Blog

  • Categories
  • Category Archives: NHS history

    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.

    1 Comment

    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).

    Tagged | 1 Comment

     

    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.

     

    Tagged | Comments Off on Health and Heartbreak

    The National Health Service, we have been told, is the closest thing we now have to a religion in Britain. Yet we are also acutely aware that this is an institution whose very future is now regularly in question. Through our new People’s History of the NHS website, and with the help of the public, we are hoping to better understand what the NHS has meant to the British people from its opening in 1948 up to its forthcoming 70th anniversary in 2018. Such a history is of obvious importance in relation to current challenges faced by the NHS. Those contributing to this history will have strong feelings on this. However we also need to remain open minded about what we will discover through a People’s History of the NHS. We appreciate the power of certain assumptions about the meaning of the NHS, but we also know that the history of meaning, belief, and experience has yet to be fully researched. Without this history those assumptions rest on fragile ground. Uncovering the People’s History of the NHS may confirm some of our assumptions, but it may also unearth surprises.

    With the support of the WellcomeTrust, a team of historians at the University of Warwick will coordinate and facilitate the People’s History website. The website aims to reach out to anyone and everyone, whether this is just to read about its findings, or to contribute views, memories, and historical materials. The website will be the home for a truly collaborative history, a place for debate, and a venue for fresh thinking about what the NHS has meant.

    The NHS has always been a site for campaigning interests, an institution around which issues of access and equality, choice, community care and accountability, amongst others, have been debated. As a campaigning group the Socialist Health Association has long been active in campaigns against NHS charges, lack of patient choice, inequality and more recently around achieving a Better NHS and Keeping the NHS Public. These issues, and the place of campaigning groups within the history of the NHS, are important in our examination of the meaning of the NHS in wider British cultural life.

    Pages from the first leaflet introducing NHS to British Public in 1948.

    We invite your members – doctors, nurses, therapists, dentists, managers, pharmacists, academics, scientists and patients both inside and outside the NHS – to tell us their ‘NHS stories’ on our website. Here members of the public can sign up to become part of our extended research team. The website will provide details of events around the country that will bring people and communities together to discuss their histories of the NHS. The MyNHS members’ section will also enable members of the public to submit their own stories, suggest topics for research, and respond to regular calls for information and memories on particular issues.

    We will use your memories, stories and opinions to contribute to a People’s Encylopaedia of the NHS. This will examine the history of meaning through an expanding series of encyclopaedia entries. Some of the headings will no doubt be obvious, but others will offer new perspectives. The entries will touch on issues often missing from the standard histories of politics and policy, triggering memories, raising new historical questions, and crucially acting as a catalyst for a new history of experience, meaning and belief. The aim is to encourage reflection, but also at times to surprise, amuse, and provoke.

    We will also use your memories, and any photographs of objects that you may send us – campaigning flyers, leaflets, cartoons – to create a Virtual Museum of the NHS. Given its place in the national psyche, it is rather extraordinary that there is no museum of the NHS, and our website will host the first one. Arranged in a series of themed Galleries, which will be regularly opened over the course of the project, the Virtual Museum will look to the cooperation of the public in helping to unearth a material and visual culture of the NHS that is fast in danger of being lost.

    We feel that our ‘People’s History’ is of obvious importance in relation to current challenges faced by the NHS. Those contributing to this history will have strong feelings regarding this. However we also need to remain open-minded about what we will discover through a People’s History of the NHS. We appreciate the power of certain assumptions about the meaning of the NHS, but we also know that the history of meaning, belief, and experience has yet to be fully researched. Without this history those assumptions rest on fragile ground. Uncovering the People’s History of the NHS may confirm some of these assumptions, but it may also unearth surprises. We cannot write this history ourselves, and so invite you to tell us why the NHS matters to you; how you feel that this institution has changed over time; and anything else besides!

    We hope that members of the Socialist Health Association, as a campaigning group, can contribute important perspectives on collective action aimed at creating an integrated healthcare system. We hope to encourage you to contribute your perspectives, beliefs and memories on the NHS to the People’s History website. There are lots of areas of crossover between your collection of materials and our historical findings. From issues around choice, primary care and prescription charges to obesity and exercise, food policy and social policy, we feel the contributions of the Socialist Health Association would both complement and enhance our historical understanding of the place of the NHS in British society.

    You can visit the website at: http://peopleshistorynhs.org/

    1 Comment

    It never happened in the way we think it happened

    Every 14 July, France commemorates the storming of the Bastille, which kick-started the French Revolution. ‘Bastille Day’ is not just a bank holiday. It is part of France’s national story, the great founding myth of French Republicanism. It is a powerful story of ordinary people rising up and overthrowing an oppressive elite.

    But it is not a true story. The history that is ‘remembered’ on Bastille Day is only very loosely based on actual events. The historical storming of the Bastille was pointless (the building was almost empty at the time), and the French revolution ended in well-known failure.

    And yet, if a historian pointed this out on Bastille Day, they would be rightfully dismissed as a pedant and a bore. Bastille Day is a founding myth, so judging it by how historically accurate it is would completely miss the point. The point of a founding myth is not to understand what happened in the past, but to foster a ‘team spirit’ here and now. It is irrelevant whether it is a true story, as long it is a shared story, which helps to create a group identity.

    In the UK, it is the National Health Service which has acquired features of a founding myth. It is a story of ordinary people getting together, putting their differences aside, and deciding to organise healthcare collectively. A nation rose above itself, and created a healthcare system run by the people, for the people. As columnist Owen Jones puts it:

    “The welfare state, the NHS, workers’ rights: these were the culmination of generations of struggle, not least by a labour movement […] set up […] to give working people a voice.”

    RAF veteran Harry Leslie Smith even became a minor political celebrity by recounting his version of the NHS founding story at a party conference:

    “It was an uncivilised time [before the NHS] because public healthcare didn’t exist. Back then, hospitals, doctors and medicine were for the privileged few. Because they were run by profit […] Sadly, rampant poverty, and no healthcare, were the norm for the Britain of my youth. That injustice galvanised my generation, to become, after the Second World War, the tide that raised all boats. […] Election Day 1945 was one of the proudest days of my life. […] I voted […] for the creation of the NHS”.

