HEALTH POLICY

Ann Wall, Barry Owen

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000143096
• Topic: Medicine
• Subtopic: Health Care Delivery

The health care system in Britain at the beginning of the twenty-first century is being subjected to radical rethinking. Health Policy examines how the NHS has developed to the point it has reached today as well as placing it in the wider context of the kinds of health care which are available to people in Britain. It looks at key issues which have arisen in the provision of health care such as rationing, the operation of interest groups, relationships between the public, voluntary and private sectors and whether the NHS has delivered care equally to all sectors of the population. In this second edition, the authors pay particular attention to the policy changes introduced by the Labour government following it selection in 1997 and places these within a wider discussion of the concept of a primary care-led system. Health Policy will be especially useful to readers who wish to inform themselves about what is happening in the NHS today or to deepen their understanding of current developments through an appreciation of how the health care system has evolved over the past fifty years. It includes useful summaries of key points, guides to further reading and a glossary of key terms.

Part I
Background

Chapter 1
Preparing the ground

Outline

The years between the two world wars, and the experience of the Second World War, produced a deep desire and readiness for fundamental changes in the relationship between the State and its citizens. In the 1945 general election, in spite of the personal popularity of Winston Churchill, the Labour Party was put into power with a resounding majority with the mandate to build the Welfare State foreshadowed in the wartime Beveridge Report. This chapter focuses on the task of restructuring the system of public health care so that it satisfied new principles more generous than those of earlier times.

The importance of the Second World War

It is tempting to see the creation of the National Health Service (NHS) and the changes that it brought to the everyday lives of the citizens of the United Kingdom in a sort of 'Big Bang' scenario made up of:

• the election of the Labour Government in 1945
• the passing of the NHS Act in 1946
• the actual setting-up of the NHS on 5 July 1948.

The temptation is understandable. The Second World War was a new kind of war that involved the whole population, civil as well as military. The 1945 general election produced the first Labour Government with a solid House of Commons majority, which could allow it to enact its programme. And the new Government enacted major pieces of legislation, including the 1946 National Health Service Act. But this view is too simple in that it paints a before-and-after picture of unqualified bad turning into unqualified good.

Even before the war, there were many signs that all was not well in the relationship between the State and the mass of the population, particularly the poor, the young, the unemployed and the sick. For example, although the British Medical Association (BMA) was ever watchful for what it saw as threats to the status, pay and conditions of doctors, it had already put forward proposals aimed at widening the availability of medical care funded through national health insurance, so that coverage would extend beyond the wage earner to include the family and to provide for specialist services.

Similarly, there was widespread recognition that existing arrangements, whereby most hospitals were run by local authorities, although about a quarter were independent and voluntary, were unsatisfactory and that the two streams needed to be more closely integrated.

However, if we compare the government's view of the obligations of the State towards its citizens, in the middle/late 1930s and fifteen years later, it is clear that there had been a fundamental re-ordering of priorities. By 1950, there was a Welfare State, which included an NHS. A decade earlier, some of the bits and pieces had existed, but not enough to form a complete jigsaw. There had been, without doubt, a major change.

The origins of change

This change can be traced back to the public health legislation of 100 years before, whereby Parliament began to define a role for local authorities. There were Public Health Acts in 1848, and (following the report of the Royal Sanitary Commission) in 1872 and 1875. However, the legislation allowed measures rather than compelled them, and the response of local authorities varied widely. But the 1848 Act created the General Board of Health and the 1872 Act created sanitary authorities with the duties of appointing Medical Officers of Health and providing public health services. The growing number of public authorities operating at local level (and not just in the field of health care) needed to be rearranged into a local government system, and this, too, happened towards the end of the century. The poor state of health of British soldiers in the Boer War led, via the setting-up of the Committee on Physical Deterioration, to the provision of school meals and school medical services early in the twentieth century and legislation was also passed relating to midwifery services.

In other words, throughout the nineteenth century, government was becoming aware of, and seeking to shape responses to, healthrelated problems. This often produced a reaction that, though in itself inadequate, did at least expand knowledge of the scale of the problem and then led to further measures. For example, the 1875 provision for the appointment of Medical Officers of Health turned out to be full of potential, for these officials were able, particularly within the emerging local government system, to act as champions of public health. The great reforming Liberal administration, which came into office in 1905, accelerated this process of the State assuming responsibilities towards those not best able to look after themselves. The Victorian view that it was up to individuals to stand upon their own two feet had been carrying less and less conviction, and was giving way to a more collectivist view. By early in the last century Britain may not have been ready for a Welfare State, but it was ready for Lloyd George, and 1919, after the horrors of the First World War, saw the establishment of a Ministry of Health.

Britain might eventually have established a Welfare State, and an NHS, even without the Second World War. But it would almost certainly have taken longer to arrive, and longer to establish, and the details might have been different. For example, without the experience of the wartime Emergency Medical Service, the case for taking the hospitals out of both local authority and voluntary control, and effectively 'nationalizing' them, would have appeared weaker.

The Second World War, like many wars, was an important harbinger of social change. The trauma of the First World War had been followed by disappointment. 'Homes Fit for Heroes' remained only a slogan; the reality, for many, was unemployment. But the Second World War turned out to be different from anything experienced before and its impact was even greater. Bombing of civilian targets meant that the whole population was involved. The whole of economic life had to be bent towards victory, and this involved controls on everyday life on a scale that had never before been experienced.

