Health Policy in Britain

Christopher Ham

• Publisher: Bloomsbury Academic
• Year: 2009
• Print ISBN: 9780230507579
• eBook ISBN: 9781350311985
• Edition: 6
• Topic: Politics & International Relations
• Subtopic: European Politics
• Index: Politics & International Relations

Systematically updated throughout, the 6th edition of this leading text takes the story of health policy to the end of the Blair era and into the early years of the Brown premiership. It offers a clear and thorough introduction to the history of the NHS, its funding and priorities, and to the process of policy making.

Chapter 1

The Development of Health Services and Health Policy

Health policy in Britain today is a legacy of decisions taken by public and private agencies over many hundreds of years. These decisions have shaped the organisation and financing of health care and the part played by government, voluntary or third sector organisations and private interests. The aim of this chapter is to trace the development of health services and health policy in the period leading up to the establishment of the National Health Service, and in the first 30 years of its existence. As well as providing a context for the rest of the book, the chapter illustrates the dynamics of health policy formulation and raises a number of questions explored in more detail in subsequent chapters.

The National Health Service came into existence on 5 July 1948 with the aim of providing a comprehensive range of health services to all in need. One hundred years earlier the first Public Health Act was placed on the statute book, paving the way for improvements in environmental health which were to have a significant effect in reducing deaths from infectious diseases. The name of Aneurin Bevan is usually associated with the founding of the NHS, and that of Edwin Chadwick with the public health movement. However, legislation and policy are not made only or mainly by outstanding individuals. It has been said of Bevan that he was ‘less of an innovator than often credited; he was at the end, albeit the important and conclusive end, of a series of earlier plans. He “created” the National Health Service but his debts to what went before were enormous’ (Willcocks, 1967, p. 104). Much the same applies to other health policy decisions. Individuals may have an impact, but under conditions not of their own making. What is more, most decisions in their final form result from bargaining and negotiation among a complex constellation of interests, and most changes do not go through unopposed. These points can be illustrated through the examples already cited.

Take the 1848 Public Health Act, for example. The main aim of the Act was to provide powers to enable the construction of water supply and sewerage systems as a means of controlling some of the conditions in which infectious diseases were able to thrive and spread. On the face of it, this was a laudable aim which might have been expected to win general public support. In fact, the Act was opposed by commercial interests who were able to make money out of insanitary conditions; and by anxious ratepayers, who were afraid of the public expense which would be involved. It was therefore only after a lengthy struggle that the Act was passed.

Again, consider the establishment of the NHS. The shape taken by the NHS was the outcome of discussions and compromise between ministers and civil servants on the one hand, and a range of pressure groups on the other. These groups included the medical profession, the organisations representing the hospital service, and the insurance committees with their responsibility for general practitioner services. Willcocks has shown how, among these groups, the medical profession was the most successful in achieving its objectives, while the organisations representing the hospital service were the least successful. A considerable part too was played by civil servants and ministers. In turn, all of these interests were influenced by what had gone before. They were not in a position to start with a blank sheet and proceed to design an ideal administrative structure. Thus history, as well as the strength of established interests, may be important in shaping decisions. Let us then consider the historical background to the NHS.

The origins of hospitals and medicine

The origins of hospitals in Britain can be traced back to medieval times when religious foundations established institutions such as St Bartholomew’s in 1123 and St Thomas’s in 1215. Hospital building took off in the thirteenth century alongside the establishment of universities across Europe and formal medical training. Even at this early stage, three types of doctor began to emerge: physicians, barber-surgeons and apothecaries, the forerunners of general practitioners. Physicians were the elite doctors and their training was based in the universities. In contrast, surgeons served an apprenticeship organised through guilds. Apothecaries were originally shopkeepers who provided basic medical care and administered drugs. Like physicians and surgeons, apothecaries were limited in their ability to offer help to patients by the rudimentary understanding of the causes of disease that existed at that time. Midwives played the major part in childbirth, and childbirth was dominated by women until the eighteenth century.