    It is a powerful story that arouses strong feelings. But like the popular version of Bastille Day, it is also almost completely untrue. The creation of the NHS had nothing to do with pressure ‘from below’. The health service was, at least initially, a brainchild of social elites, not a product of ‘People Power’. The general public never demanded a government takeover of healthcare.

    This is well documented in a paper in the English Historical Review, entitled “Did We Really Want a National Health Service? Hospitals, Patients and Public Opinions before 1948”, which reviews contemporary survey evidence. To quote from a contemporary summary of various surveys:

    “[T]he evidence before us seems to indicate a fairly large amount of resistance to State interference in the field of medicine […] roughly half the population was opposed to any major change on the health front, a quarter disinterested and a quarter in favour”.

    The author of the paper concludes:

    “[I]t is clear that little evidence exists to support those seeking to claim an inclusive popular mandate for radical reform as a justification for implementing contentious policy”.

    A paper in Studies in American Political Development, which examines the political factors behind the emergence of publicly funded healthcare systems in different countries, also finds:

    “the overwhelming evidence is that these early programs were promulgated by government elites well in advance of public demands”.

    It is equally a myth that the NHS opened up the benefits of modern medicine to everybody, while under the preceding system only the rich had access to healthcare. Of course there were substantial improvements in health after the creation of the NHS – but there were also substantial improvements in health before the creation of the NHS. In long-term time series of population health data, the impact of the introduction of the NHS is not discernible. Pre-NHS trends and patterns, positive and negative ones, mostly continued.

    Does any of this matter? People love the NHS today, so who cares about ancient history?

    Unfortunately, there is a massive difference between the French and the British founding myth. Bastille Day refers to an abstract event in the distant past; the way we interpret it today has no tangible impact on contemporary politics. There is therefore no reason why people in France should not remember this event in an idealised way.

    The NHS, in contrast, is not just a founding myth. It is also an actual healthcare system that treats actual people, here and now. There is nothing wrong with sacralising a historic event, but there are big problems with sacralising a health system, especially if it means that even well-founded criticism is treated as heresy (or in the best case, misrepresented as an attack on individual doctors and nurses).

    And it is about time for a bit more honesty about the NHS’s shortcomings. As I show in my new IEA Discussion Paper ‘Diagnosis: Overrated’, the NHS is falling behind comparable health systems in a lot of respects, and this is about more than just a lack of money (although that is a factor). The NHS derives much of its sacrosanct status from its founding myth story. If we want a more honest debate about the future of the health service, shedding some light on its mythical past is not such a bad way to start.

    This was first published on the Institute of Economic Affairs blog.

    Tagged | 9 Comments

    Yesterday, Lord Neil Kinnock unveiled a blue plaque commemorating Nye Bevan and Jennie Lee on their London home.

    The blue plaque

    It was 10 years after I first wrote an application to English Heritage asking them to consider one. And it was Jennie Lee’s birthday.

    Pulling the chord, Neil praised the lion and lioness of Labour politics in front of a crowd of MPs, Lords, journalists and members.

    I was asked to say a few words about why I had made the application as an enthusiastic 16 year old…

    At 16, I had contracted meningitis the week before my GCSEs. I was admitted to St George’s Hospital in Tooting.

    I lay in a hospital bed, for weeks on end, receiving treatment money quite literally couldn’t buy and care from nurses as loving and attentive as if I was one of their own.

    First class care, without having to wait and worry about a first class bill at the end of it.

    My family at home were free to worry only about me – not about whether they could fund my healthcare or keep our home.

    So when I was discharged I looked into the history of how this wonderful service came to be… and it led me to the inhabitant of the house now adorned with a blue plaque.

    The son of a miner from Tredegar, South Wales, who made Britain the envy of the world.

    But it also led me to the Labour Party.

    Because one man – even with the strength of will Nye had – couldn’t deliver a National Health Service, saving millions from the fear of falling ill, alone.

    It needed a Labour government.

    We have an NHS and we have the Open University – a wonderful achievement of Jennie Lee’s – because of a crucial combination of principle and pragmatism.

    A combination Bevan was famous for.

    Yes, he had the highest ideals – a vision for a socialist model of healthcare – but he also knew that to deliver it, Labour needed to win over the whole country.

    So my hope for this blue plaque, unlike others, is that it is not a relic of Labour’s glorious past – but instead a reminder – to all those who walk past it and share our values – of what our future could hold.

    Tagged , | 1 Comment

    Nye Bevan’s creation of the British NHS in 1948 has to be one of the greatest achievements by any single politician. The list of formidable opponents he had to take on is impressive, but he prevailed.

    At its creation he famously warned that “The NHS will last as long as there are folk left with the faith to fight for it”.  Few compromises were made , but as early as 1951 he had already resigned over the introduction of dental and spectacle charges.

    In 1952 he produced a collection of essays “In Place of Fear”.  His warnings 63 years ago are as relevant today.

    Ironically those opposed to the NHS have taken Bevan’s advice.

    “No political party would survive that tried to destroy it”

    “No government that attempts to destroy the Health Service can hope to command the support of the British people”.

    “They knew the Service was already popular with the people. If the Service could be killed they wouldn’t mind, but they would wish it done more stealthily and in such a fashion that they would not appear to have the responsibility”.

    Perhaps the first organized ideas to get rid of the NHS came from Arthur Seldon , one of Thatcher’s heros, in his 1968 book “After the NHS” published by his creation , the Institute of Economic Affairs.  The plot evolved further in Thatcher’s time and has been carried forward by the Neo-Liberal policies of all British Governments since. Health is a multi-trillion dollar business for exploitation , not a service.

    So , as Bevan stated in 1952…

    “The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health”.

    “Powerful vested interests with profits at stake compel the public authorities to fight a sustained battle against the assumption that the pursuit of individual profit is the best way to serve the general good”

    “A free Health Service is a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst”.

    “a public undertaking of this magnitude is big business. It touches trade and industry at a hundred sensitive points”.

    For these reasons  the NHS needed to be destroyed in a devious secret way, and because profit and big business over-rides Bevan’s higher moral values…..

    “no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means”.

    “Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide”.

    “The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged”.

