England is not as it was in 1948. Then, Everest had not been climbed, food was rationed, people rode the city streets in trams and crossed the Atlantic in Cunarders. London and other cities had been devastated by bomb damage and St Paul’s towered over the city’s buildings. Since then, there have been immense changes in society. The loss of Empire, greater knowledge of international problems and crises, increased affluence, near-universal car ownership, a desire for greater individuality and self-development, a loosening of discipline, authority and hierarchy, and a loss of both certainties and stability. Developments in the media and communications with colour TV, Internet, social networking and mobile phones – beyond imagination in 1948 – have altered the way we communicate with each other.
The pattern of health service in the minds of its founders owed much to Lord Dawson’s report of 1920, and was already conceptually 25 years old when the NHS Act (1946) was passed. The NHS was the political creation of a particular epoch when, because of the experience of war, we were more disciplined, all neighbours, and used to a life organised with great purposes in mind. The Atlee government nationalised utilities, transport and steel. The underlying principle was that members of society were entitled to what they needed in health care and social support. Few other countries, outside the Eastern bloc, followed the route of providing them from central taxation. The Act created a hierarchical structure that could adapt to the growth of specialisation and clinical science. This avoided much of the duplication and the unnecessary expenditure characteristic of the competing hospitals and the gaps that existed before 1948. The NHS was created to solve problems of access limited by the ability to pay and of inequity of geographical provision. Sometimes the solution was better organisation without great additional expenditure. Unusually, for such a vast organisation, most of the highest talent worked on the ‘shop floor’. The service dealt with a largely indigenous population that could still consider itself an island nation. As with many great ventures, things did not turn out as had been predicted.
Seven decades later, perhaps the most surprising thing is that the NHS is still here. In spite of regular prophesies of doom and proposals to adopt other systems of funding commonplace elsewhere, the NHS and its pattern of funding from central taxation survives. The quality of care, though often and rightly challenged, is in a different league from 1948. We spend far more of a far bigger gross national product on health care. The workforce is far greater; the buildings have been largely replaced. On the downside, some forms of care have quietly been shed – for example, dental and optical services, and the custodial care of the infirm elderly.
What was not, and could not have been foreseen by the founders of the NHS, was the impending rate of change in medical and allied sciences. Bevan, to his credit, realised that the service would advance and develop if it was to be a success. In medicine far more has happened since 1948 than in all the centuries back to Hippocrates. Countries do not stand in isolation; many developments are worldwide in their impact, for example, the new drugs, genetic medicine and the new imaging technologies that have been introduced. Until they are listed, as many are in this resource, it is hard to comprehend how great the advances have been. People rapidly come to accept advances as the normal order of affairs and yesterday’s revolution becomes today’s routine.
Summarising the decades, from 1948 to 1957, the NHS had to develop its basic pattern of organisation, elaborate systems of governance and finance, and begin to move towards a rational and even spread of specialist services. Building materials being in short supply, the new service made do with outdated and inadequate buildings. Much attention was paid to hospital consultant staffing. Steadily rising costs created anxiety, and the Guillebaud Committee was established to examine the NHS and its expenditure. The Committee showed that, in real terms, expenditure was barely rising at all, but pointed out deficiencies requiring attention, among them services for the elderly, and in pregnancy.
By the second decade, the NHS was taking shape and Britain was entering a period of economic growth. Attention turned to general practice, where morale was low and standards variable. The GPs’ Charter of 1965 introduced a structural framework that made future development easier. Enoch Powell’s Hospital Plan (1962) provided the basis for the creation of a national scheme of district general hospitals. Governments of both persuasions came to believe that more priority should be given to those who required protection – the chronic sick and the mentally ill. However, in reality these ‘Cinderella’ specialties commonly took second place to the demands of acute medicine and surgery. It became policy to begin to transfer the care of the mentally ill from the asylum to the community, and a similar approach was adopted in respect of the mentally handicapped who had often been accommodated in large hospitals in the country, away from relatives and friends. This movement was accelerated by a series of scandals involving the care of these groups, as well as the frail chronic sick, many of whom were not, as yet, receiving active geriatric care.
