We’re facing tough decisions if the NHS is to survive as Bevan intended

Mar 1 2008 by Madeleine Brindley, Western Mail

As Wales celebrates St David’s Day, the Western Mail launches a series of features to mark the 60th anniversary of the country’s greatest contribution to the wellbeing of every man, woman and child in the UK. Health Editor Madeleine Brindley reflects on the birth of the National Health Service and considers its future

THE birth of the NHS was a turning point in not just British social history, but the world’s. When the first patient was treated on July 5, 1948, in the full knowledge that their healthcare would never cost a penny again, it was the first time anywhere in the world that completely free healthcare was made available on the basis of citizenship rather than the payment of fees or insurance premiums.

The NHS has been beset with numerous problems since that momentous day almost 60 years’ ago when Aneurin Bevan’s vision became reality; its knees have buckled repeatedly under the weight of demand from patients and a perpetual shortage of cash.

But it has survived numerous political assaults over the course of those six decades, it has embraced technological and medical advances and has, at least in Wales, largely managed to resist creeping privatisation which has consumed so many other national institutions.

The NHS remains a much-loved institution – despite its problems, thank-you letters continue to outweigh complaints every year – not least because we know that the expertise of the thousands of staff will always be available to us in our hour of need.

Nye Bevan said of the NHS, “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 of their fellows, have access, when ill, to the best that medical skill can provide.”

A sign of how seriously we revere the health service is evident in the millions of pounds that past patients raise for their local hospital or the massive groundswell of feeling which is stoked at any time that communities feel an element of that service is under threat from faceless bureaucrats or meddling politicians.

But we also take the NHS for granted. It is only when we need to call on its services that we appreciate the vast organisation and the efficiency with which it provides.

The NHS has been described as “the most far-reaching piece of social legislation in British history”. And indeed, its existence is almost unparalleled in the developed world.

But for an institution has made such a difference to so many lives, not least because it means we no longer have to question whether we can afford to care for our own health – a daily occurrence in those countries with paid-for or insurance-based healthcare systems – its birth was far from assured when Bevan joined the post-war Labour government.

After Bevan published his Bill on the health service in 1946, one former chairman of the British Medical Association, which represents doctors, said, of his proposals, “I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to national socialism as practised in Germany.

“The medical service there was early put under the dictatorship of a ‘medical fuhrer’. The Bill will establish the Minister for Health in that capacity.”

Doctors initially opposed the new service by nearly 10 to one – the BMA was concerned that by nationalising both the charity hospitals and the former poor law hospitals run by local authorities, Bevan would strike down doctors’ cherished professional independence, and their right to buy or sell general practices. It feared their new role, with a salaried income, would reduce doctors to the status of mere civil servants.

The co-operation of doctors was essential to Bevan and his plans for the NHS. Although doctors make up only a small proportion of the healthcare workforce, today – as was the case 60 years ago – the NHS would be unable to function without their presence.

Bevan undertook a charm offensive – wining and dining BMA leaders at an exclusive London restaurant. Dr Roland Cockshot, who was among those to be entertained by Bevan, said, “We screwed our nerves up – we might have been going to meet Adolf Hitler.”

But after noticing the Welsh minister’s well-tailored suit, Dr Cockshot was forced to revise his opinion of the charismatic Minister for Health. And yet despite this the doctors remained flatly opposed to his health service. Once the Health Bill became an Act in the closing months of 1946, the BMA immediately adopted a policy of non co-operation with the health service and refused to negotiate with the minister on their conditions of service.

But Bevan was determined to prevent a sectional interest derailing an act of Parliament. He described the BMA as a “small body of politically poisoned people” who had decided “to fight the Health Act itself and to stir up as much emotion as they can in the profession.”

The solution came in 1948 when Bevan struck up a working relationship with the Royal College of Physicians, which was headed by Churchill’s personal doctor, Lord Moran. By allowing the consultants to work inside the health service and at the same time still treat their lucrative private patients, Bevan bought the backing of the consultants by, as he put it, “stuffing their mouths with gold.” The rest of the medical profession soon followed.

Much has been made in the past 60 years of Bevan’s compromise with the doctors – indeed some argue that it remains at the root of some of the most long-standing problems. But surely this deal should be seen within the wider picture of the NHS – without it, would we even have an NHS?

