Defending democracy and the National Health Service
The Lancet, Volume 379, Issue 9820, Pages 997 - 998, 17 March 2012
Published Online: 24 February 2012
The dismantling of the National Health Service (NHS) and of the welfare state proceeds apace. The historic settlement of 1948, born of the recession of the 1920s and 1930s and the carnage of World War 2, is being picked apart systematically by the UK's Coalition Government, which ironically includes the remnants of the Liberal Party that played such an important part in building the foundations of the welfare state in 1906 and 1911. In 1906, in the aftermath of the Second Boer War, about a third of working-class recruits to the armed forces were found to be unfit for military service on account of physical stunting and poor health—this despite 100 years of global economic domination by the British Empire. Fearful of the rise of Germany as a military force, the Liberal administration introduced free school milk and meals and established the school health service. In 1911, with the storm clouds of war on the horizon, David Lloyd George introduced the National Insurance Act, which provided schemes for health and unemployment insurance for working men to protect them against the worst threats of ill health.
The shift from partial to whole population coverage, which pooled risk and removed the fear of pauperisation through ill health, came about as a result of a convergent solidarity, born of a society that had been “all in it together” through the Blitz and the dark days of 1940 and 1941, when the future of Britain itself was felt to be in peril. When the Beveridge Report, the blueprint for the postwar welfare state, was published in 1942, queues extended along the pavements outside Her Majesty's Stationery Office in High Holborn, London, and the document was sold out by lunchtime. I treasure my father's copy. It gave him the confidence and security, as one of the early diabetics to benefit from insulin, to respond to the Government's encouragement to replace the war dead by adding two postwar children to the family, despite a precarious hold on an aspiring middle-class life that had been threatened by the fear of what had until then been seen as a devastating illness.
The aphorism that, “if you don't know your history, you'll be compelled to repeat it”, has never been truer than with social policy as applied to health and welfare. The question as to who should be responsible for ill health has long been a matter of debate. In 1847, just before the demographically led “year of revolution” in Europe, Salomon Neumann in Germany was arguing the case for an extended role for the state in public health and the provision of medical care in the following terms:
The state argues that its responsibility is to protect people's property rights. For most people, the only property which they possess is their health; therefore, the state has a responsibility to protect people's health.
Fearing the masses of young, disaffected men in the burgeoning industrial towns, the German Government responded.
In Britain, the Parish arrangements of the Poor Law struggled to provide a civilised response to ill health in the slums, and the class system ensured a divide between those who could afford to have access to the voluntary hospitals and those whose fate was destined to be in the underfunded Poor Law hospitals, which were almost always staffed by less-skilled clinicians. The services of mental health care were the responsibility of parishes and they contracted out care to private “mad house” providers, whose “year-of-care” with “personal budgets” for patients inevitably led to many scandals that involved chained patients in rags or patients fed on gruel.
One of the frightening aspects of the current UK Government's policies is the apparent ignorance of ministers and civil servants not only of their own history, but of the body of evidence that until so recently informed social policy in this area. Those of us who were fortunate to study at the feet of the formidable team at the London School of Economics during the 1960s and 1970s can only be aghast at the wilful ignorance of timeless truths from the likes of Richard Titmuss, Jerry Morris, Brian Abel-Smith, and Peter Townsend. Titmuss's insights, in particular, remain powerful and relevant. That “services only for the poor are poor services”, and that there are essentially three alternative models for social policy: the Residual Welfare Model, the Industrial Achievement Performance Model, and the Institutional Redistributive Model.
For the past 60 years the UK has had the Institutional Redistributive Model, which sees social welfare as a major integrated institution, providing universal services outside the market on the principle of need. As I write, we are being dragged into some hybrid of the Industrial Achievement Performance Model, which holds that social needs should be met on the basis of merit, work performance, and productivity, and the Residual Welfare Model, which is based on the premise that there are two natural channels through which an individual's needs are properly met: the private market and the family. At a time when the NHS has never been more popular and when there is increasing evidence of its cost-effectiveness, we are sleep-walking into its destruction.
The building blocks are being put in place by the Health and Social Care Bill for a return to an insurance-based system, starting with personal budgets and year-of-care funding for long-term conditions and with the specification that Foundation Trust Hospitals will be able to raise 49% of funding from private patients. The pathway is clear to recreating voluntary and Poor Law hospitals, this time under the same roof. This assault on universalism has been eloquently described by Martin McKee and David Stuckler, who identify a key milestone as being the vilification of poorer people and the creation of a mindset among those in middling positions that those beneath them are scroungers and undeserving. The Poor Law concept of the deserving and undeserving poor is alive and well, and living in 10 Downing Street and Richmond House. These ideas are sitting comfortably alongside the Orwellian doublespeak of the New Localism, at the same time as the UK's rich tradition of local public health is being nationalised and centralised. Although there is a commitment to reducing inequalities in health, a whole raft of Coalition Government policies is taking us in the opposite direction.
The role of the private sector in providing what are essentially utilities, whether the utilities of energy and water, housing, public transport, education, or health and social care, is assumed to be essentially benign, even whilst many private cosmetic clinics are turning their backs on any responsibility for aftercare to their patients as a result of the safety scare over silicone-gel breast implants. In the meantime, mass circulation newspapers feed hostile and negative propaganda in defiance of the facts about public services in general and the health services in particular, softening both them and the public up for carpet-bagging private organisations to move in to cream off profitable short-term opportunities, leaving the costly areas of obstetrics, accident and emergency, psychiatry, care of the elderly—not to mention high-end, innovative surgery—to residual state provision, with massive increases in transaction costs en passant.
As we struggle to prevent a misguided Secretary of State for Health from progressing his malign Health and Social Care Bill, it is worth reflecting on Titmuss's comments on the ethics and economics of medical care: “I happen to believe”, he says, “that the conflict between professional ethics and economic man should be reduced as far as humanly possible.” It is my contention that nobody should be allowed to dismantle the NHS if they have not read, understood, and digested the writings of Titmuss and his colleagues. As we stand on the verge of possibly irreversible damage to one of the hallmarks of what it is to live in a civilised country, it is time to rise up and defend an institution that was built by our parents and our grandparents and which we owe to our children and our grandchildren to maintain and to pass on to them and to their guardianship.