Dr Charles Webster November 1992 Contribution to Health, Wealth and Poverty conference.
It was not until the Report of the Working Party on Inequalities in Health (the ‘Black Report‘) of 1980 that the issue of inequality come into prominence in NHS circles, some thirty years after the NHS was established. The Black Report was unrepresentative. More characteristic was the Royal Commission on the NHS, an investigation which ran parallel with the Black Working Party, and which was friendly to the Labour government. Its report (1979) contained no reference to Black and no index reference to equality, inequality or indeed to poverty. This lapse in the Royal Commission Report suggests a serious and worrying paradox: the NHS was established to generate greater equality in health provision and thereby reinforce the effect of related social measures. Yet the question of inequality occupied a low priority and was only belatedly addressed. Even then, reaction to this issue was minimal and certainly not proportionate to the scale of the problem. With respect to this serious shortcoming both Labour and Conservative governments were almost equally culpable. The problem was discovered, or rather re-discovered, in the 1980s in the harsh circumstances of the Thatcher regime – since it had been discovered in the interwar years.
It is necessary to understand the attitude that built up in public health circles in the course of the earlier part of this century. There was the belief that the slow incremental expansion of the health services, with an increasing degree of public investment, would gradually but surely overcome the problems which we associate with inequalities. Even at the beginning of the century there was a complacency building up that the health services had already attained a great deal and that health indices had reached what was called at that time an ‘irreducible minimum’. It was not until 1911 that the first Registrar General’s Inquiry into Social Class Mortality revealed that this complacency was not well founded. It revealed for instance that infant mortality rates were averaging 76 per 1000 for the middle and upper classes and 160 for the families of miners. Similar degrees of disadvantage applied widely, for instance to maternal mortality and tuberculosis mortality. These worrying discrepancies represented the tip of the iceberg of ill health, because the morbidity indices were not available, and have never been adequately available.
Deadly Equation
Regardless of findings of this kind, which were confirmed in every Registrar General’s investigation, the degree of complacency in the field of public health became greater in the interwar period and during the depression. Something of a ‘deadly equation’ was reached during this period. The idea that wages, regardless of their level, or benefits, regardless of the low level at which they were set, plus the public health measures undertaken at the time, were sufficient to maintain subsistence and eliminate preventable diseases. That meant that if there were social class discrepancies in the field of health it could only be because of the biological disadvantage of those concerned or the moral deficiencies of the social classes who were affected. So the bureaucrats in public health, led by the Chief Medical Officers of the day, were able to mount a conclusive campaign to assist the policies of retrenchment of National governments of the time. It is scarcely possible to believe some of the statements which were made at the time. The Chief Medical Officer in his Annual Report in 1933 said that there was “no available evidence of any general increase in physical impairment, in sickness or in mortality, as a result of the economic depression or unemployment.” That could of course be something reproduced by the official documents of the 1980s.
But the official establishment at this time was not able to succeed with its propaganda on behalf of the policies of complacency. Increasingly the social scientists and nutritionists were able to establish that the levels of unemployment pay or the levels of low pay of the lowest paid workers were insufficient to ensure the minimum subsistence of the classes concerned.
The official data was increasingly exploited by the critics of the bureaucracy and of the National governments to demonstrate that the problem of inequality was far greater and far more susceptible to policy intervention than was allowed for by the government. The leading investigator in this field was Richard Titmuss, whose books Poverty and Population (1938) and Poverty and Wealth (1943) have attained the status of social science classics. To quote from Titmuss: “Despite a considerable fall in the absolute rate, the range of inequality or total infant mortality is as great, if not greater than in 1911″(1943). “We are in fact further away from the goal of equalised health than we were thirty years ago and this despite the rise in the annual cost of social services from £55m in 1911 to £420m in 1930/2. ” “Is it too much to suggest that if the gradient of economic inequality had become greater with the years, a statistical study of infant mortality would have yielded results very different from those recorded in this book?” In other words, Titmuss was writing conclusions that we might again be writing in the 1980s and 1990s. But Titmuss also not only identified clearly the problems in income and health but also the very important phenomenon of the misallocation of resources. This is a complex issue, but the unplanned system of health services in existence at that time – the kind of unplanned system that we are now reverting to again – had resulted in a haphazard, wasteful and eccentric pattern of services which often resulted in extravagant and inappropriate services, resulting in the most useful services being least developed in the areas of greatest need. This is not a universally shared summary of the health service situation in the interwar period and it is indeed contradicted in a recent paper in Public Administration by Martin Powell, but I consider that paper to be erroneous.
Social Medicine
Inequality was actively debated and it was amply apparent to the planners of the National Health Service that the problem of inequality would not simply wither away. It would require positive intervention and innovation across a broad front of social policy. The problems of health policy could not simply be treated in isolation. A new medical specialism called social medicine evolved at that period, which was devoted to many of the aims which flowed from the work of Richard Titmuss and his colleagues.
Bevan’s conception of the health service was broader and more imaginative than had ever been envisaged even by the more adventurous wartime planners. Bevan described the health services as “the biggest single experiment in social service that the world has ever seen undertaken”, and he said that “undertaking to provide all people with all kinds of health care creates an entirely new situation and calls for something bolder than a mere extension and adaptation of existing services.”