And there were more specific factors at work. The formation of the Coalition Government under Churchill in 1940 brought the Labour Party into the heart of government, with the Labour leader, Attlee, assuming the post of Deputy Prime Minister by 1942. Apart from what this did to public perceptions of Labour politicians, it also gave them experience of ministerial office.

The war also showed that extensive State direction of economic life was a practicable proposition. Five years' experience of a war economy showed that the argument that there were areas of activity where government was simply incapable of getting involved was groundless. And, quite apart from direct controls, 1941 saw the first budget put together along Keynesian lines, i.e. being used as a device to keep inflation down. This opened the way for budgets to be seen as more than just devices for keeping government expenditure to a minimum but, instead, as a method of guiding the economy, sometimes towards deflation and sometimes towards expansion. In other words, budgets could be used as a way of helping governments to do things rather than as a brake on their ambitions. This had further implications for the role of the Treasury, which henceforth would find it more difficult always to say no.

The Beveridge Report

The high point of this climate of change was the publication of the Beveridge Report in 1942, which was a blueprint for the future Welfare State, based on three fundamental assumptions:

• the NHS;
• family allowances;
• the maintenance of employment (Addison 1994, p. 169).

The Coalition Government was divided in its reactions to the Report. Broadly, the Labour members were in favour of acceptance at once, while the Conservatives were more hesitant, sometimes opposing its recommendations in principle. Churchill was reluctant to give firm undertakings before the war was over, preferring to wait and see what would be affordable. He was able to impose his view on the Cabinet, which in turn made Labour MPs unhappy with Labour ministers. But the widespread approval given to the Beveridge Report in the country at large could not be ignored, and by the Spring of 1943, Churchill was broadcasting promises that the war's end would see a new House of Commons legislating in a number of major areas. Although no detailed commitments were given, this was almost a promise that victory would be followed by the implementation of a great number of Beveridge's proposals.

By the end of the war it would have been close to unthinkable for the post-war government - Labour or Conservative - not to have started constructing what became known as the Welfare State, including a national system of health care. Education in the period after the war had already been taken in hand with the passing of the 1944 Education Act, and family allowances were provided even before the Labour Government took office.

Post-war negotiations with the doctors

Although it was evident that a national system of health care was necessary, there were still many details to be decided. The government had issued tentative proposals for a comprehensive health care system during the war, but these had envisaged a major role for local authorities that horrified the BMA and led to a stalemate until the 1944 White Paper A National Health Service got discussions going again. Even so, the BMA fought a rearguard action almost until July 1948. The leading figures in the BMA only gave in when faced with the undeniable fact that many GPs were actually signing up to the new Health Service (the consultants and their Royal Colleges had been more receptive to Aneurin Bevan's ideas from the start).

As the Labour Minister of Health, Bevan had a reputation as something of a socialist firebrand, but he was also a skilled politician, and was willing to build upon existing ideas and to negotiate. Possibly the most fundamental decision concerned what to do about the hospitals. Within a few weeks of becoming Minister of Health, Bevan decided, effectively, to nationalize them. The Emergency Medical Service during the war had shown that this was a possibility, and there had been serious concerns about the financial viability of the voluntary hospitals after the war. Bevan decided that the most effective solution would be to bring all the hospitals under the control of his Ministry. There was disagreement within Cabinet but, with the backing of Prime Minister Attlee, Bevan won the day.

The details of these disagreements and compromises can be found elsewhere (see Addison 1994, Chapter 10; Hennessy 1992; Timmins 1996; Willcocks 1967). What is more important is to note the basic shape of the system that came into being in July 1948, and the principles that it was supposed to enshrine.

The new NHS

The NHS was essentially tripartite, being composed of:

1. Hospitals
2. General medical and dental practitioners, pharmacists and opticians
3. Health care services (provided by local authorities)

See Figure 1.1.

In one sense this was an extension of what had gone before, since by 1939 there was already quite a wide range of health care available to most people. These arrangements had grown up in a rather piecemeal fashion, however, and were less than adequate in coverage, quality and geographical distribution. To some extent, then, the NHS was meant to tackle questions resulting from a lack of clarity and inefficiency. It had a practical, administrative element to it, which Klein (1995) describes as a rational paternalist approach (an approach that stretched back to Edwin Chadwick's General Board of Health exactly 100 years before).

Figure 7.7 The tripartite NHS

And yet the NHS was meant to be much more than this. One of Bevan's favourite words was serenity, by which he meant peace of mind and freedom from worry. It was the task of the new Service to provide serenity for all and without distinction. The 1946 Act took a particular view of health care, seeing it not as an individuallybased right made real through a transaction between doctor and patient, funded via insurance. Instead, health care was established as a public good, freely available to all, an intrinsic part of a civilized society. This explains why, for example, the very wealthiest, who could easily afford to pay for private health care, were included in the scheme. They, too, were a part of society. They paid their taxes and they were also entitled to use the NHS.

The importance of taxation

People do not pay taxes solely in order to finance the services that they, individually, receive. Taxation is essentially a collective undertaking, and individuals pay in order to finance, in a general way, the activities which government undertakes for the benefit of society as a...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• Dedication
• Contents
• List of illustrations
• Part I: Background
• Part II: The issues
• Part III: The future - new possibilities
• Glossary
• References
• Index