The decade 1968–1977 was a time of transition. Economic growth was reduced in 1973 when the OPEC countries raised the price of oil. The ripple effects of the international recession gradually overtook the NHS and the medical schools. Powell’s Hospital Plan had to be cut back, although new hospitals were now slowly being built. In the UK, as in many countries, low-paid manual workers were increasingly dissatisfied, union power grew and industrial action became prevalent. General practice was, however, flourishing, partly as a result of the GPs’ Charter. Imaging was revolutionised with computed tomography (CT) and magnetic resonance imaging (MRI). Nevertheless, money had to be found to deal with problems in the long-stay sector revealed by reports on hospital scandals. The combination of economic recession, labour disputes and rapidly rising health care costs stimulated organisational change. The managerial revolution began with NHS reorganisation (1974), which established coterminosity of local authority and health service boundaries, and a planning and prioritisation system. The Labour government also established a resource allocation system – Resource Allocation Working Party (RAWP) to balance disparities between the regions, even at a time of financial stringency. As a result, the most serious financial problems since the NHS began appeared in London’s acute hospitals.
By the fourth decade, it was clear that similar problems were emerging in many countries as health care costs rose faster than the funds available. Pessimism replaced optimism. There was increasing disenchantment with the idea of a welfare state, and professionals were challenged as to whether they always knew best. The principles underlying health care and the NHS were questioned at the Alma-Ata conference of the World Health Organization. The Black Report on inequalities, far from popular with the Conservative government of the day, demonstrated that not all was well. Managerial solutions proved, each in turn, a chimaera. NHS reorganisation was followed by restructuring (1982) that reduced co-terminosity and increased the importance of health districts. The Griffiths Report (1983) established general management, and moves to contracting services to the private sector began. Enthoven reviewed the NHS (1985). Medical progress, the technological imperative and the importance of caring for the growing numbers of elderly people drove demands ever higher while resources grew more slowly, so that, by the end of the ten years, the Presidents of the Colleges were announcing that something had to be done. The political consensus on the NHS was breaking down.
1988–1997, the fifth decade, saw continuing clinical developments, for example, genetic medicine and minimally invasive surgery. Primary care was accorded increasing importance, and care was transferred from institutions into the community where possible – and sometimes where it was not particularly desirable. GPs had a new contract imposed on them. The hospital service was being reshaped, driven by increasing medical specialisation. Nurses reorganised their education with Project 2000. The NHS reforms of 1990 radically altered the system of health service finance as the purchaser/provider system was implemented, and the beginnings of an internal market appeared with GP fundholders and hospital Trusts. More decisions could be taken at local level. Many fundholders energetically set about changing their services. Hospital Trusts enjoyed new freedoms to alter the way they worked. Hospitals came under two conflicting pressures: to decentralise and improve access to services; and to concentrate other activities on fewer sites where this improved the outcome and the quality of care. Belatedly the medical profession was beginning systematic audit of the results of its work. The ordered structure of Ministry, Region and District was removed. No longer was the pattern of provision necessarily similar from place to place. However, the fundamental pressures remained the same – improving technology, changes in population structure, changes in the level of morbidity and increasing public and professional expectations. While the service did not collapse, it showed signs of continuing strain, which nurses and doctors continued to see as due to a shortage of resources, inadequate staffing, and poor facilities which limited performance.
The sixth decade (1998–2007) saw Labour in power and a series of organisational changes with the extinction of regional authorities, a new accent on quality, regulation and inspection, a desire to give patients a greater voice in their health service, and to liberate hospitals with effective management by granting them Foundation Trust status. Labour raised the growth rate of the NHS substantially, but the additional money was not well spent. Much new hospital building was taking place, fueled by the Private Finance Initiative (PFI).While decades earlier there were scandals of poor care in long stay hospitals, now it was the turn of the acute sector, with cardiology problems in Bristol and abysmal care at Mid Staffordshire, triggering the Francis Report and examination of all acute hospitals and their staffing levels.. A worldwide economic recession was in the offing.