    Bevan was proud of the…

    “massive contribution the British Health Service makes to the equipment of a civilized society. It has now become a part of the texture of our national life”.

    ….a texture that is being destroyed.

    He predicted , correctly, how the dismantling would happen

    “Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialized medicine”.       

    So we see the attacks on foreigners , NHS staff including doctors and nurses, and a daily menu of anti-NHS stories, where apparently the NHS is to blame for the failure of Government to have sensible public health policies. Lack of staff, poor performance and governance issues are the NHS’s fault , not Government. Even funding is now not the Government’s fault. It appoints a man (Simon Stevens) who says the service needs £x and so the Government pretends to give £x.

    Bevan’s arguments for free treatment for foreign visitors are the same today , and perhaps more persuasive as the Country is much richer now than in the aftermath of the World War.

     “One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous”.

    “The fact is, of course, that visitors to Britain subscribe to the national revenues as soon as they start consuming certain commodities, drink and tobacco for example, and entertainment. They make no direct contribution to the cost of the Health Service any more than does a British citizen.

    However, there are a number of more potent reasons why it would be unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody. Happily, this is one of those occasions when generosity and convenience march together”.

    But this Government are to devise ways of distinguishing “the sheep from the goats” and with help from the right-wing press greatly exaggerate the cost to con the public. They ignore both generosity and convenience in pursuit of their ideology.

    Bevan tackled the elephant in today’s room and that is the conflict of  money interfering with clinical decision making. Well before Blair introduced “Payment by Results” Bevan had this to say…

    “Neither payment by results nor the profit motive are relevant”.

    “In claiming them, capitalism proudly displays medals won in the battles it has lost”.   

    “Danger of abuse in the Health Service is always at the point where private commercialism impinges on the Service; where, for example, the optician is paid for the spectacles he himself prescribes, or the dentist gives an unnecessary filling for which he is paid. Abuse occurs where an attempt is made to marry the incompatible principles of private acquisitiveness with a public service”.

    “They are silent where economies could be made at the expense of profits”.

    And the consulting room is being polluted by rationing , financial spreadsheets and biased clinical decision-making despite Bevan’s warning…

    “The consulting room is inviolable and no sensible person would have it otherwise”.

    Other ways of funding are back on the (secret) agenda. Bevan considered many methods and dismissed all but state funding.

     “Some American friends tried hard to persuade me that one way out of the alleged dilemma of providing free health treatment for people able to afford to pay for it would be to ‘fix an income limit below which treatment would be free while those above, must pay. This makes the worst of all worlds. It still involves proof, with disadvantages I have already described. In addition it is exposed to lying and cheating and all sorts of insidious nepotism.

    And these are the least of its shortcomings. The really objectionable feature is the creation of a two-standard health service, one below and one above the salt. It is merely the old British Poor Law system over again. Even if the service given is the same in both categories there will always be the suspicion in the mind of the patient that it is not so, and this again is not a healthy mental state”.

    But today this is being pushed forward and again with the “help” of some American “friends”

    Breaking up the NHS and “devolution” is happening despite Bevan’s warnings…

     “no local finances should be levied, for this would once more give rise to frontier problems; and the essential unity of the Service would be destroyed”.

    His other great adversary was of course the BMA…

     “But the hardest task for any public representative charged with the duty of making a free Health Service available to the community is overcoming the fears, real and imaginary, of the medical profession”

    “…the propaganda of the British Medical Association, which warned the people at one time that, although they would be paying their contributions, the Health Service would not be there to meet their needs”

    “In dealing with the medical profession it is wise to make a distinction between three main causes of opposition to the establishment of a free National Health Service. There is the opposition which springs from political opinion as such. This is part of the general opposition of Conservative ideas, and it is strong in the medical profession, though the expression of it tends to be supercharged with the emotions borrowed from other fears and ambitions. Second, there is the defence of professional status and material reward. The latter, of course, they share with other pressure groups. Then, thirdly, there is the opposition which springs from the fear that lay interference might affect academic freedom and come between the doctor and his patient”.

    They warned that doctors would be made into civil servants, there would be no free choice of doctor and

    socialized medicine would destroy the privacy of doctor-patient relationship

    “The BMA refused…a graduated system of capitation payments (which) would have discouraged big lists”

    …..a system it eventually accepted. .They claimed the “independence of medicine is at stake”, and voted 9:1 against the Act. It was said this was the “first step, and a big one, towards National Socialism as practiced in Germany”.  The BMA have re-written history and now claim to have been in support of the NHS.

    The Government and Jeremy Hunt in particular would be wise to recognize Bevan’s views on GPs….

     “I have a warm spot for the general practitioner despite his tempestuousness   The family doctor is in many ways the most important person in the Service. He comes into the most immediate and continuous touch with the members of the community. He is also the gateway to all the other branches of the Service”

    And how much is now devoted to administration ?

    The separate expenses of the bodies engaged in the administration of the British National Health Service amount to about 3 per cent of the total sum spent

    It was no more than 4% until the introduction of the market and now the commercialization of the NHS has increased this to at least 16%. When the U.S system is properly established it will rival their 36%.

    Bevan not only achieved the creation of one of the institutions that help define our nation , but one that the British people claim to be most proud of.

    He knew and predicted the threats to its existence from the outset.   In “In Place of Fear” he tried to warn us all.     Have we let him down ?

     

    Tagged , | 3 Comments

    The UK medical NGO Merlin has recently agreed to join forces with Save the Children.

    To ensure that Merlin’s story is recorded and its achievements and contributions to the humanitarian and health sectors are properly recognised and understood, Merlin has commissioned ‘A History of Merlin’ that will be published in 2015. The intention is to tell the story of Merlin’s development, the work it undertook and the people who made it happen. The work is being led by John Borton, an experienced researcher and consultant within the humanitarian sector, assisted by Luke Kelly, a post-doctoral historian based at the University of Manchester.

    Merlin provided health care in disaster and conflict-affected areas (in countries such as Chechnya, Zaire/DRC, Sierra Leone, Azerbaijan, Afghanistan, Sri Lanka, Albania, Myanmar and Libya) and made a significant contribution to the management of diseases such as TB, Lassa Fever and Malaria.

