The Welsh Public Health Association

The National Health Service as precursor for future society

This paper was presented by Professor Julian Tudor Hart MB Bchir DSc DCH FRCGP FRCP at the PHA Cymru conference on 5 July 2002

Margaret Thatcher set the agenda still followed today by a government elected on an implied promise to set a new course entirely. Defying its own history, its members, and most of its voters, New Labour reaffirms her most fundamental belief: that there can be no alternative to rule by the world market, and that it must penetrate every part of society, today and for the foreseeable future.

My experience suggests this is not so. Albeit precariously, in the NHS we already have the beginnings of an alternative economy, driven by human needs rather than pursuit of profit. Together with medical science, this still grows within the belly of the beast. If staff and patients succeed in defending it from penetration by for-profit investors, this subset economy could provide foundations for a fundamentally different, more democratic, secure and sustainable society, akin to those which past generations imagined, lived and often died for. In the NHS we have not just a social machine, running as well for profit as for public service. The NHS is the most promising embryonic child of developed capitalism, whose future scope could far transcend the imagination of its philistine parent.

Beginnings

The NHS was conceived in the high tide of Left consensus in 1942-4.i It came to birth on the ebb, on 5 July 1948, as we entered four decades of cold war. Three years later, with the NHS just beginning to take shape, I qualified in medicine.

My second junior hospital post was in the tuberculosis wards of Watford General Hospital in 1952. Only four years previously it had been a custodial workhouse, with clinical wards added as afterthoughts. Most of the people it still housed were inmates, not patients: young and old men and women who had lost their homes, or round pegs who couldn’t fit any of the square holes available in the rigid society of those days. In one half of this stone warehouse lived women, girls over 5, and all younger children. Men and boys over 5 lived in the other half. Men on one side who were married to women in the other, or children who had parents there, could see them during visiting hours. Inmates still provided the labour required for hospital kitchens, cleaning and laundry, virtually unpaid. They also provided personal service for the workhouse master and mistress, who remained in genteel retirement. The legacy of Edwin Chadwick, pioneer of Public Health but principal author of the Poor Law Amendment Act of 1834, which made him the most hated man in England, ii still provided our default social philosophy. Good was done to the people, seldom for them, never with them. Cold charity continued everywhere until, in one unit after another, innovative NHS professionals and assertive NHS patients locally defeated it, using new laws to develop their counter-culture of social solidarity within local realities.

In those days many students still entered medical school simply because they had medical fathers, uncles or grandfathers, and saw no easier way to make a living. Even at its best, clinical medicine was still so frequently ineffective that doctors dared not measure their work by its intended outcomes as longer or happier lives. They measured not doing, but trying. They meant well and sometimes actually did well, but always did something – almost anything – simply to prove they were trying. They thus hoped to preserve their hitherto most potent weapon, the so-called placebo effect – hope sustained through perceived caring. ii

Bevan’s NHS registered everyone with a personal doctor. All were included, and all transactions in the new NHS economy were cash-free, values without costs, the economic burdens of personal illness shared by the entire community. Starting with Hugh Gaitskell in 1952, successive governments have, with increasing success, sought to destroy this potentially revolutionary seed. They reintroduced payments whenever and wherever they could get away with it. Every prime minister, Labour or Tory, agreed that in a free market society, nothing of real value could or should be free. In their world as they saw it, everything and everyone had a price, every act had a cost, every value had to be measurable in cash terms. They saw Bevan’s cash-free NHS as a folly, a necessary but transient concession to public intoxication with the prospects of a fundamentally new world after the outbreak of peace.iv

But it was too late to put the genie back in the bottle. Everyone except doctors loved the NHS, a love at first sight that has lasted ever since. To the distress of politicians longing to return to market realism, this love was based on exactly what they most detested, a reverence for the most basic principles of social solidarity: it’s bad enough to be ill, without also having to pay for care of illness.

Within just a few months, even doctors found themselves charmed. Their complex and difficult work got easier in three important respects – everyone was entitled to care, money no longer complicated clinical decisions, and relationships were no longer poisoned by bad debts.