The seventh decade (2008–2017) was largely dominated by the financial stringency following the sub-prime mortgage problem and the international monetary crisis. Though in theory the NHS was protected, its growth rate fell and staff pay was restrained. Many Trusts moved into deficit, often exacerbated by bills from PFI. Politically there was first a Conservative/LibDem Coalition government, under which a disastrous structural reorganisation was imposed; messy, contentious, unrelated to the main issues faced by the NHS, and undermining strategic planning. Subsequently the vote to leave the European Community, and two Conservative administrations with marginal majorities, distracted attention from the NHS. Marmot’s review of health variations, the demographic problem of an ageing population, the rising costs of a health service improving as new technology and treatments were introduced, the need to reconfigure the hospital service and ever-increasing patient expectations were a toxic mix. Salvation was sought in joint working of local authority and health services, as in 1974. A new chief executive attempted to improve matters without the need for further legislation, and to re-introduce planning without those responsible having either the authority or the money to achieve much.
The overall verdict on the NHS must be positive. It has achieved Bevan’s main aims, largely removing the fear that care during illness would be unavailable or unaffordable (and, at the same time, redistributing income from the rich to the poor). However, some things were done better than others. While many achievements and some problems are worldwide, others, particularly those that are organisational or financial, are particular to the NHS or are predominantly found in countries that have provided health services from taxation, where there is a finite limit on expenditure on care, and not for insurance-based schemes.
Benefits of organisational unity
Where variation of service provision remained the norm, the NHS made it possible to systematise care. The health service formalised a rational system of provision based on the GP as gatekeeper, supported by district hospitals and tertiary centres of referral, which is only recently beginning to break down. The challenge to this pattern came from the belief that competition improved care, that some local autonomy was required, the need to respond to a new understanding of the improved outcomes that came from greater centralisation of care, the problems of delayed referrals, and financial imperatives. Unlike the situation in many other countries, because the NHS is a single organisation, it has the potential to deal with significant problems on a national basis. Professional advice, once obtained, could be implemented throughout the country. This applied both to clinical problems and to structural issues, for example, AIDS, National Institute for Clinical Excellence (NICE), the development of group practice and clinical networks.
Shortly before the NHS began, the surveillance of communicable disease came under the aegis of the Public Health Laboratory Service (PHLS), and the benefits of a single national organisation, capable (like microorganisms) of transcending geographical boundaries, were repeatedly demonstrated. The PHLS and its successors became flagships of excellence, part of a national security system against the dangers of the development of drug resistance and the emergence of new infections.
In the second decade, the Committee on Safety of Medicines became responsible, after the thalidomide debacle, for licensing new drugs. Although the UK was tardy in the adoption of some vaccines, a national immunisation programme was introduced and progressively refined. By any standard this was a success. Central organisations such as NICE have become important in assessing the effectiveness of drugs and medical procedures and have established a worldwide reputation.
Some opportunities of national organisation were missed. Although the GPs, the district hospitals and the regional centres provided an effective structure for care, there were repeated failures to develop methods to assess health care needs. Innovative schemes such as the national morbidity studies were seldom developed, as they might have been, into useful tools that could satisfy scientific or health care policy requirements. The data held by the NHS has yet to be fully mined.
Clinical improvements fall into two groups. Some are based on definable scientific advance, for example, the prevention of haemolytic disease or phenylketonuria in newborns,. If such developments provide obvious advantages to patients, are comparatively simple and there is no substantial cost, they are often introduced rapidly once the science is firm. The application of scientific knowledge is slower, however, if the benefits are less clear cut, or if a professional group believes it will be adversely affected by the change. The development of Academic Health Science Centres to speed the translation of knowledge into practice should help this.
Secondly, there are changes in working methods, for example, the acceptance of group general practice, improvement in geriatric care or the centralisation of expertise. These may take far longer to implement. It was 30 years before day surgery became commonplace and much the same before the centralisation of major trauma was accepted.
The control of the infectious diseases was the advance that, above all others, probably influenced the shape and work of the health care system. Within the first 20 years, the incidence of tuberculosis and its death rate were greatly diminished. Sanatoria and fever hospitals closed, and are forgotten. Immunisation controlled other infections, such as diphtheria, poliomyelitis and measles. Antibiotics altered the pattern of chest infections out of all recognition, affecting the acute episodes and the long-term pattern of disease. The almost complete disappearance of rheumatic fever brought to an end one of the commonest causes of chronic heart failure. The control of syphilis largely eliminated diseases such as tabes dorsalis and general paralysis of the insane, conditions unknown to the medical students of today but which featured regularly in examinations in 1948. Drugs helping the mentally ill ultimately made possible the closure of asylums. As a result, the case-mix of wards has changed so that the majority of patients are elderly with long-term conditions and multiple problems. Our new epidemics are more related to personal behaviour, smoking and obesity.