    We are looking for ex-Merliners or those who worked with or observed Merlin in some way to contribute to the History Project via our website. All those wanting to feed their recollections and reflections on Merlin, or perhaps to share Merlin-related documents and images with the Project team, are invited to do so via the site at:

    www.merlinhistoryproject.uk

    All contributions will be treated in confidence and kept secure in accordance with the Privacy Policy provided on the site.

    The website:

    • Explains the Merlin History Project;
    • Presents a preliminary timeline of 50 key events in Merlin’s 21 years;
    • Shares the PDF archive of Annual Reviews and Newsletters that we have managed to build up over recent weeks;
    • Enables Merlin’s former staff, trustees, supporters and partners, and also any observers of Merlin’s work over the years, to submit their recollections and reflections to Luke and myself;
    • Provides a contact form for those wanting to correspond directly with Luke and myself on particular issues or perhaps to share Merlin-related documentation and images with us.

    On completion of the Merlin History Project in March 2015, it is hoped to retain the website as a means of sharing the projects outputs and a selection of key documents and images.

    The opportunity to feed into the Merlin History Project provides a valuable opportunity for the humanitarian sector, not only to ensure that Merlin’s story is accurately told, but also as a case study providing insights into the organisational and financial challenges experienced by international humanitarian agencies during the last 21-years of rapid growth and evolution in the humanitarian sector.

    Tagged , | Comments Off on Invitation to contribute to the Merlin History Project

    The author is a member of BMA Council, a former (1987-97) President of the Medical Practitioners’ Union, a former (1992-8) Chair of the BMA Public Health Committee, a former (1987-90) Chair of the Greater Manchester Socialist Health Association, Director of Public Health for Stockport, UNITE’s Spokesperson for Doctors Employed in Local Government and author of “Medicine and Labour – the Politics of a Profession”. The evidence is entirely personal and not connected with any of the organisations and offices above, which are quoted for personal descriptive purposes only.

    1948-1974 the NHS cleared the slums, cleaned the air, eradicated polio and diphtheria, established new rehabilitation services, rebuilt the hospitals, and created an internationally-admired general practice system, all with the lowest level of health spending in the developed world.  The mechanisms for these achievements have now been abolished. Consequential failures led to further dismantling, like saving the Titanic by repeatedly attempting to ground it on the iceberg. Health policy since 1974 has done for health systems what design of the Titanic did for maritime safety. A wide consensus, portrayed as state of the art, delivers its main contribution from analysing the disaster.

    The NHS was a mechanism to pursue health as a social goal, deploying  committed health professionals and health workers to support socially owned organisations addressing the determinants of health as well as providing health care free at the time of use, according to need rather than ability to pay, planned to optimise resources, and financed by general taxation.

    Little of this remains in England. Health care is still funded from general taxation according to need rather than ability to pay. None of the other principles remain.

    NHS principles have been destroyed by

    • 1974 reorganisation which diminished local control
    • Centralist managerial policies of the Thatcher Government
    • 1974 removing local authorities from the NHS, redefining environmental health out of the NHS, and thus removing NHS mechanisms to address social and environmental health determinants
    • Competition introduced into NHS markets by the Blair Government
    • The 2012 Health & Social Care Act

    The case for an NHS remains compelling because

    • At most 50% (and perhaps only 10%) of health improvement results from health care – most  derives from social, environmental and behavioural determinants. Bevan’s vision, shared with the BMA, of an NHS addressing determinants of health remains fundamental. Indeed the BMA was right in 1945 to advocate factory inspectors becoming part of the NHS for expansion into an occupational health wing; Bevan supported this but Bevin successfully opposed it.
    • Healthcare and health improvement require active engagement of communities and individuals. Bevan’s vision of an NHS pursuing health as a social goal is as valid as ever, reinforced by Warnock’s calculations.
    • Communities and individuals need honest committed professional advice in those decisions. The BMA was right in 1945 to defend professional responsibility; Bevan was right to concede that, shaping an NHS professional family.
    • Economically, healthcare markets do not work. EU law requires either full blown markets or a public service. The former will bring deteriorating quality and rising costs.

    Commercial healthcare markets do not optimise resources or improve quality because

    • Consumers depend on provider advice
    • Risk sharing is necessary, creating “moral hazard” (a belief in the best rather than the optimal).
    • Commissioning authorities as market-makers of the market fail to solve this since measuring performance adequately is difficult. Making profits by exploiting information anomalies is easier than by improving services.
    • Hospitals and pharmaceuticals both have downwardly sloping cost curves and high entry costs so, according to Pigou’s theorem, a simple market will clear with unused capacity and high prices. (Adjustment of this market leads to some other versions of Pigou’s theorem such as that where the market in unrationed services clears by reducing quality, relevant to waiting times)

    The argument that the “NHS must be reformed” because “it must meet the needs of an ageing population” is valid, but the reform needed is NHS restoration not commercialisation.

    • An ageing population will reduce healthcare costs, not increase them, provided that healthy life expectancy rises as fast as or faster than life expectancy. This necessitates a healthy ageing strategy rooted in prevention.
    • An ageing population especially requires collaborative efforts of society in reablement and promotion of independence
    • NHS restoration is than commercialisation at  resource optimisation

    An NHS Restoration Act should

    • reverse commercialisation provisions of the 2012 Act
    • address determinants of health
    • improve healthcare planning
    • establish occupational health services
    • ensure provision independent of ability to pay, addressing the problems of charges and top-ups
    • democratise the NHS
    • promote a social and professional ethos and restrict competition, but provide alternative routes to innovation and dissemination of good practice
    • protect professional freedom to give honest advice
    • abolish the distinction between health and social care
    • account for health impacts of government policies
    • stop economic markets acting as choice editors obstructing healthy lifestyles
    • provide redress and appeals processes more efficiently than current clinical negligence processes
    Tagged | 3 Comments

    Socialist Health Association Briefing for Prospective Parliamentary Candidates

    September 1991

    This briefing selects aspects of the NHS reorganisation which the SHA sees as most damaging to the fundamental principles of the NHS. It aims to fill in the background to the crisis in the NHS and to address matters which affect the public.