The NHS gave all GPs lists of real people, with names and addresses, for whose care they were responsible. In law, they were expected to try their best. In practice, this was defined as doing more or less what other GPs usually did for similar populations. In other words, it depended on conscience, perceptively described by George Bernard Shaw: “Doctors are just like other Englishmen: most of them have no honour and no conscience: what they commonly mistake for these is sentimentality and an intense dread of doing anything that everybody else does not do, or omitting to do anything that everyone else does.” v

As an imperial nation, the English were especially prone to this moral laziness, but the problem is general and permanent. A central task of university education must be to raise conscience into consciousness: to move beyond passive conformity, toward active and imaginative innovation. Each major advance in knowledge should compel us to redefine what is intolerable. vi This collective, consensual conscience becomes real when it is accountable to independent judgment, using measured evidence. To be genuinely representative and independent, judges must be locally informed and aware of best international practice. Experience shows that justice will be done only if these judges have to endure personally the consequences of their own decisions. We want judgements by our equals, informed by sharing the common experience, not by our betters.

In public service, to mean well is not enough: we must do well, vii measuring what we have done, and opening our results to critical public gaze. For the time being, this has to be through a scientifically ignorant and sensationalist press, but we can and must create our own local organisations for local leadership and accountability. The NHS, with its socially inclusive system of registered patients and its cumulative personal medical records, created possibilities for moving beyond rhetoric, towards verifiable achievement. It provided socially inclusive and continuing data frames, necessarily absent from marketed care systems where patients wandered about as consumers, seeking episodic care from competing providers.

The free, inclusive NHS gave us the means to do our best for everyone, to measure what we had achieved, and thus learn to do better. It gave us the means, but not the motivation to use them. Social motivation depends on social understanding. Locked into quasi-independent status as GP shopkeepers, or as patrician consultants doubling their already large incomes by private work alongside and in competition with their work in public service ,viii ix such understanding was rare. Bevan had to create the outlines of a socialised service, almost without social doctors. x Now we have many social doctors, and many more social health workers of other kinds. The problem today is our dearth of social politicians.

Furious resistance of the BMA to the birth of the NHS, which it now denies but every contemporary witness remembers, grew from fear of enslavement as public servants. Doctors knew what servants were: most of them had servants of their own, demonstrating their status as genteel professionals. They accepted that public servants must do the dirty work in an unequal and unjust society, so they grovelled to authority above them, and condescended to patients below them. GPs with consciences defined by conformity clung to their status as independent contractors as if their souls depended on it, determined never to become anyone’s servant, either for their patients or for the State.

Nine months after qualifying, I entered general practice in London’s Notting Dale, then a social frontier between affluence and poverty. The most obvious difference between my medical shop and others was a brass plate on the door: “No Private Patients”. The NHS was in this one respect a paradise; a service open to all according to need, in which doctors could dissent from their colleagues with impunity. They say in Aberdare that before the NHS, when doctors were called to a sick person at home, they’d announce their arrival with the shout: “Who’s paying?” My friend, comrade, and fellow-dissident Dr Alastair Wilson, whose daughter Anne is in this audience, surprised everyone with a new shout: “Who’s sick?” That’s the difference between shop keeping and public service. The NHS made it possible for doctors to consider first what was useful, not what was profitable, and still make a decent living. Even in the worst circumstances, some doctors have always found ways to serve human needs rather than profit, though usually at high cost to themselves and their families. The NHS made altruism possible not just for martyrs, but for all doctors. They could work rationally to address the human condition rather than maximise their own incomes. This was attractive not only to socialists like Alastair Wilson, but also to conservatives with a social conscience, capable of asking themselves how much is enough. xi This created exciting (but so far neglected) possibilities for an extremely broad alliance to defend and extend public service.

Medical Care Works

Liberal retreat from social responsibility since the 1970s has been assisted by doubts, often well intended, that personal clinical medicine has any significant effect on public health. xii Clinical medicine is effective not just by sustaining hope, but through material interventions which really prevent or change the course of otherwise mortal or disabling illness. Because of the rapid succession of safe and effective antibiotics between 1935 and 1953, mine was the first generation of medical students of whom none died during their undergraduate years or soon after, from either tuberculosis or septicaemia, mostly acquired from their own patients, living or dead. Uniformly fatal or permanently disabling diseases such as bacterial meningitis, malignant hypertension, bacterial endocarditis, and poliomyelitis became treatable or preventable through clinical action. It was a period of undeniably effective innovation. Most major causes of premature death became treatable, with measurable and substantial effect on early mortality and continued illness.

