The past, present and future of the NHS

Submitted by Anon on 27 October, 2007 - 8:45 Author: Mike Fenwick

Next year is the 60th anniversary of the foundation on the NHS. Two generations of British peoples’ lives have been affected by the NHS in one way or another — as health workers, patients or carers. It’s difficult to imagine a time in the past without it, or a future with it gone. For the labour movements that fought for it, free healthcare for all at the point of demand, expressed an notion of social equality and solidarity. All that is now under threat.

The trade union-organised demonstration on 3 November is an opportunity to prepare ourselves for the battle ahead to save the NHS.

Before the Second World War health care in Britain was dependent on how much money you had to spend on it. The government had little role in provision beyond public health information on hygiene or communicable diseases. It was assumed that the individual, not the state was responsible for paying for the health of themselves and their families.

Health care was available in a patchwork system of local GPs, voluntary (charity or church funded) hospitals or Poor Law hospitals set up in the 19th century. Only in the 20 great teaching hospitals would specialities like surgery be available. Elsewhere have a go GPs would be holding the knife, often with terrible consequences.

If you were rich health care was available. If you were poor your options were limited to charity or running up big debts. Contemporary insurance schemes covered only male workers and were not available in every workplace. Women and children needed to have the support of a local dignitary or a philanthropic GP to get consultation, never mind treatment. Often charity hospitals would only treat the “deserving poor”. The majority of Britain’s workers could literally not afford to be ill.

The lack of health care was made worse by problems of poor housing — rapid industrialisation in the nineteenth century had created huge slums — poor sanitation and poor nutrition. Life expectancy in 1936 was sixty. One in fifteen children would die before the age of eleven. Funerals for children, nowadays an unexpected tragedy, were commonplace. The poor health of the working class was only noticed by the ruling class when it was bad enough to affect their own interests. During the Second Boer War (1899-1902) the generals had become immensely concerned because almost half of those volunteering to fight were medically unfit to do so.

Early attempts — initially under Lloyd George — to set up a comprehensive system of unemployment and other benefits collapsed as the economic crises of the 1920s struck. As unemployment grew, benefits were cut again and again; and a proposed cut (of 20%) led to the collapse of a Labour Government under Ramsey McDonald. Many Cabinet members resigned. McDonald formed an “all-party” (effectively Tory) national government. The cuts went through. The now opposition Labour Party and labour movement, those who had faced up to the betrayal, were virtually annihilated in the 1931 election.

In the absence of a health service, and a strong labour movement to fight for it, the working class had to hope their illnesses were minor and would go away. In the 1930s chronic illness could land you in an underfunded, understaffed municipal hospital — it was somewhere you went to die. People would use home cures or quack medicines, often just sedatives, to try help themselves. Even these “tinctures and potions” were a handy source of profit for the chemists and doctors who would provide them.

The imperative for change came with the Second World War. With large civilian causalities expected from German air raids there was a pressing need to create a national health service to keep the country working.

The Emergency Medical Service provided 1,000 new operating theatres, and tens of thousands of new beds. It created a National Blood Service (now next in line for privatisation). At the start free treatment was limited to war casualties, but over the course of the war was extended to war workers, child evacuees, firemen etc. Although the elderly and others were still excluded from free care, by the end of the war the principle and feasibility of a national health service had been comprehensively demonstrated.

This wartime health service was consolidated and expanded by the radical Labour Government of 1945. Coming to power after a landslide victory it was mandated to “build a land fit for heroes”, something originally promised after the First World War.

A militant and expectant working class made sure Labour kept to their promises. When the Beveridge Report, the blueprint for the Welfare State, was first produced in 1942 it had enjoyed cross party support in Parliament. At the war’s end the Tories started to backtrack, wanting to restore capitalism and the rule of profit to normal. They objected to, amongst other things, the nationalisation of hospitals.

Nye Bevan, as Minister for Health, fought to have the full plan implemented. His biggest battle was with the medical profession, who did not want to become employees of the state. That battle ended with a compromise: doctors would remain independent but contracted to the NHS. This is now being exploited by New Labour as it seeks to recreate a private health service.

Accounts of the NHS’s inauguration day, 5 July 1948, demonstrate both the depth of previously unmet needs and the joy of a class at last able to claim as a basic right decent, free, healthcare. One story from a rural GP illustrates this. The doctor was asked to go and visit a woman who had been bedridden for 15 years, never able to afford for a doctor to visit.