    The Background

    The National Health Service has been reorganised four times by successive Tory governments since 1974. Each reorganisation has demoralised the staff and confused the public. The latest reorganisation, triggered by Thatcher initially to contain costs, is defined by the NHS and Community Care Act 1991, which came into effect in April 1991. However implementation of the Community Care proposals have been deferred to 1993.

    The Act sets up a market in health care, which forces hospitals and doctors to compete for patients, removes the last vestige of local accountability, diminishes the rights of users and reduces choice and accessibility.

    There undoubtedly is a need to improve patient care and accessibility to services, to deal with lengthy waiting lists, to address public health issues and to bring the NHS under democratic control. None of these needs require the wholesale commercialisation of the NHS.

    It is very important that the principles on which the NHS was established are constantly reaffirmed – that it should be funded from taxation and free at the time of need.

    It is easy to demonstrate the dangers of the Tory reorganisation but important not to undermine the public confidence in the concept of the NHS. During the passage of the NHS and Community Care Act through parliament in 1990 a Gallup Poll found that 71% of the people polled disapproved of the ‘reforms’ and 75% believed that the NHS was not safe in Tory hands.

    Building on that confidence is the most important thing we can do.

    1.Is the NHS underfunded?

    According to the latest figures available, in 1987 Britain spent £432 per person on health services. West Germany spent £1,060, Sweden spent £1,002, and the US spent £1,252. The Tories claim that the NHS has never had so much money spent on it or employed so many doctors and nurses. This can be refuted on many grounds:

    • advances in medical technology make expensive treatment possible, which people are rightly demanding;
    • NHS inflation   is   higher   than   retail   price inflation as it refers to wages and salaries, new drugs and equipment, rather than goods in shops;
    • a growing proportion of the population who are elderly requires increasing care
    • many doctors, nurses and auxiliary staff work part-time;
    • staff numbers are measured in ‘whole-time equivalents’: reductions in the official working week increased the  figures substantially, without providing any more posts;
    • doctors and nurses now have so many administrative duties that less time is available for patient care;
    • the effect on health of poverty, homelessness and unemployment has been demonstrated, and is an added cost to the NHS;
    • the fabric of the NHS property is crumbling. In 1988 the Public Accounts Committee estimated that £2 billion was needed to maintain and restore existing buildings to an   adequate standard. 75% of our hospitals and other NHS buildings were built before 1918 and only 8% since 1965;
    • the BMA has estimated that the NHS needs an extra £6 billion a year.

    2 What is the internal market?

    The establishment of the internal market means that health care is bought and sold between District Health Authorities, NHS Trusts, and the private sector. Buying and selling presupposes that treatment is costed and that the buyers will be looking for the best bargain for their patients. In 1991 the BMA estimated that the new administrative posts advertised by the NHS would add some £80 million yearly to the wages bill for 4,000 extra staff to provide financial information. In addition, in 1990-1991 the government spent £306m on implementing the reforms of the NHS, and £50 on tax relief on private medical insurance.

    3 GPs and the internal market

    Budget holders

    Practices with over 9,000 patients are able to opt for their own budgets, so that they can buy services for their patients from NHS directly managed hospitals, Trusts, private hospitals and laboratories. They are funded per capita with some weighting, and are able to negotiate the most advantageous contracts for both in-patient and out­patient services. Some doctors are demanding priority treatment for their own patients from hospitals desperate for contracts (queue-jumping) and some are employing consultants to see their patients in their own surgeries. Budget-holders tend to be in ‘leafy suburbs, with a higher proportion of patients who have some private insurance, so per capita payments will buy more and quicker treatments for the non-insured patients. All this amounts to the two-tier service in action.

    Non-budget holders

    GPs who have not opted for their own budgets are required/expected to refer their patients to the hospitals where their DHA has negotiated contracts. They lose the right to refer patients where they wish – except with special permission from the DHA, which has a fund for extra-contractual referrals (ECRs). There are reports of ECR funds being exhausted after only five months.

    The Royal College of General Practitioners has complained that the internal market “will seriously damage patient care and the doctor-patient relationship”. They mean that patients will not be sure whether decisions are being made for financial reasons or in their own best interests. There is also the danger that practices will be forced into competition which must mean that some will be losers.

    4 Hospitals and the Internal Market

    District Health Authorities (DHAs)

    DHAs are responsible for meeting the health needs of their local population and are expected to assess the needs of their area. They will either provide services for their local populations or purchase them from other health authorities or the private sector (including Trusts). Their senior staff are either managers of the services they provide or purchaser who seek and negotiate contracts for patients of non-budget-holding GPs. DHA meetings appear to be divided into two parts with the members dealing with ‘purchaser’ and ‘provider’ reports separately.

    Both purchasers and managers of directly managed units in the DHA are accountable to the District General Manager of each DHA. It is too early to see any clear advantages or disadvantages of this split, apart from the impact of the internal market and the pressure on purchasers to negotiate the cheapest deals and on providers to fill their beds by selling services. It is the internal market which is the real danger to the principles on which the NHS was founded.

    What are NHS Trusts?

    The NHS and Community Care Act (1990) gives hospitals and other NHS units the opportunity to ‘express an interest’ in opting out of local health authority/board control and out of the planning system. 66 hospitals and other units applied in the first round and ‘consultation’ took place during the summer of 1990. 57 were allowed to ‘opt out’ in April 1991, in spite of advice from accountants Coopers and Lybrand to the DoH that only 12 had financial viability. (This advice cost £500,000.) Some 113 units have applied in the second wave. ‘Consultation’ in general ended on 31 July 1991. Invitations for the third wave are being invited from all remaining hospitals from September 1991.

    5 What does ‘opting out’ mean?

    • William Waldegrave, Secretary of State for Health, himself confirmed that Trusts were out of his control when he stated in April 1991: “It is not for governments to tell hospitals how to organise their services and how many staff to “
    • Each Trust is run by a board of ten appointed directors, with some accountability to the NHS Policy Board but none to local people. The chair is appointed by the Secretary of State. Just one meeting a year must be held in public.
    • Self-governing Trusts will be run as a business, selling their services to their local DHA to fund-holding GPs, other health authorities, the private sector, insurance companies.
    • They are free to set their own rates of pay and conditions of employment, as well as numbers, types and grades of staff they employ (except junior doctors). They are not covered by national agreements. They do not necessarily recognise all relevant trade unions.
    • They can borrow capital, within an overall limit (smaller than most anticipated), retain profits, sell land and buildings, and contract out blocks of services.
    • Employees of a health authority or hospital, elected councillors and employees of NHS trade unions are specifically excluded from appointment as directors. This raises questions of civil liberties, and excludes people likely to be in touch with local needs and opinions.

