Health and the National Health Service

John Carrier, Ian Kendall

• Publisher: Taylor & Francis
• Year: 2015
• eBook ISBN: 9781135310950
• Edition: 2
• Topic: Law
• Subtopic: Law Theory & Practice
• Index: Law

The NHS came into existence in an atmosphere of conflict centred on the strong ideological commitment of the Post-war Labour Government and the opposition of the Conservative Party of that time to the idea of a universally available and centrally planned medical care service. There was also opposition from some sections of the medical establishment who feared the loss of professional autonomy.

Setting health policy in both an historical and modern context (post 1997) Carrier and Kendall weigh up the successes and failures of the National Health Service and examine the conflicts which have continued for over sixty years, in spite of efforts to solve financial problems in the NHS through increases in funding as well as structural and organisational change.

After looking at recent responses to supposed failures of the NHS, they conclude that the NHS has successfully faced the challenges before it and is likely to continue to meet the changing health needs of the population. Financial stresses, concerns about the quality of care and demographic change, with consequent issues for the elderly and the chronically ill, continue to be urgent and politically contentious issues.

This book is appropriate for a wide range of undergraduate and postgraduate students studying health policy and the NHS.

Part IBefore the NHS

1 Before ‘new liberalism', the long history of the state and health care

DOI: 10.4324/9781843146117-1

The National Health Service had its direct roots in the medical services of the Poor Law.

(Hodgkinson 1967: 696)

We begin our history not only before the twentieth century, but also before the full impact of industrialisation and urbanisation was discernible. The reason for taking this longer-term historical perspective is that long-standing conflicts and divisions have influenced a number of subsequent developments in health and health care in the UK, at least in part because ‘most of the basic characteristics of British medical practice were … clearly in existence by 1900’ (Stevens 1966: 11). The major state interventions of the twentieth century, National Health Insurance (1911) and the National Health Service (NHS) (1946), were constructed around the divisions within the medical profession and the voluntary sector which had existed in the nineteenth century. Furthermore, conflicts identifiable within late-nineteenth century health care played a part in how the interventions of the state were structured:

The new Poor Law was thrust on England in an age of economic and social dislocation. The grave consequences of this upheaval were the mass of actual pauperism engendered and the migratory army of poor who were turned adrift to find livelihood and shelter in the new urban slums. Action for this chaotic flotsam and jetsam was inevitable, but fear was its conditioning agent; and national unrest made immediate legislation in the early thirties imperative.

(Hodgkinson 1967: 1)

The origins of contemporary conflicts relating to issues associated with health and health care might plausibly be located in the development of the nation state rather than the establishment of a national health service. With the emergence of nation states and national economies, issues of poverty and destitution became matters of concern for governments, a concern, it has been suggested, connected as much with repression as with compassion (Bruce 1961: 23). In the UK we can identify the Elizabethan Poor Laws (1598 and 1601) as indicators of this concern. In so far as ill-health was either a cause, or a consequence, of poverty and destitution, the activities of the Poor Law of 1601 (Poor Law) included some degree of care and support for sick paupers (Abel-Smith 1964: 3–4). The availability of even rudimentary health care was therefore an indirect consequence of a very limited form of public assistance; this meant also that such health care would be part of whatever conflicts would be associated with the subsequent development of this public assistance.

Some well-documented and enduring conflicts were between parishes, as Poor Law authorities, concerning the locality responsible for particular paupers (Bruce 1961: 3). These disputes between parishes were one indication that this system of public assistance was intended to expend minimal sums of public money to achieve broader social and political goals. It was also an enduring theme, and it was not surprising that the entire framework of parish-based relief should be the subject of particular interest and conflict in the early part of the nineteenth century when escalating expenditure generated concerns about its economic effects.

The resulting new Poor Law followed a Royal Commission and an Act of Parliament (Poor Law Amendment Act 1834) and has been widely identified with the liberal ‘laissez-faire’ ideology and the concept of ‘The Liberal Break’ (Doyal 1979: 142; Fraser 1973: Ch. 5; Gilbert 1966: 13–14; Thane 1982: 11). The core ideas of the latter included notions of individualistic freedom and self-help, and were essentially antithetical to anything more than minimal state intervention in areas broadly encompassed by the categories of economic and social policy. From this perspective the final decades of the old Poor Law had been an exercise in misplaced compassion involving excessive state expenditure on public assistance and excessive state intervention in social and economic affairs through the mechanism of ‘outdoor relief’. The latter involved a situation in which many parishes had been party to the establishment of a range of ‘allowance systems’ supporting families in the community beyond the confines of the poorhouse.