The hospital phase of serious illness was shortened by more effective drugs, less traumatic operations and, on the social side, improvements in housing that allowed discharge to a reasonable environment. Orthopaedic patients, who had often stayed in hospital a long time, could be discharged early once the principles of internal fixation and joint replacement were understood. Cataract extraction used to involve a week or more of total immobility, with the head supported by sandbags; now patients are treated on a day basis. Changes in obstetric practice allowed early discharge of maternity patients. Pharmaceutical research gave doctors an immensely improved armamentarium, making care in the community possible for many who had previously required hospital admission. At the same time, it made hospitals potentially dangerous places because of the very potency of the drugs in use. It all added up to a wider range of preventable and treatable disease, therapy that was less traumatic to young and old alike, more rapid hospital throughput and different demands on primary care.
Sophisticated systems have allowed the application of scientific, physiological and genetic principles to pharmaceuticals, medicine and surgery. Much of clinical medicine has been rewritten. Surgical instruments have been refined beyond the dreams of 1948. Only when an attempt is made to itemise the developments to which the NHS has had to adapt, and for which funds have been necessary, is it clear how vast these have been. The public has come to value advances in health care so there is tension between the expectations of the public and the capacity to cure, on the one hand, and the ability of the health service to deliver, on the other. People have become increasingly aware of what is possible and clinicians define clinical need more broadly. Clinical progress, as in joint replacement for arthritis, generates new and justifiable demands for care. Changes in people’s tolerance of distress lead to demands not previously experienced. Sometimes demand may fall, with the reduction in incidence or the disappearance of conditions such as the infectious diseases, or with the recognition that some procedures are obsolete. Evidence-based medicine is a pressure in the right direction.
GPs and primary health care
In 1948 Britain had GPs throughout the country, yet their distribution was uneven and their standards were variable. The service was barely adequate for the needs of the time, let alone those to come. It was known from the beginning that primary health care was essential if the function of the hospital service, woefully deficient in many places, was to be maintained. The characteristic ease of access to and continuity of care by GPs, often over many years, was almost unique to the UK and underpinned the NHS. It has been undermined for complex reasons. Progressively as the burden of disease has shifted, GPs have become less involved in sudden acute illness, terminal care, childhood infections, tuberculosis and childbirth, and have greater responsibilities for health promotion, chronic conditions, and the care of elderly people which they share with other members of the primary health care team. General practice has undergone a revolutionary change in its organisation. A cottage industry of single-handed doctors, working from their own homes and with little support, has evolved into a network of organised and sizeable groups, sometimes federating across practices, in good accommodation, with a substantial infrastructure and much influence on other parts of the NHS. But it does not now operate round the clock. Twenty-first century practitioners require time off, like the rest of society.
Hospital services and secondary health care
Hospital services can also be regarded as a success story. Increasing numbers of hospital consultants were appointed and distributed more evenly throughout the country. Specialisation and sub-specialisation developed apace. The consultant-led ‘firm’ largely disappeared and hospital medicine became a team game, between colleagues in different specialties and in clinical networks between hospitals as the need to centralise people with less common and more severe problems became apparent. Better outcomes are the result of restructuring the pattern of care in many specialties – from children’s services to cancer and major trauma.