    6 Moving into the Market?

    Between April 1991 and April 1992 the Department of Health instructed authorities to maintain a ‘steady state’: that is, they were to continue to refer patients where they had previously referred them. There were to be no surprises.

    In fact, since April 1991, fearful of losing out, hospitals have begun to market services without accurate costing being available and inadequate accounting systems, resulting in serious over­spending and panic cuts in services to stay within their budgets.

    Within six weeks of the official start of the internal market Bradford Hospitals Tryst announced the loss of 300 jobs. The Tory flagship, Guy’s and Lewisham Trust, admitted “an inevitable reduction in direct patient care” in making spending cuts of £6.8m, involving axing 600 jobs.

    NUPE has reported that Lincolnshire Ambulance Trust new non-emergency staff have had their pay cut by almost 28% – a cut of £2,400 to £6,200. The Northumbria Ambulance Trust demands that staff work 12 hour shifts, with no overtime and a cut in annual leave.

    Trusts are good news for some senior managers. Guy’s and Lewisham Trust pays its chief executive £90,000 plus perks. Royal London Trust is paying its chief executive £70,000.

    The NHS trade unions are the best source of information about local situations.

    It is significant that one General Manager, commenting on the second wave of applications to ‘opt-out’ from DHAs in the same RHA, states: “Concern generally has been expressed about the timing of second wave Trusts, given the possibility of a change of government by mid-1992 and the knowledge that an in-coming Labour Government, on the basis of statements made in opposition, would overturn any Trusts that had been established. Thus there is scope for considerable turmoil and the waste of much senior management effort.”

    The need for ballots

    ‘Consultation’ has been a sham with local opinion and staff campaigns ignored. The Labour Party has demanded ballots of local people before a hospital or other unit is allowed to become a Trust.

    Tory reliance on ballots for schools and local authority housing to opt out does not apply to the NHS. Even the Parliamentary Social Services Committee (Tory-dominated) has stated that opting out should only go ahead if “the local population have indicated through a ballot that they would support the hospital becoming self-governing”.

    8  What do the ‘reforms’ mean for ordinary patients?

    • Patients of non-budget-holding GPs may lose out in the waiting list race if budget holding GPs continue to demand priority for their own patients, overtly or privately.
    • Patients will be referred where their GP or DHA has a contract, rather than where they may wish to go. They may have to go to different hospitals or units   for   different Trusts will specialise in the most lucrative specialties.
    • Patients may have to travel for treatment. Exeter orthopaedic patients are offered operations in Westminster Hospital because Riverside Health Authority, with a waiting list of 791 for orthopaedics, has no money for local people – a bizarre and costly result of the
    • NHS funds are being used to up-grade rooms for private patients, with their own catering and hostesses, carpets, telephone and other comforts required by private patients, but too good for NHS patients.
    • Cuts in community services are being made all over the country to help meet the financial pressure on hospitals. People are losing chiropody, family planning clinics, well women clinics and the many domiciliary services on which elderly people rely.
    • With the abolition of free eye examinations, ophthalmic services have virtually been privatised.
    • The new Contracts for GPs and Dentists have increased paperwork with only limited gain in accountability. For example payment to GPs for achieving targets in immunisation have led to loss of service in areas of deprivation, where GPs have no hope of attaining their Dental services for children in deprived areas have deteriorated since the introduction of capitation fees.

    A brief summary of the structure of the NHS 1991

    NHS Policy Board

    Chaired by the Secretary of State. Non-executive members from in and outside the NHS. Responsible for strategy. Sets objectives for and monitors the NHS Management Executive. Determines finance for the NHS, within limits set by the Treasury.

    NHS Management Executive

    Chaired by the Chief Executive of the NHS. Implements policy. Divided in two with one half specifically responsible for operational matters. Members appointed by the Secretary of State.

    Regional Health Authorities (RHAs)

    Eleven members including non-executive Chair appointed by the Secretary of State. Five executive members including Regional General Manager and Director of Finance. One non-executive member to be from a university with a medical or dental school. Responsible for monitoring DHAs and ensuring policy is disseminated to them. Also responsible for some regionally organised services, eg blood and ambulance services. Also manage CHC staff and appoint one third of the members.

    District Health Authorities (DHAs)

    Eleven members including a non-executive Chair appointed by the Secretary of State. Five executive members including the District General manager and the Director of Finance. Responsible for purchasing/commissioning services for the local population based on assessed needs and within the budget allocated. No local authority or trade union input.

    Family Health Service Authorities (FHSAs)

    Eleven members comprising a non-executive Chair, nine non-executive members, including four professional members and the Chief Executive. Responsible for administering GPs and dentists’ contracts and monitoring their performance. Also provide support to GPs on specialist functions such as health promotion , and computerised screening systems (call and recall). Organise the registration of patients with doctors.

    Self-governing Trusts/National Health Service Trusts

    Run by a board of directors with a non­executive Chair appointed by the Secretary of State. Members made up of an equal number of executive and non-executive members. At least two of the non-executive members are from the ‘local community’ and are appointed by the RHA. Others appointed by the Secretary of State. The executive members should include key managers. The board is responsible for determining policy, monitoring its execution and maintaining the Trust’s financial viability.

    Directly Managed Provider Units

    Responsible for operational issues of delivering care and treatment to meet contracts, usually managed by a Chief Executive (General manager). Accountable to the DHA through the District General Manager.

    Community Health Councils

    Half the members are appointed by relevant local authorities, others elected by voluntary organisations and appointed by the RHA. Established in 1974 to act as ‘patients’ watchdog’ and monitor local services, powers have been diminished over the years, but they are still a source of accurate information.

    This initial briefing is intended to help Prospective Parliamentary candidates who may have no previous involvement with the NHS.

    The SHA plans future briefings to cover the background to waiting lists, the development of the purchaser/provider split, Labour Party health policy and the debate on democratic control of the NHS.