It was not until 1518 that the College of Physicians of London was formed to exercise control over the licensing and examination of physicians. Subsequently, surgeons separated from barbers and established the London Company of Surgeons in 1745 and this became the College of Surgeons in 1800. The Society of Apothecaries was involved in regulating general practitioners in London, although the extent to which it was effective in this role has been questioned (Porter, 1997). The nature and content of medical education in the eighteenth century was highly variable and many doctors practised without formal qualifications. Only in the nineteenth century with the passage of the Apothecaries Act in 1815 and, more importantly, the Medical Act in 1858, did the state act to regulate medicine.

The Apothecaries Act required apothecaries to have the Licence of the Society of Apothecaries, the receipt of which rested on a combination of training and clinical experience. The Medical Act created the forerunner of the General Medical Council (GMC) with responsibility for licensing doctors and overseeing education and disciplinary matters. In place of a variety of forms of local regulation, a single national register of qualified medical practitioners was created for the first time. Although ostensibly intended to protect the public, the Medical Act also served the interests of doctors by enabling controls to be exercised over the number of doctors in practice. At a time when medical practice was almost entirely private practice, control over entry helped to maintain medical incomes and exclusivity (Stacey, 1992). This was particularly important for general practitioners who were the biggest group of doctors at that time and who sought protection from the unqualified. The important point about the Medical Act was that it led to a system of state-sanctioned self-regulation that has persisted with minor modifications until this day.

The development of hospitals was set back by the dissolution of the monasteries by Henry VIII and the impact this had on institutions for the sick that had had their origins in religious foundations. In London, only St Bartholomew’s, St Thomas’s and the Bethlem survived until the resurgence of hospitals in the eighteenth century. In parallel there grew up the dispensaries as an early form of outpatient care that also provided drugs for the sick. The role of hospitals developed further in the nineteenth century when specialisation among doctors led to the establishment of specialist hospitals. By 1860 there were at least 66 special hospitals and dispensaries in London concerned with children’s health, nervous diseases, orthopaedics and other needs (Porter, 1997). In the second half of the nineteenth century, public infirmaries were created separate from the workhouses that provided relief for the poor, and in this way the basis for state involvement in hospital provision was laid down (see below). Another important development was increasing separation between specialists who controlled care in hospitals and general practitioners who worked in the community. The end of the nineteenth century saw the emergence of the referral system under which specialists became consultants to general practitioners. This division of labour among doctors was to have long-lasting implications for the practice of British medicine and the organisation of health services.

Public health services

While the Medical Act of 1858 was a landmark in the development of the medical profession, the most important area of state involvement in the provision of health services during the nineteenth century, in terms of the impact on people’s health, was the enactment of public health legislation. Infectious diseases like cholera and typhoid posed the main threat to health at the time. The precise causes of these diseases remained imperfectly understood for much of the century, and the medical profession was largely powerless to intervene. In any event, the main reason for the decline in infectious diseases was not to be advances in medical science, but developments in the system of public health. It was these developments which provided an effective counterweight to the sorts of urban living conditions created by the industrial revolution and within which infectious diseases could flourish.

The 1848 Public Health Act provided the basis for the provision of adequate water supplies and sewerage systems. Behind the Act lay several years of struggle by Edwin Chadwick and his supporters. As Secretary to the Poor Law Commission, Chadwick played a major part in preparing the Commission’s Report of an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain, published in 1842. The report, and the ever-present threat of cholera, created the conditions for the Act, which led to the establishment of the General Board of Health. Subsequent progress was variable, with some local authorities keen to take action, while others held back. In practice, a great deal depended on the attitude of local interests, as the Act was permissive rather than mandatory, and the General Board of Health was only an advisory body.