Of course, effective methods of prevention or treatment only work if they’re applied. You might think this would be self-evident, but people have a wonderful capacity to believe that application of new knowledge makes moral rather than material demands on professionals. Application of new knowledge requires new resources – new planning and organisation, newly educated staff, often new medication or equipment, and more time for both staff and patients to move beyond established customs and expectations, thinking and acting in more complex, imaginative and generous new ways. xiii Let me give two striking examples.

A safe and fully effective diphtheria vaccine became commercially available in 1923. No State programme of diphtheria immunisation was introduced in UK until 1940-41. Consequently, between 1923 and 1940, roughly 3,000 children died each year from this entirely preventable disease. Until evacuees from city slums arrived on their doorsteps, most of the Great and Good were more interested in low taxes and rates than in mass immunisation programmes. Within five years of appropriate organisation and resourcing, diphtheria disappeared as a significant cause of death. xiv

Or take asbestos. The first good evidence of lethal risk from industrial exposure was published in 1898, the first UK government report which officially recognised the existence of a problem appeared in 1930,xv yet more than a century after it was recognised, the Trades Union Congress estimates that 18,000 people died from working with asbestos between 1997 and 2001, and there is a current death rate of 4,500 a year from this cause. xvi This year, 104 years later, our appeal judges ruled that if workers have been exposed to asbestos dust by several different employers (as is usually the case), no single employer is liable for damages. [You can see some of the newest information or some of the latest news at a leading health resource.]

Human rights are first won and then thrive only so far as they are fought for, resourced, and used. Only when there is hammering at the gates do human rights ever win priority over property rights. Clinical imagination depends on having enough resources to do more than meet customary expectation, which necessarily and rightly has priority. xvii Doctors between the wars expected to treat diphtheria, not to prevent it, because prevention entailed social action, which lay outside their business. And indeed they treated cases individually with great effect, reducing death rates far below pre-1914 figures. Yet they failed to see that in the case of fully preventable diseases, the only tolerable death rate is zero. If resources or organisation are lacking in public service, most doctors will become apologists for system failure, just as within fee-for-service medical trade, they will become credulous advocates of anything and everything profitable, with or without evidence of effectiveness. xviii

Three barriers to delivery of medical knowledge

Advances in medical knowledge have continued almost exponentially throughout my lifetime, but their useful application to personal care has followed a much flatter trajectory. Full application of knowledge meets three huge obstacles.

Firstly, in fully industrialised or post-industrial economies, the nature of our main health problems has changed, requiring both simpler social solutions on a much bigger scale, and far more complex solutions at the level of personal treatment.

Secondly, throughout the world, transition of medical care from cheap illusion to effective but costly reality encouraged retreat by States from social responsibility for application of medical knowledge. As medical care moved from religion to science, it became real, and real things cost.

Thirdly and finally, trade in personal medical care expanded rapidly as a profitable commodity with unlimited market potential, particularly where corporate investors could transfer their risks to the State and gain quasi-monopoly status as private providers of public service. xix This redirected investment from poorest and most vulnerable groups, and from planned prevention and anticipatory care.

From invasions to mutinies

In the period of relatively easy advance from 1935 to the early 1960s, the main precipitating causes of premature death were either infections, or physical injuries. Both conformed well to a simple model of episodic rather than continuing care. Otherwise healthy bodies were invaded or injured by external agents, as though diseases had an independent existence, separate from their human hosts. xx xxi

Treatment depended on devising “magic bullets” that hit the invader without hitting its host. Patients could then return to an independent life, and the transaction was closed. In this episodic model, doctors and other health workers were active and informed providers, patients were passive and ignorant consumers. Patients sought treatment because they felt ill, and for these diseases this seemed an efficient prompt for effective action. Antibiotics for infective illness appeared to fit well to this model, and their success encouraged everyone to view other clinical processes in the same way.

Conquest of fatal infections in young people helped to create an aging population in which premature deaths occurred later. From the 1960s, main causes of premature death and chronic illness changed, resembling internal mutinies more than external invasions. Cancers, diabetes, high blood pressure, strokes, coronary heart disease, asthma, inflammatory arthritis, epilepsy, bipolar depression, schizophrenia, and multiple sclerosis all begin as revolts of some cells in some body systems, disrupting normal biochemical processes from inside the body economy. As we come to understand them better, we find their processes lie centrally within patients’ bodies, and their causes lie centrally within patients’ lives. In an aging population, diseases rarely occur as single problems, and can no longer be solved by ignoring the co-morbidity usually (not exceptionally) present. xxii Solutions to these complex and multiple problems, either through treatment or prevention, must usually be applied not episodically but over years, often lifetimes. They require active and intelligent participation by patients in their own care, and in decisions about their care. These solutions can’t be delivered effectively or efficiently to passive or ignorant patients through one-stop repairs. Most of these problems are easier to solve at an early stage when symptoms are either absent or trivial, so feeling ill is not an effective or efficient prompt.