The NHS has been built on compromises – as it has aged those compromises have become more apparent. For example we tolerate waiting lists, despite of the founding principle of universality; we pay for dental care and sight tests, regardless of the idea that healthcare is free at the point of delivery.

Until last year, when Wales became the first country in the UK to abolish prescription charges, about a fifth of us paid for our medicines, through the prescription fee – dubbed a “tax on illness”.

Bevan may have chosen the Park Hospital (now Trafford General Hospital) in Manchester, to formally mark the start of the NHS – the hospital is still regarded as the NHS’s birthplace after admitting the first NHS patient – but the concept of a health service, which is free at the point of delivery and available to all, was conceived in Wales.

Bevan was, after all, the MP for Ebbw Vale in addition to being Minister for Health. He had grown up in a landscape dominated by heavy industry which experienced all the social and health problems associated with the rise of King Coal and King Steel.

His early politics had been heavily influenced by the conditions in which he lived and worked, with more than a dash of socialist doctrine.

In addition, Bevan was committed to the Tredegar Medical Aid Society, which was one of the UK’s most successful community-based self-help schemes for workers and their families.

Almost all of the town’s residents were covered by the scheme – members paid subscriptions, which entitled them, and their dependants, to receive the most comprehensive and the best medical, surgical and dental services in the country, according to need and free at point of care.

When he created the NHS, Bevan said, “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more.

“We are going to ‘Tredegar-ise’ you.”

And former Labour leader Neil Kinnock would later say, “The mixture of cunning and passion that he [Bevan] had to employ in establishing the NHS is widely recognised. Less attention has been given to the way in which he learned the arts and crafts of providing and managing communal health care in the Tredegar Workmen’s Medical Aid Society.

“But, as he testified, the experience of a local working model that embodied all the principles of universal donation during fitness for universal provision during illness was invaluable. It made the rapid establishment of a national system feasible because that task was then more a matter of refinement and enlargement rather than one of raw invention.”

When the NHS was introduced in 1948, it sparked a huge surge in demand for medical care from people who had previously been denied access to free treatment. This demand has scarcely abated in the 60 years since.

The ongoing scandal of seeing ambulances queuing outside hospitals, waiting to offload their patients; of patients spending tens of hours waiting to be seen in A&E; of hundreds of patients stuck in hospital, even though they are well enough to go home, dramatically illustrate this disparity between demand and provision.

Such images threaten to undermine the NHS itself – after all, what is the point of having a health service, which is free at the point of delivery for all, if the sick are unable to access it?

The fundamental problem of the NHS is that it is used purely as a sickness service. Since its introduction, it has – rightly – been a safety net, patching us up when our health fails.

In doing so, it has helped to create a culture of dependency among us – why should we worry about our health when the NHS will always be there to help?

Bevan created a health service committed to caring for everyone from cradle to grave – or as Professor Marcus Longley, of the Welsh Institute for Health and Social Care, prefers, from womb to tomb. Nowhere in this system is there an onus on the patient to take some responsibility for their own health and wellbeing.

It is, of course, inconceivable to suggest that we should all try to treat ourselves when our health fails dramatically, but it is realistic to suggest that we should all be taking better care of ourselves.

The future sustainability of the NHS depends, in a large part, on its ability to balance demand and existing resources. The breadth and depth of medical knowledge is continually expanding, but financial resources are not keeping pace.

As much as we would like it to, the NHS does not have a bottomless purse with which it can pay for current treatments, let alone all the imminent but expensive developments in the pipeline.

If the NHS is to survive in the form that Bevan intended it to – the Welsh Assembly Government has pledged to uphold Bevan’s founding principles – then we, as a society, face some tough decisions in the near future, not least about exactly what we expect the NHS to do.

If we expect it to continue bearing the full burden of our own health, then we must reconsider not only how the health service is funded, but how it is organised to manage that demand. This means embracing and adapting to change, providing that the basic level of care, which we have come to depend upon – and expect as a right – in the last 60 years remains in place.

And, if we accept that there are steps that we can all take to look after our own health and we become proactive participants in the health service, rather than being just passive NHS consumers, then perhaps we can start moving towards having a true National Health Service, rather than a National Sickness Service.