    SHA publications

    New series: Towards Equality in Health: Unequal Risks: Accidents & Social Policy

    Food for Wealth or Health Equal Shares in Caring Income and Health

    and coming soon:

    Healthy Change

    each at £3.50 (£2.75 for members)

    Putting People First – A Socialist Health Service for the 1990s (£3)

    Their Hands in our Safe – the theories behind the Tory ‘reforms’ of the NHS (£2)

    Socialism and Health – bi-monthly

    Published by the Socialist Health Association, 195 Walworth Road, London SE17 1RP (071-703 6838) Printed by RAP, 201 Spotland Road, Rochdale OL12 7AF

    Comments Off on Briefing for Prospective Parliamentary Candidates

    In retrospect it is clear that those who fought Nye Bevan’s plans for setting up the National Health Service were right in at least one important respect. The setting up in 1948 marked a revolution in the relation between the state and the medical profession. But it was not quite the revolution that the critics had anticipated and prophesied. It did not mean the triumph of bureaucracy over professionalism or the subordination of doctoring to ministerial diktat. Instead, it created a situation of mutual dependency. On the one hand the state became a monopoly employer: effectively members of the medical profes­sion became dependent on it not only for their own incomes but also for the resources at their command. On the other hand the state became dependent on the medical profession to run the NHS and to cope with the problems of rationing scarce resources in patient care. The subsequent history of the NHS can, in institutional and political terms, be seen largely as a series of attempts to manage this mutual dependency, to find ways of accommodating the frustrations and resentments of both sides in the partnership, and to devise organisational strategies for containing con­flicting interests within the framework of the NHS. My theme, in short, is that it is possible to understand what is happening in the NHS today—and indeed what has happened over the past 40 odd years—only if it is seen as the stage on which the tensions built into its design are acted out. For the drama to conflict between state and profession is not an accidental byproduct of Britain’s healthcare. It is the inevitable outcome of the financial and institutional framework that was set up in 1948. The puzzle is not that there has been so much conflict but that it has, so far, been possible to cope with it in such a way as not to destroy the NHS.

    Symmetrical frustration

    For 40 years the state and profession have been engaged in a repetitive cycle of confrontation. The issues have changed over time (though some constant themes are evident), and so have the personalities, as Labour secretaries of state have yielded to Conserva­tive ones in the demonology of the medical profession (the special place of Mr Kenneth Clarke in this respect mainly reflects a lack of collective memory). Yet despite 40 years of bickering and recrimination the NHS has survived. Despite decades of denouncing the inadequacies of the NHS the medical profession remains dedicated to its defence. Despite the political costs of being regularly pilloried in the media for its stinginess the government proclaimed its loyalty to the principles of the NHS in the 1989 review. Despite the frequent protestations that the NHS is on the point of collapse public support remains undiminished. Consensus about the desirability of the NHS has survived and contained the conflict within it. How has this been achieved? What are the prospects of main­taining the balance in the coming decades?

    One answer may be that there is a neat symmetry of frustration in the relationship between the state and the profession. In the case of the state it is its control over money that makes the NHS such an attractive proposition; in the international context the NHS is quite clearly the “best buy” model for delivering comprehensive universal health care at the lowest price and in a reasonably equitable way. [1] But it is, of course, precisely this control that frustrates the medical pro­fession—in Enoch Powell’s words: “The unnerving discovery every Minister of Health makes at or near the outset of his term of office is that the only subject he is ever destined to discuss with the medical profession is money.” [2] If the medical profession is not engaged in wrangles over its own pay it is battling for more funds for the NHS. Conversely, the NHS provides a setting in which the medical profession can exercise its skills with almost complete autonomy: within the limits of the available resources NHS doctors have been more free to exercise their professional judgments than their peers in the United States and in most other Western countries. But it is, of course, precisely this autonomy that frustrates the government. If ministers are to achieve their priorities they are sooner or later driven to question medical practices and to search for ways of achieving some sort of influence over clinical decisions on such matters as, for example, lengths of stay or expenditure on drugs.

    There are other factors also. In the case of the state, to concede autonomy to the medical profession is also to delegate responsibility for rationing: the NHS allows political decisions about resources to be disguised as clinical decisions about individual patients. In the case of the medical profession the system allows it largely to control entry and thus to assure employment for its members: the fact that doctors (like every other group) frequently consider themselves to be underpaid should not disguise the fact that the NHS guarantees them an income linked to the going rate for the professional middle classes. In the past the medical profession has done well out of the intervention of the state in medical care: a profession that had a sizable proletariat of insecure and poorly paid practitioners before 1911 has become collectively more secure and wealthier with each step in the evolution of the state system. Above all the NHS commands loyalty that transcends self interest, whether political or professional. It is because there is a general perception that the NHS is an admirable instrument for distributing health care fairly – that it is preferable to have a system where the incentives are to do too little, even if this means more queues, rather than do too much- that consensus has hitherto contained conflict and that the individual discontents have not led to a repudiation of the 1948 settlement.

    Once we recognise, however, that these discontents are not just accidental aberrations but are built into the design of the NHS it follows that we cannot simply take the comfortable view that the future will be like the past. Having lived with these tensions for the past 40 years why should the NHS not accommodate them in coming decades? Given the certainty that conflict will continue and the possibility that the NHS may be living off an inherited but not necessarily renewable capital of commitment and loyalty, is it possible to devise better strategies for managing the resentment generated by the mutual dependency of the state and the profession? What, in particular, can be learnt from past efforts to do so?

    Economy before logic

    One option, clearly, is to try to transmute political into technical issues: to fly on automatic pilot instead of engaging in a constant dispute about the route. Here the most obvious example is the attempt, stretching back to the early days of the NHS’s history, to devise a formula for determining medical pay by analysing data rather than by engaging in a power struggle. It was to achieve precisely this aim that the government set up the Royal Commission on Doctors’ and Dentists’ Remuneration in 1957 [3] the independent review body that devised both the notion of and the mechanism for comparing medical incomes with other professional incomes; the mechanism still survives today. As Professor John Jewkes pointed out in a dissenting memorandum:

    The responsible Government Departments are in the extra­ordinary, and perhaps unique, position that they largely control the demand for, the supply of, and the price offered for the services of the medical and dental professions…. It is this grip of the Government which explains why the profes­sion has spent so much time, inevitably without success, in search of a formula which would in perpetuity protect it against arbitrary action on the part of the State. For the same reason it is only to be expected that, in any new major settlement with the professions, doctors and dentists will not be wholly, nor perhaps even primarily, concerned with the new level of earnings established. They will also be vitally interested in the light thrown by these decisions, in terms of works not of words, upon the view which the Government holds as to the place of the medical profession in society.. ..