The new order ushered in by the 1834 legislation was intended to proscribe the role of public assistance by a more precise delineation of who might be in receipt of such assistance. The principles underpinning the new Poor Law were not new, but were clearly intended to be more rigorously adhered to than had apparently been the case in the final years of the old Poor Law. The Poor Law had never sought to provide aid to all the poor, but its function of assisting only those who were completely destitute was now set down with greater clarity. The means by which such a minimal role could be maintained, whilst causing no offence to work incentives and the value of self-help, was the ‘less-eligibility’ or ‘workhouse test’. Conditions within the workhouses of the Boards of Guardians, the new Poor Law authorities, were to be made less eligible than that of the lowest paid worker in the community and there was to be no poor relief offered beyond the confines of the workhouse. The framers of the Poor Law ‘had assumed the individual to be poor because he was evil, and as such might be treated with a generous helping of salutary harshness’ (Gilbert 1966: 26). The Poor Act 1834 was ‘conceived for the welfare of the wealthy’ (Hodgkinson 1967: 695).

The outcome was health care for the poor ‘marked by a chilling and pervasive atmosphere of deterrence’ (Brand 1965: 86), the intention being the maintenance of an ideal-type of minimal state intervention in health and welfare, an institution-based/less eligibility residual model. Almost the only thought from officials high and low was, ‘reduce expenditure and save the rates’. Year after year, the Annual Reports congratulated the country ‘that the cost of relief was diminishing when compared with the wealth and population of the nation’ (Hodgkinson 1967: 65). Within 25 years, at least one medical practitioner would develop plans for a state medical service on an insurance basis (Rumsey 1856: 265–9), and within 50 years a President of the Poor Law Board would write that:

the economical and social advantages of free medicine to the poorer classes generally, as distinguished from actual paupers, and perfect accessibility to medical advice at all times under a thorough organisation, may be considered as so important in themselves, as to render it necessary to weight with the greatest care all the reasons which may be adduced in their favour.

(Hodgkinson 1967: 332–3)

Thus, subsequent developments and the trend away from the model embodied in the new Poor Law were anticipated by professionals and managers in the nineteenth century, although this trend would be accompanied by continuing conflicts about its desirability. The new Poor Law was intended also to provide a more efficient system of administration. A smaller number of larger Poor Law authorities were established. Boards of Guardians replaced parishes, and there was to be more central control through the Poor Law Commission. This may represent one of the earliest examples in British social policy of the tendency ‘to seek administrative solutions to problems that are basically economic or technological’ (Brown 1972: 132). It would certainly not be the last occasion on which larger units of administration and more central control were seen as the most appropriate reform.

If one of the intentions of the new Poor Law was to limit what medical assistance it might offer in terms of quantity and quality, then it might be said to have done a service to those sick paupers for whom it was providing relief! The limitations of contemporary medical education, medical practice, and hospital care, in the first half of the nineteenth century, have been well documented. For hospitals the ‘most notorious and persistent of … controversies centred upon the question of whether [they] actually killed more people than they cured’ (Harris 1979: 287). Medical education was rudimentary, although improving through the adoption of scientific findings into the curriculum. Practice was commercial not social in orientation, and therefore not rationally distributed to match needs, and hospital care varied in quality, distribution, and successful outcome for the patient (Eckstein 1958: 15–16; Stevens 1966: 23).

The operation of the new Poor Law did not altogether accord with the aims of its advocates. There is evidence of a considerable continuity of personnel and practices between the pre-1834 and post-1834 situations with the relatively limited powers of the central Poor Law Commission providing ample opportunity for local variations in the scale and standard of provision (Brand 1965: 82; Thane 1982: 12; Abel-Smith 1964: 47 and 50). After 20 years of operation the vast majority of paupers were on outdoor relief (Fraser 1973: 48), one indication that the new Poor Law might have constituted some sort of response to rural destitution but could hardly be made to work at all for the poverties of industrialism.