The rule of halves

Because of these complexities, and because of permanently insufficient resources (particularly in primary care) new knowledge about these problems is not fully applied. In 1972, two Americans, Wilber and Barrow, xxiii described the Rule of Halves, which they had found in a community survey of high blood pressure: half the people with high blood pressure were not known, half those known were not treated, and half those treated didn’t have their blood pressure controlled.

Technically, high blood pressure is simple to diagnose and treat. It’s full of quantified measurements attractive to community health activists, health economists and politicians, so compared with more obviously complex problems, progress should be easy. In 1997, about 35 years after tolerable and effective medication became generally available, the US National Health and Nutritional Survey (NHANES III) reported only 24% of US hypertensives aged 18-74 achieved target control (<140/90 mmHg). The equivalent UK rate is estimated at 6%. Even France, best in the world table, achieves only 33%.xxiv

What about other treatable chronic conditions? In 1992 I reviewed UK evidence, and found that as an order of magnitude, the Rule of Halves held equally for type II diabetes and asthma, and probably for most other chronic problems. xxv Later evidence has confirmed this.xxvi-xxvii From our experience of attempting full detection and follow-up of all common and important chronic disorders in the whole population of Glyncorrwg, treating according to current best evidence, we estimated that to reach 80% or more of our targets, our already prodigious workload had to rise by at least 12% overall, with a small rise in average medication costs. We needed a larger and more diverse team, and had to involve patients more actively in their own care. Most of our patients with chronic health problems had more than one kind of problem, so there were not only too many of them for specialist care to be feasible, their problems were also too diverse. They needed skilled community generalists, not hospital-based specialists. xxviii

Closing the gap

The NHS is increasingly seen not as a continuing personal service to avoid or minimise breakdown, but as an emergency service to maximise salvage. For continuing health care, does this gap between medical knowledge and its application affect public health? In 1961 I began work in Glyncorrwg, then and now one of the UK’s poorest communities. My first task was to address patient demands in line with contemporary best practice: to meet wants, not search for needs. In the circumstances of that time, that was hard and exhausting work, not least because most of it seemed almost irrelevant to health. By 1965 we were beginning to get on top of this entirely demand-led care. By 1968 we were able to start a programme of active search for health needs throughout our practice population of roughly 2000. This began with systematic case-finding and regular follow-up throughout the registered population for high blood pressure and nicotine addiction, with virtually 100% coverage. Later we turned to other targets, mainly family planning, diabetes, obesity, alcohol problems, chronic lung disorders, psychotic illness and incontinence.

My responsibilities for this work ended in 1987. Our team then reviewed the results, comparing death rates under 65 for the five years 1981-86, in Glyncorrwg (which had developed a cumulative proactive programme since 1968) and in the socially similar community of Blaengwynfi (which had received only traditional demand-led care from three successive doctors between 1968 and 1985).xxix The first of these doctors provided care of at least average quality, and the last two, Dr Stan Hill and Dr Brian Gibbons (now Junior Secretary for Health in the Welsh Assembly) provided exceptionally good care, but without planned search or active recall for follow-up.

We found age-standardised death rates under 65 were 28% lower in Glyncorrwg than in Blaengwynfi over the five-year period. Differences were mainly in deaths in the first year of life and cardiorespiratory causes of death, the pattern expected when care becomes more effective.xxx

Care in Blaengwynfi was also associated with lower than expected mortality in such a deprived community, though less so than systematic proactive care in Glyncorrwg. In 1981-9, ranking all 55 electoral wards in the County of West Glamorgan for deprivation by Townsend Index, both villages lay in the five most deprived wards. Ranking the same 55 wards for age-standardised mortality under 65, Glyncorrwg lay in third place alongside the most affluent areas of Swansea), and Blaengwynfi ranked thirty-second. Good demand-led care had obviously made a difference, but could become substantially more effective if supplemented by systematic search, recall, patient participation and planned clinical policies applied to the entire population. This evidence is limited by its small numbers and “natural experiment” design, but on this policy issue, it’s almost all there is.xxxi It seems unlikely that these large apparent differences were either not real, or not caused by our proactive policy.