Chadwick’s campaign was taken forward by John Simon, first as Medical Officer to the General Board of Health, and later as Medical Officer to the Medical Department of the Privy Council, which succeeded the Board in 1858. Simon’s work and the report of the Royal Sanitary Commission, which sat from 1869 to 1871, eventually bore fruit in the establishment of the Local Government Board in 1871, and the Public Health Acts of 1872 and 1875. The 1875 Act brought together existing legislation rather than providing new powers, while the 1872 Act created sanitary authorities who were obliged to provide public health services. One of the key provisions of the 1872 Act was that local sanitary authorities should appoint a medical officer of health. These officers – whose origins can be traced back to Liverpool in 1847 – were significant figures, both in the fight against infectious diseases, and in the campaign for better health. It was mainly as a result of their activities at the local level that more concerted action was pursued.

Mothers and young children

From the beginning of the twentieth century, the sphere of concern of medical officers of health extended into the area of personal health services as the result of increasing state concern with the health of mothers and young children. One of the immediate causes was the discovery of the poor standards of health and fitness of army recruits for the Boer War. This led to the establishment by government of an Interdepartmental Committee on Physical Deterioration, whose report, published in 1904, made a series of recommendations aimed at improving child health. Two of the outcomes were the 1906 Education (Provision of Meals) Act, which provided the basis for the school meals service, and the 1907 Education (Administrative Provision) Act, which led to the development of the school medical service. It has been argued that these Acts ‘marked the beginning of the construction of the welfare state’ (Gilbert, 1966, p. 102). Both pieces of legislation were promoted by the reforming Liberal government elected in 1906, and the government was also active in other areas of social policy reform, including the provision of retirement pensions.

At the same time action was taken in relation to the midwifery and health visiting services. The 1902 Midwives Act made it necessary to certify midwives as fit to practise, and established a Central Midwives Board to oversee registration. The Act stemmed in part from the belief that one of the explanations for the high rates of maternal and infant mortality lay in the lack of skills of women practising as midwives. Local supervision of registration was the responsibility of the medical officer of health, whose office was becoming increasingly powerful. This trend was reinforced by the 1907 Notification of Births Act, one of whose aims was to develop health visiting as a local authority service. The origins of health visiting are usually traced back to Manchester and Salford in the 1860s, when women began visiting mothers to encourage higher standards of childcare. The state’s interest in providing health visiting as a statutory service mirrored its concern to regulate midwives and provide medical inspection in schools, and the importance of health visiting was emphasised by the Interdepart-mental Committee on Physical Deterioration. The 1907 Act helped the development of health visiting by enabling local authorities to insist on the compulsory notification of births. An Act of 1915 placed a duty on local authorities to ensure compulsory notification.

Arising out of these developments, and spurred on by the 1918 Maternity and Child Welfare Act, local authorities came to provide a further range of child welfare services. These services included not only the employment of health visitors and the registration of midwives, but also the provision of infant welfare centres and, in some areas, maternity homes for mothers who required institutional confinements. However, the Ministry of Health, which had been established in 1919, continued to be concerned at the high rate of maternal deaths, as the publication in 1930 and 1932 of the reports of the Departmental Committee on Maternal Mortality and Morbidity demonstrated. Particular importance was placed on the provision of adequate antenatal care. This led to an expansion of antenatal clinics, and, after the 1936 Midwives Act, to the development of a salaried midwifery service.

Health insurance

The 1911 National Insurance Act was concerned with the provision of general practitioner (GP) services. The Act was an important element in the Liberal government’s programme of social policy reform, and it provided for free care from GPs for certain groups of working people earning under £160 per annum. Income during sickness and unemployment was also made available, and the scheme was based on contributions by the worker, the employer and the state.