The new Poor Law was coming under pressure from two closely related factors. The first was the doubling of the population of Great Britain between 1801 and 1851, and again between 1851 and the outbreak of the First World War. Alongside this there was the movement of the population from rural to urban settings. The second factor was the social conditions in these urban settings, the new industrial towns and cities, dramatically demonstrated by Chadwick and others (Brand 1965: 2–21; Hodgkinson 1967: Ch. 17). These factors formed the basis of the initial case for specific state intervention in health care made by the ‘public health movement’, an intervention that could claim some support from those who favoured policies to minimise public expenditure on health and welfare:

To apply the prevention principle to the new social problems necessitated a new type of activity. Departure from ‘laissez-faire’ was inevitable.

(Hodgkinson 1967: 621)

With the steadily mounting population came the new sanitary problems and mounting urban deaths. ‘Laissez-faire,’ still the favourite nineteenth century watchword, provided no solution.

(Brand 1965: 1)

[A] … hell of depression and misery and hopeless degradation. Foul odors, vermin, vile food, drunkenness and promiscuity were the chief by-products of its depauperate and crowded existence: crime and disease were but the inevitable psychological and physiological responses.

(Mumford 1940: 12, on the industrial slums of Victorian England)

[Sickness] … destroys a man’s capacity for labour, and if he has failed to make timely provisions (or if wages are too low to do so) he is at once prostrated, when sickness overtakes him, and has therefore of necessity to look for help to others. Whilst therefore adhering in their entirety to the principles of the Poor Law Amendment Act, we may yet admit that medical relief is in its nature, not only the least objectionable of all modes of relief, but it is within reasonable limits admissible and in the existing state of society, even necessary.

(Nicholls 1854, quoted in Hodgkinson 1967: 59)

The Vaccination Act 1840 was an indicator of a potential conflict between the ideology that was intended to underpin the social policies in the first half of the nineteenth century and the social problems of the period. This piece of legislation provided for free vaccination to all who applied for it without reference to their circumstances. Vaccination was the first of the free health services provided by the legislature on a national scale. A beginning in positive health measures had been made, and it was administered through the channels of the Poor Law (Hodgkinson 1967: 31).

However, this identification of a social problem with a forthcoming administrative response can suggest that health reforms of the time logically followed the identification of ‘public concerns’ (Paulus 1974). It can easily be forgotten that this expansion of state intervention was extremely contentious at the time. Cholera scares seem to have been ‘of great service to the advancement of English sanitation’, reformers being well aware that this fear of cholera could be used to good effect to enact changes that had more impact on other threats to the public health (Brand 1965: 45), but support for reform ‘waned with the passing of … [each] … epidemic’ (Brand 1965: 2) and was anyway not sufficient to convince the leader writer in The Times who argued that the population might wish to take their ‘chance with cholera and the rest’ rather than be ‘bullied into health’ (The Times, 1 August 1854), As one commentator was to observe subsequently, it was not until a considerable time after the passage of the Public Health Act 1848 that ‘that there was a general conviction that it might be better to suffer the compulsion of being kept alive than to enjoy the privilege of being allowed to die in an epidemic of fever’ (Wilson 1938: 21). Such attitudes are one explanation of the delay in getting effective public health legislation on to the statute book.

The marked differences between death rates in urban and rural areas were being documented by the Registrar-General in the 1830s, yet it was 1848 before the first Public Health Act was passed. This has been identified as one of the earliest examples of state control over the lives of individuals in a predominantly laissez-faire society (Doyal 1979: 142), although it was permissive legislation and had a limited impact. Almost a quarter of century would pass until a comprehensive and mandatory piece of legislation was placed on to the statute book (Thane 1982: 40) and there would be graphic evidence after its enactment of a failure to use the resulting statutory powers effectively (Gilbert 1966: 28–9). If there were a necessary logic to public health legislation, it was a logic that took many years to be accepted by the government. The ‘public health problem’ of Britain’s industrial cities had claimed many victims between the emergence of the ‘objective evidence’ collected by government civil servants and the acceptance of the need for action by the politicians in government. To identify a problem did not necessarily mean that a state-supported solution to eliminate th...

Table of contents

• Cover
• Half Title Page
• Series
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Biographical details
• Preface
• List of tables and figures
• Introduction
• PART I Before the NHS
• PART II The NHS, July 1948–May 1979
• PART III The NHS, 1979–2010
• PART IV Case study
• PART V The NHS, 2010–2015
• Bibliography
• Index