Conclusions

This shift beyond an episodic repair service toward whole-community continuing care has implications hitherto ignored by most health economists, the media and politicians. Welsh Assembly Health Secretary Jane Hutt is a precious exception.

Our central government expects its episodic repair service to provide more or less standardised solutions, and to respect patients as customers. This is the positive thrust of managed care in USA and “reform” of the NHS. xxxii Its itemised processes translate readily to commodity trading for profit, regulated to ensure standardised quality, with legal redress when this fails. Continuing health care, on the other hand, makes increasing demands on patients to work with their carers as fallible co-producers of health, xxxiii xxxiv and on society to use a growing proportion of its social product for public needs rather than private greed. It assumes that more and more national wealth feeds into the social rather than the personal wage, an old assumption shared by the whole Labour movement before 1997. For the NHS as a whole and for primary care in particular, these two paths are mutually exclusive and antagonistic. Politicians who sit astride that fence too long risk their potency. The more often they twist and turn, the greater that risk becomes. xxxv

Effective and efficient application of new medical knowledge to all who need it depends increasingly on continuing relationships between professionals and the people and communities they serve. Lay people need to be valued by professionals for the evidence they can bring to reach accurate and effective joint decisions both for diagnosis and treatment. As current hysteria over Measles, Mumps and Rubella vaccine testifies, cumulative experimental evidence can’t be applied to everyone if it’s not understood by everyone. People encouraged to believe that complex social problems can be solved by bombing from 15,000 feet may also believe in horoscopes, in their own racial superiority, that AIDS in Africa is imaginary, or any other absurdities their newspapers offer for their dyseducation and entertainment.

According to Richard Jolly, editor of the United Nations Report on World Development, in 1996 there were 358 $ billionaires on our planet. Their total wealth equalled the combined incomes of the poorest 45% of the world population, 2.3bn people. xxxvi These unelected people run the global economy, most of the press, and most of our politicians. They steal the present world from the poor, and the future world from our children and grandchildren. They deny even the possibility of any alternative to their society, fuelled by greed for six days of the week, precariously balanced by bucket loads of sentimentality on the seventh. They try to confine our imaginations to trivial pursuits without danger to their rule.

The future depends not on them but on you. Only you, who work in public services for human needs rather than profit, can stop the invasion and demoralisation of public service by for-profit investment, and the corruption of universities by shifting from shared truth to intellectual property. Only you can develop our potentially independent, needs-driven economies of health and education in their own preferred directions, reinforced by their empirical and research experience, toward peripheral participative democracy, where people can regain their dignity and self-respect as sceptical but mutually supportive co-producers, not credulous consumers. With few exceptions, studies comparing non-profit public service with for-profit health care show higher output, efficiency and staff morale, and much lower administrative costs, in non-profit public services, xxxvii-xxxviii but this is not the main issue. Non-profit public service is the only substantial and growing area within which we can develop alternatives to the unsustainable economy and society fuelled by greed.

Like Marx, Adam Smith’s reputation has been damaged by people who thought they were following his work, but never read it with critical intelligence. Like Marx, he understood that defence of property has been the main purpose of the State throughout history. As he wrote in The Wealth of Nations: “Civil government, so far as it is instituted for the security of property, is in reality instituted for the defence of the rich against the poor, or for those who have some property, against those who have none at all.” xxxix

Adam Smith was the father of economics. Though he died 28 years before Marx was born, in some ways he was also the first Marxist. What has changed since 1762, when Smith published his Wealth of Nations, and even more since 1867, when Marx published Das Kapital, is that even in defence of property, a fully developed modern State can be ruled only by consent. To win and retain that consent today entails development of public services sufficient to sustain the pretence that global capitalism serves the interest not of 358 dollar billionaires, but of all humankind.xl Public services originated as a defence of property and legitimation of power, but that is not all they have become. Health, educational and social service professionals do want and do try to serve the people, not themselves or for-profit employers. They are learning that new knowledge can’t be imposed paternalistically on a grateful but ignorant population, that it can be effectively applied only through joint work with the communities and people they serve. They will not sell themselves into a more sophisticated industrial slavery, producing not health but a bottom line for accountants.

History has not come to an end. We are now entering its most exciting chapter. What once was illusion, you must make into reality.

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