient department connected with the public hospital for the treatment of minor ailments and accidents, a hospital with wards for the treatment of serious illness, divided according to the class of dis­ease to be treated. Under the same administration should be placed the special hospitals for the insane, the inebriate, the persons suffer­ing from infectious disease, epileptics, etc. These hospitals would continue their work as at present, but with a further degree of co­operation. The social and scientific value of co-ordination between all departments of medicine cannot be overstated, but the prevailing idea underlying all should be prevention. Every opportunity would be given for consultation between the members of the staffs throughout the whole service. At the large central hospitals students would be taught their profession and when qualified to treat disease, would be drafted to those places in need of help.

In each locality the district health office would keep records of disease and of the means employed for its prevention or cure. Such a register of sickness would enable the student for the first time to find out the extent of the incidence of disease, both qualitatively and quantitatively, and the effect of the methods of treatment em­ployed over the largest possible area.

The cost of the State medical service should fall in part on the national Exchequer; and partly on local taxation, in order to encourage efficiency in prevention. The economy of organization, the greatly lessened cost of illness due to the increase in sanitary control, the immense amount saved in the reduced number of working days lost through illness—computed at the present time at £7,500,000 per annum—would make the health tax seem light, and it would be regarded as a profitable form of insurance. The doctor’s bill comes now at the worst time, especially when the head of the family has been ill; then the small tax in time of health would save many an illness from its most painful side. It is true that the efficient treatment of disease would cost more than the present inefficient methods—in the case of the lower middle class, for instance, the provision of skilled nursing assistance, drugs, dressings, and suitable food would be a fresh charge on the community —but it should not be any part of Socialist policy to lessen the expenditure on preventing disease. If all the broken-down members of society, all its mentally defective persons, all those suffering from debility, incipient phthisis, alcoholism, or heart disease were to be properly taken in hand by the comparatively small residue of moderately healthy persons, it would begin to dawn upon us that these evils are largely due to the waste and folly of present-day commercialism. It is voluntary neglect and blindness that makes things as they are tolerable, and compulsory charges for treatment levied socially would effectively counteract neglect,, and would open the eyes of the most blind. From the point of view of the public, it has been argued that the ample and free provision of medical assistance, would, mean an unnecessary demand for drugs and treatment on the part of an increasing number, of people. “The poor,” wrote Sir William Gull, have an idea that disease comes from Providence, and that it must be cured by drugs. Now, if there is any idea that ought to be rooted put it is this”; and the practice of modern medicine is becoming more and more a matter of advice as to methods of living and general regimen. In a word it is becoming educational, and fulfilling the words of Sir John Simon: “In proportion as medicine has become a science, it has ceased to be the mystery of a caste.” The enormous consumption of drugged sweets and patent medicines of all kinds is but a reflection of the impotence of the genuine practitioner to cure disease, whose cause is of daily recurrence, and which a change of environment or habit can alone effectually remedy. The patient seeks advice which the doctor dare not give—it is too Utopian—he receives a drug which fails, and in despair turns to those patient remedies which are advertised to cure all ailments, until finally he falls a victim to some parasitic industry or insanitary home condition.

A New Army Organization

The work of co-ordinating and organizing the medical service is perhaps the most important piece of Army reorganization which awaits the statesman of the twentieth century; for disease is an enemy with which we are daily at war, whose victims number annu­ally five hundred thousand in dead alone, while the wounded are ten times as. numerous. Something has been done by organization; yet while the nation seems so indifferent to the story told by the death rates of adults and infants, and only deigns to register a few of the ailments that affect its members, but little can be expected. It is the duty of the Socialist to teach people to think, not only imperi­ally, but in communities, and also, perhaps, to feel in communities as well. Our forty thousand doctors need the guiding hand of a states­man who will do for the health of the people what War Ministers desire to do for its external security.

The falseness of the conception of Socialism as a disintegrating force, and as a dividing up of wealth or material advantages, will be again demonstrated by its application of the problems of public health and medicine. From the provision of surgery to that of sewers its tendency is towards a unification and an amalgamation of interests, and wherever this has taken place it has brought, immense social benefit in its train. The water supply, when co-ordinated and municipalized, was no longer the, source of disease and death that it was in the days of individual enterprise, and the provision of an organized body of medical officers of health has already accomplished a steady reduction in the death-rates, as well as in the incidence of disease, —to mention only two instances.

Medicine and Statecraft

The individual practitioners of the country, acting against that class interest which a commercial age has bound up with the mis­fortune of their fellows, have done much to improve the lot of the people; but when the medical man has been at the same time some­thing of a statesman, the results of his work have been enormous. The work of Sir G. Baker and many others in the eighteenth cen­tury was followed by that of Chadwick, Southwood Smith, and Sir J. Simon in the nineteenth. The secret of their success was the fact that they realized that sickness was a burden on the rates which had to be prevented, and they diagnosed a diseased condition of society which lay beneath the individual suffering they saw around them. They realized that there was a social pathology very analogous to that of the individual organism, that health was a national asset, and that the poverty of masses of the population was but a symptom of a disease—a circulatory disease—that might end in social destruc­tion. While the marriage between medicine and statecraft opens up immense possibilities for the development of the race both physically and morally, it is none the less important, now that the work of the statesman is becoming more and more that of the organizer of economic social conditions, that he too, should be imbued with the same spirit that characterizes the physician or surgeon. He will have to apply or administer remedies distasteful to the sufferer; to perform operations upon a living society, such as the removal of vested interests and social abuses, which have become closely bound to the life of the people; and in doing this it will be well for him to avoid unnecessary pain, using to this end such anaes­thetics as compensation and the time limit in his operations for nationalizing health. But the statesman as physician will also realize where and in what degree society is undeveloped, and he will constantly aim at the building up of industries and professions into orderly and organized service. The complete socialization of medical practice will at once raise it from the commercial level to which the modern world has brought it to the height of a profession whose powers for usefulness will be fuller and wider than ever before, so making it one of the greatest forces in the emancipation of humanity from the horrors of modern competitive industrialism.

 

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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

3 Comments

Healthcare before the NHS

Jeannie Duckworth, Austin Macauley  ISBN 978-1784558147  £7.99

The establishment of the NHS in 1948 coincided with the epidemiological transition, something most have now forgotten and which this book reminds us of.  Death from infectious disease, for which there was very little effective treatment available even if you could pay, was common. Children of all social classes commonly died in infancy and mothers in childbirth.  Richer families had better prospects of survival, but not much.  Epidemic illness swept through the population repeatedly.

The limited health service established by the 1911 National Insurance Act only extended to workers, not to their families, and it did not include hospital treatment. Duckworth’s book gives a helpful explanation of such medical provision as was available, but it concentrates on the most significant health problems – childbirth, infected milk, malnutrition, rickets, diptheria and other fevers, polio, and tuberculosis.

There are a very interesting chapters on what are now called special schools, and the amazing open air schools for delicate children, which took place literally in the open air – in parks, mostly.  There were 96 open air day schools in 1937 and 53 open air residential schools.  Lessons sometimes had to be abandoned because of blizzards.

 

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