Women in particular benefited as they had usually been excluded from the various previous “insurance schemes”. Gynaecological problems going back 20-30 years were at last treated. Getting surgical treatment was now possible. Free prescriptions, dentistry and glasses were also available on that first day. Those things are now, of course, lost to us.

Despite the fact that Britain was all but bankrupt with the cost of war, the NHS overspent massively in its first year, as a huge backlog of medical complaints came to the attention of doctors for the first time. But there was never an issue about the NHS producing a surplus, and no profit by proxy. The government had a duty to provide health care and the cost was secondary to the moral principle.

But the financial squeeze would get tighter. Bevan eventually resigned from government rather than introduce prescription charges. Cut backs on the NHS were to finance rearmament. Bevan thought that a betrayal of principle and denounced it as the “arithmetic of bedlam”.

The story since 1948 has been one of a constant battle to maintain and develop the health service against its critics. Yet it still remains remarkably cheap and efficient compared to health services elsewhere in the world. Spending on the NHS has recently increased in order to bring it back to the European average. But much of that money has been wasted on creating an internal market, or given over to the private sector through “modernisation” projects.

Bevan said that the NHS should be “always growing, changing and improving”. During the 1950s, 60s and 70s, despite tight budgets, it did do that. New district general hospital were built, bringing together a range of services under one roof, making available some specialities in rural areas, things never before seen outside of London and the big teaching hospitals. Starting in the early 60s old asylums were closed as new medicines enabled the treatment of mental illness in the community, changes that went on into the 1990s.

Despite a raft of pre-election promises Blair’s first Health Secretary, Frank Dobson did little to restore the service from the ravages of the Thatcher years. A succession of New Labour Ministers have set about dismantling the NHS. Many of them have had close links with the private sector firms that circle the NHS, vulture like, ready to feed on the rich pickings that may be offered up. They now echo the Tory critics who at the creation of the NHS said such an institution has no place in the modern world, that health care is a personal rather than social responsibility.

The pace of “reform” is gathering. It is a process of creating a parallel private health service by imposing competition between individual hospitals, breaking down the national system of mutual support and collaboration that Bevan helped create. Instead of social solidarity, the business model is now the template for the NHS’s future. New Labour now really does “think the unthinkable”. The scale and scope of these changes can be bewildering and the real costs are well hidden. As chancellor, Gordon Brown was the architect of much of the new system.

The health horrors of the 1930s are creeping back into everyday life. Diseases such as TB can be found again in the inner cities. The growing gap between rich and poor is recreating the grinding poverty in working class communities that the NHS and the welfare State went some way towards abolishing. One of the most rampant new epidemics of the poor is mental health problems such as depression and anxiety. Treatment with effective talking therapies rather than pills is largely the preserve of the middle classes. We have, in mental health at least, a two tier health service, one for the haves and one for the have-nots.

Whn it was created the NHS was an example to the world. It was copied, with some countries, such as in Scandinavia, going even further in developing fully integrated social and health care systems. The British NHS is no longer a model to follow. New Labour is following another model — that of the United States. The US, lacking a strong enough workers’ movement and suffering from some of the biggest social inequalities, was the one major industrial nation not to have socialised medicine. There health is still a business, a big business at that. In the US the 1930s never went away. Michael Moore’s movie Sicko should be seen by everyone as a warning for the future and echo of the past state of health care in Britain.

The actual experience of living in a Britain without the NHS now rests in the memories of our older generation. But the memories are vivid, their anger and worries about the future explain why some many of them are involved in fighting for it now. The foundation of the NHS was not inevitable and its future never been guaranteed. From the very start it needed to be defended against those that would see it fail, would like to rip it apart as an affront to the holy principle of profit. That fight goes on, and it will require a militant labour movement determined to stand up in the face of the capitalist “common sense” view of the world where everything must have a price in order to have a value.

We need to restablish the NHS on the principle that human need and the right to life are more important than profit. The campaign for the NHS should be one of the major elements on which we rebuild our labour movement, and instill in the labour movement the courage to go beyond reform, to challenge the basis of capitalism itself. For as long as capitalism creates and defends amarket where life can be bought and sold, the NHS will be under threat. Although support for the NHS is broad and deep, its existence will only be secured when coupled with the fight for socialism.

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