    Subsequently, however, both Labour and Conserva­tive administrations, ncluding the present one, have shown their belief that the logic of national economic management must override the logic of the NHS pay determination machinery. Most dramatically the first review body—originally appointed in 1962—resigned in 1970 because the government was prepared to implement only half the 30% increase recommended. It was this which precipitated a major confrontation between the government and the profession, with the BMA advising its members not to cooperate in NHS administration or to sign national insurance medical certificates in protest against what was seen as “arbi­trary action” by the slate. The successor body was appointed on the understanding that its recommendations would not be rejected or modified by the govern­ment “unless there were obviously compelling reasons for so doing.”[4] In the event, Britain’s stormy economic history has provided quite a few such compelling reasons. The experience of pay determination there­fore warns against optimism about the scope for insu­lating the NHS from political or economic pressures by means of technical fixes, whether by devising formulas for pay or formulas for determining its budget by allocating a fixed proportion of the national income.

    Engineering consensus

    Inevitably, it would seem, the management of mutual dependency and the resulting conflict depends on the political system — that is, political context, style, and conventions that shape the relationship between the state and the profession. Here it is possible to identify some important changes that distinguish the past decade from the previous 30 years. From the 1950s to the 1970s the NHS provided perhaps the most convincing text for those who argued that Britain had a corporatist policy making system, with policy emerging from a process of negotiation and bargaining between Whitehall ministries and interest groups like the medical profession, industry, and the trade unions. [5,6] It was a system in which differences might on occasion erupt into open conflict—as was indeed the case with the NHS-but where all participants were constrained by the knowledge that they had a shared interest in maintaining the framework. In the words of Sir George Godber, one of the main architects of change at the time,[7] it was a period in which progress was largely made within the NHS by a process of engineering consensus.

    In the 1980s, however, the Conservative govern­ment has explicitly challenged and repudiated the notion of a corporatist approach to policy making. Corporatism has been identified as a source of stagnation, institutional sclerosis, and the pursuit of self interest at the expense of the public interest. Consensus became the enemy instead of being the objective. It is view of politics that sees a strong state dealing with strong citizens (strong because they are empowered by the giving of more resources and more say over their lives, whether in housing or education) rather than with interest groups like professions, which act as the agents of their members. It therefore implies a quite different political style; the old conven­tions have been relegated to the history books. It also implies a different view of the “place of the medical professional in society”: like other professions, such as law, it becomes increasingly regarded as just one more lobby or pressure group rather than carrying some special imprimatur deriving from the nature of its expertise or its claims to represent a particular set of values

    Exclusion in 1989

    The contrast can be illustrated by comparing the 1974 reorganisation of the NHS with that now being implemented. In 1974 corporatism as interpreted by the secretary of state, Sir Keith (now Lord) Joseph, ruled supreme. The new design of the NHS was hammered out in consultation with the professions. The product of committees, it spawned yet more committees in an attempt to ensure that every interest in the NHS would be represented.[8] In doing so it universalised veto-power and by seeking to satisfy everyone managed to please no one. Indeed, it seemed to show that corporatism led only to rigidity and inflexibility. Conversely, the 1989 review seemed to be based on the belief that it would be possible to avoid repeating the mistakes of the past by not trying to consult or satisfy any of the NHS interest groups. It was the first time in the history of the NHS that the medical profession was systematically excluded from the decision making process leading up to the review; an exclusion which may perhaps explain the subse­quent bitterness rather more than actual policy content. Indeed, the BMA’s subsequent advertising campaign served largely to advertise the fact of the profession’s exclusion. It drew attention to the profession’s loss of privilege: in happier, corporatist days the profession had its own direct and private links with civil servants and ministers—an iron triangle of consultation that turned out to be made of cardboard in the 1980s.

    Looking to the future, therefore, it seems clear that the way in which the relationship between the state and the medical profession is managed will depend not on what happens within the NHS but on what happens to Britain’s political system. If the 1980s turn out to be an interregnum-if the assault on the role of interest groups proves to have exhausted itself—then there may well be a return to the politics of the double bed: peace between partners through propinquity.

    The emphasis might then once again be on trying to engineer consensus through the participation of professions, trade unions, and other interest groups in the policy process—the European rather than the American model. It seems unlikely, however, that memories of the 1970s and earlier decades will disappear entirely or that the risks of corporatist stag­nation will be quietly accepted. If the professions are once again to be seen as partners in the policy process rather than pressure groups exclusively pursuing their own interest it may mean that they will also have to show their willingness and capacity to adapt and change and, above all, to recognise that they are accountable as much to the society that grants them their privileged status as to their own members. If such a new political settlement cannot be achieved, however, it seems unlikely that the NHS will survive long into the twenty first century.

     References

    1  Organisation for Economic Cooperation and Development. Financing and delivering health care. Paris: OECD, 1987.

    2  Powell JE. Medicine and politics. London: Pitman Medical, 1966.

    3  Royal Commission on Doctors’ and Dentists’ Remuneration. Report. London: HMSO, 1960. (Cmnd 939.) (Chairman: Sir Harry Pilkington.)

    4  Review Body on Doctors’ and Dentists’ Remuneration. Report. London: HMSO, 1971. (Cmnd 4825.)(Chairman: Lord Halsbury.)

    5  Eckstein H. Pressure group politics. London: Allen and Unwin, 1960.

    6  Beer SH. Britain against itself. London: Faber and Faber, 1982.

    7  Godber G. Change in medicine. London: Nuffield Provincial Hospitals Trust, 1975.

    8  Klein R. The politics of the NHS. 2nded. London: Longman, 1989.

    First published in the British Medical Journal 3 October 1990

    Tagged | 2 Comments