05 July 2014

On this day, 1948: the NHS

On 5 July 1948 the National Health Service was born. It aimed to provide comprehensive medical treatment to all which was fee at the point of service. If the birth was straightforward, the gestation certainly wasn’t.

Previously, medical care had to be paid for, if you were sufficiently rich; if you were poor, you might end up in a Voluntary hospital, effectively a charitable institution at which consultants worked for “the honour”, usually appearing for a couple of half-days a week. The rest of their time their business was the business of making money. If you could afford to, you could attend a general practitioner; and if you were poor you usually had to do without.

In the Welsh valleys, the local population formed associations and opened community hospitals from the early part of the 20th century. These provided care for all members of the community. The best known now was at Tredegar; Tredegar was also the birthplace of Aneurin Bevan, and the system of the funding and provision of the community hospital there was the model for the future NHS; the NHS was conceived in Tredegar.

The system of voluntary hospitals had to be considerably strengthened during WW2 because of the numbers of civilian casualties; at the same time it was recognised that the voluntary hospitals were largely bankrupt.

The Beveridge report was published in 1942. It was an enquiry into social conditions in the UK, and identified five “giant evils”, squalor, ignorance, want, idleness, and disease.

There was strong medical opposition to the concept of an NHS initially; many feared the loss of their independence, becoming merely functionaries of the state, and their earnings. General practitioners did not become employees of the state, rather they became self-employed contractors to the NHS. Their NHS earnings had been estimated from their income tax returns. Unfortunately, many GPs were paid not in cash but in kind, and did not represent this on their returns. It’s quite possible that many had also been economical with the actualitiĆ©, but they could hardly complain. The remuneration of hospital consultants was worked out on the back of a fag packet (literally) by Bevan and Lord Moran, the president of the Royal College of Physicians, and a man largely removed from the realities of everyday life, even though his brother was a GP in Barrow-in-Furness. Bevan later confided that he had been willing to pay up to three times the rate agreed with Lord Moran. If this wasn’t enough, Bevan also agreed a system of “merit awards”, by which consultants could enrich themselves; or as Bevan himself put it, he “stuffed their mouths with gold”.

These pecuniary inducements, along with general sensibilities, were enough to overturn the British Medical Association’s views, and the profession accepted the NHS.

Originally, there was a totally naive view that the vast health improvements would lead to a decrease in the cost of the NHS budget; this never happened, and funding for the service has remained a difficult political problem.

In infancy, childhood and now maturity the NHS has been subject to many “reforms”. “Reform” in NHS-speak does not mean improvement, rather it is synonymous with “saving money” or doing something political for the sake of it, or to enhance politicians’ egos. If the service that the NHS supplies must now be “evidence-based”, such an evidence base is unnecessary for politicians to speak of “reform”.

The infant that was born with such promise 66 years ago did indeed grow into a pretty healthy child and young adult. In its early forties, it suffered a classic mid-life crises with the advent of “managers”, an administrative layer previously unnecessary. And now, as an old age pensioner, there are the inevitable signs of all the stresses and strains of the years: what was once, perhaps, the envy of the world is now seen as such only by the unsighted.

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