The effectiveness of the NHS in the promotion of the fight against inequality was severely curtailed for a number of different reasons. Immediately one of the most desirable features of the NHS, its tax funded basis which maximised its redistributive effect, was limited first with the introduction of direct charges (for example the controversies about prescription charges and charges for dental and eye services) and also, perhaps less talked about but equally important, the introduction of a higher rate of NHS insurance contribution. At the greatest levels, 20% of NHS expenditure was met from charges and contributions. This immediately implied the introduction of a levy which fell most heavily on the lowest paid workers and the poorest section of the community. It was this kind of problem which was overlooked by people like Richard Titmuss in the course of the 1950s and 1960s. At first they hoped that increased expenditure on the health services would eliminate these problems and cause the difficulties to the least well off to be lessened when it became possible to reduce and eventually eliminate such charges. This circumstance of course never occurred. Expenditure on the NHS was effectively pegged down by successive governments and it was never possible to eliminate the charges and NHS contributions.
Leadership Vacuum
It would be nice to talk about the way in which the structure of the NHS, particularly between 1948 and 1974, held back attention to the question of inequality. But in many different respects the NHS made this problem more difficult to tackle. The tripartite system of health service organisation before 1974 was fragmented to a degree that made unified planning impossible. Health service administration was in the hands of more than 600 different bodies. There was some loose idea that this structure could be brought into some kind of unified action by determined leadership from the then Ministry of Health. The Ministry itself however was characterised by complete division and lack of capacity to produce guidance on any subject. All it could do was produce large numbers of circulars which were ignored by the authorities concerned. There was also tremendous imbalance between the sectors of the NHS. The hospital service was absorbing some 70% of expenditure and a new regional framework was itself divided and fragmented and incapable of assuming leadership on hospital planning. The disasters of hospital planning gradually came to the surface with the weakness of the Hospital Plan of 1962. Appalling decisions were made in the capital programme for hospital building which subsequently occurred, the effects of which are beginning to be apparent with reports like the Tomlinson Report.
It was not until a series of hospital scandals, particularly the Ely Hospital Report produced in 1969, that the rottenness of the hospital system became publicly apparent and no longer possible to avoid. It was above all the adverse publicity in the wake of the Ely Hospital scandal that set the Labour government scurrying back to the drawing board and attempting for the first time to lay down priorities, first for the mental health and mental handicap services and then for all other services which related to the disadvantaged groups. Although priorities documents were an important feature of the 1970s it was not possible to produce dramatic action as a result of these new statements of priorities.
If one then runs through the disadvantages and defects of the NHS in the period before 1980, it amounts to a catalogue of weaknesses which provoked alarm among all those concerned with the quality and quantity of services available to the disadvantaged sections of the community. The NHS was basically failing to perform functions which Bevan had stated were vital to its very creation. The result was not an overwhelming sense of concern within the NHS to redress these grievances and to move resources in the direction of disadvantaged groups. The response was very similar to the situation in the interwar period – a degree of complacency which was quite inexcusable. The pressure for change came again from outside agencies, very often representing particular disadvantaged groups and in the case of the Labour Party, one particularly important document which drew together a great deal of the criticism of other groups was the collection of papers published under the editorship of Townsend and Bosanquet, Labour and Inequality (1972). This publication reflected on the weaknesses of the chronic hospital sector, the over-investment in the teaching hospitals, regional disparities in hospital expenditure and what it regarded as an alarming unplanned development of hospital services which had led to the concentration on large new building projects in the London teaching hospitals. These were all problems which the Department of Health and Social Security were very reticent to admit, but the Department was forced for the first time to address the question of improving services for the disadvantaged and to adopt positive targets for the services associated with these new priorities. ‘Priorities’ documents became a feature of the 1970s and led to a degree of optimism that the problem of inequality would at last be addressed seriously.
Black Report
One by-product of this concern was the decision to establish, under the Chief Scientist of the period, Sir Douglas Black, an investigation into inequalities in health – quite uncharacteristic of government inquiries of that time, or all times (they tend to be coverups). Black showed the tolerance and breadth of vision to include in his team Peter Townsend, who had been one of the leading outside critics of the government. Thereby, the Black Report brought to this question of inequality the tenacity of purpose which had been displayed by Titmuss in the 1930s. Indeed it was the pupils of Titmuss who were the authors of the Black Report. It was just unfortunate that the political atmosphere of the 1980s did not replicate the mood of humanitarianism and enlightenment which dawned during the darkest days of World War Two and enabled the National Health Service to be established.
I would just end by citing a quotation from Labour and Inequality which helps us to be aware of the dangers of complacency in thinking about this problem. Looking back on the 1960s the editors concluded that the Labour government seemed “to show little awareness that there were problems at all”. At the least, constant vigilance was needed to ensure that the NHS was truly national. They were forced to accept that the problem of inequality had been seriously underestimated by the Labour governments up to 1970. This error was to some extent corrected in the 1970s but effective action was precluded by the economic crisis of the time and other problems confronting the NHS, some of them of the Labour government’s own making. Of course we will look back on the 1980s as wasted years, and even perhaps as a return to the situation of the 1930s. Inequality therefore remains a major challenge to the next Labour government and it is important for the success in this central mission that the Labour government should display a leadership of the kind provided by Aneurin Bevan at the beginning of the National Health Service.