Like other major pieces of social legislation, the Act was not introduced without a struggle. As Gilbert (1966, p. 290) has noted, ‘The story of the growth of national health insurance is to a great extent the story of lobby influence and pressure groups’. Gilbert has shown how Lloyd George pushed through the Act to come into operation in 1913, but only after considerable opposition from the medical profession. The doctors were fearful of state control of their work, and of the possible financial consequences. They were persuaded into the scheme when the government agreed that payment should be based on the number of patients on a doctor’s list – the capitation system – rather than on a salary, thereby preserving GPs’ independence. Also, it was decided that the scheme should be administered not by local authorities, but by independent insurance committees or ‘panels’. The insurance companies and friendly societies that had previously played a major part in providing cover against ill health were given a central role on the panels. The professional freedom of doctors was further safeguarded by allowing them the choice of whether to join the scheme, and whether to accept patients. Finally, the financial fears of the profession were assuaged by the generous level of payments that were negotiated, and by the exclusion of higher income groups from the scheme. The exclusion of these groups created a valuable source of extra income for GPs. By the mid-1940s around 21 million people or about half the population of Great Britain were insured under the Act. Also, about two-thirds of GPs were taking part. Nevertheless, the scheme had important limitations: it was only the insured workers who were covered, and not their families; and no hospital care was provided, only the services of GPs. Despite these drawbacks, the Act represented a major step forward in the involvement of the state in the provision of health services.

Hospital services

As we noted earlier, public provision of hospitals developed out of the workhouses provided under the Poor Law. The voluntary hospital system had a much longer history, being based at first on the monasteries and later on charitable contributions by the benevolent rich. Of the two types of institution, it was the voluntary hospitals that provided the higher standards of care. As the nineteenth century progressed, and as medicine developed as a science, the voluntary hospitals became increasingly selective in their choice of patients, paying more and more attention to the needs of the acutely ill to the exclusion of the chronic sick and people with infectious diseases. Consequently, it was left to the workhouses to care for the groups that the voluntary hospitals would not accept, and workhouse conditions were often overcrowded and unhygienic. Some of the vestiges of this dual system of hospital care can still be observed in the NHS today.

It was not, perhaps, surprising that workhouse standards should be so low, since one of the aims of the Poor Law was to act as a deterrent. The ‘less eligibility’ principle underpinning the 1834 Poor Law Amendment Act depended on the creation of workhouse conditions so unattractive that they would discourage the working and sick poor from seeking relief. The Act was also intended to limit outdoor relief: that is, relief provided outside the workhouses. In the case of medical care, this was provided by district medical officers under contract to the Boards of Guardians who administered the Poor Law. Vaccination against smallpox was one of the services for which medical officers were responsible, beginning with the introduction of free vaccination for children in 1840.

There was some improvement in Poor Law hospital services in London after the passing of the 1867 Metropolitan Poor Act. The Act provided the stimulus for the development of infirmaries separate from workhouses, and the London example was subsequently followed in the rest of the country through powers granted by the 1868 Poor Law Amendment Act. However, the establishment of separate infirmaries coincided with a further campaign against outdoor relief. This was despite the fact that in some areas public dispensaries, equivalent to rudimentary health centres, were provided for the first time. Nevertheless, the legislation which encouraged the development of Poor Law infirmaries has been described as ‘an important step in English social history. It was the first explicit acknowledgement that it was the duty of the state to provide hospitals for the poor. It therefore represented an important step towards the NHS Act which followed some eighty years later’ (Abel-Smith, 1964, p. 82). And as Fraser has commented, ‘through the medical officers and the workhouse infirmaries the Poor Law had become an embryo state medical authority providing in effect general practitioners and state hospitals for the poor’ (Fraser, 1973, p. 87).

The 1929 Local Government Act marked the beginning of the end of the Poor Law, and was a further step on the road to the NH...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Figures and Tables
• Acknowledgements
• Preface to the Sixth Edition
• Abbreviations
• Introduction
• 1. The Development of Health Services and Health Policy
• 2. Health Policy under Thatcher and Major
• 3. Health Policy under Blair and Brown
• 4. Financing Health Services and the Rediscovery of Public Health
• 5. Policy and Priorities in the NHS
• 6. Policy-making in Westminster and Whitehall
• 7. Policy-making in Scotland, Wales and Northern Ireland
• 8. Policy-making in the Department of Health
• 9. Implementing Health Policy
• 10. Auditing and Evaluating Health Policy and the NHS
• 11. Power in Health Services
• 12. Looking Back and Looking Ahead
• 13. Reflections on the Reform of the NHS: 11 Lessons for Policy-makers
• Guide to Further Reading
• Bibliography
• Index