Progress had been made before 1948 towards the better organisation of hospitals. Some local authorities – for example, Birmingham, London and Middlesex – had rationalised services. King Edward’s Hospital Fund (King’s Fund) had long used its influence to improve the pattern of London’s voluntary hospitals. The Nuffield Provincial Hospitals Trust worked with the Ministry on the Hospital Surveys, which backed a region/district pattern. As hospital specialties became increasingly dependent on each other, it became important to bring them into closer relationship. The district general hospitals (DGH) policy was implemented. First, hospitals were grouped under a single hospital management committee to form a functional entity. Later came merger, closure and rebuilding, at first spurred by the 1962 Hospital Plan and later by the private finance initiative. The idea of a single good hospital for a specific population, rather than competitive services, was in tune with the professional wishes of many doctors but clashed with the ideas that competition could be a spur to efficiency and better services, and co-operation across wide areas might lead to the best clinical outcomes, as in stroke and trauma. In the 1960s there was a clear vision of the pattern of a hospital service. This clarity is now lacking. We are in an era of mergers, reconfiguration and debate about whether care, particularly for long-term and chronic conditions in an ageing population, should be more in the community.
The development of the NHS has created new problems, while not always solving old ones. One difficulty concerns the organisation of clinical staff in a way that is efficient and conducive to the provision of good treatment. In primary health care, the developments have been largely beneficial and coherent, with the emergence of well-housed group practices. The same has not been the case in the acute hospitals. The NHS inherited a firm system, in which each patient was the responsibility of a single consultant, who usually held beds on two wards – male and female. Consultant-led teams were the rule, and each covered its own emergencies. The consultant had a small and well-defined team of juniors, and close relationships with the nursing staff. Now, the firm system has largely gone and no effective alternative has as yet emerged. More patients are admitted and they spend less time in hospital. Patients, nurses and doctors have less time to get to know each other. Beds are seldom allocated to specific specialties, and each ward may contain a continually changing mixture of cases. Junior doctors find that their patients are distributed widely around the hospital, and receive less support than they did in the past from experienced ward sisters. Juniors who, in 1948, had almost no time off for the six months of their job, now cover for each other and see patients previously unknown. Lacking support of resident seniors or consultants is not only stressful but dangerous for patients, and the European Working Time Directive makes matters worse.
Balancing the budget
From a financial point of view, the NHS is highly cost-effective in comparison with health care in other developed countries. The fact that Britain spends substantially less might be regarded as a success but, although the UK achieves good value for money, it can be argued that the UK does not spend enough. Queues for care tend to be found in centrally funded systems with public provision of care, paid out of taxation and with a limit on total expenditure, as opposed to insurance-based systems in which rising demand tends to lead to rising provision and expenditure. Insurance-based systems, such as those common in Europe, are not plagued by this problem. No pride can be taken in the length of time patients wait for elective procedures in hospital, for the difficulty experienced in the admission of emergencies or for failures in some sectors of community care.
Bevan chose central taxation to fund the NHS and that meant parliamentary control. The measure of freedom that could be allowed to nationalised industries with a product to sell was not possible for the health service. Bevan had a second objective for the NHS – the redistribution of income. All would receive the same service, those who were better off being taxed to meet most of the bill. There are, however, limits to taxation. From its earliest years, there were arguments about whether the country could afford the NHS, the extent to which it was underfunded and the pay and conditions of its staff. Lord Knutsford, in 1924, said that the record of the state in health care was that, whilst it might do its bare duty, it would be done without grace. Enoch Powell expressed similar sentiments. Service development has always been considered with an eye on the costs.
The result has been a queue, a waiting list to control demand. A shortage of consultants constrains the apparent level of service required. When there are long delays for treatment, GPs refer fewer people; when there is only a minimal service, as in the early days of renal dialysis, activity is constrained. Enoch Powell was among many Ministers to make abortive efforts to eliminate waiting lists by special initiatives. Labour, by the introduction of targets and a boost to NHS funding, almost got on top of the problem, but with financial stringency we have slipped back.
As the decades passed, new technology and pharmaceutical developments produced an inexorable rise in costs. Advances in operative surgery, by making more diseases amenable to cure, also increased expenditure. New treatments such as bone marrow transplantation were sprung on management that learned late in the day of their adoption. Specialists were slow to appreciate the potential for economy, for example, by shorter stays in hospital. The obsolescent forms of treatment were comparatively cheap; the newer ones were vastly more expensive, placing the service under continuing and increasing financial pressure.
Yet doctors cannot, (or are loath to), ration care – to deny it to people who may not be entitled to it, to those seeking to enrich their lives rather than to maintain their health or earning power, to those who pay substantial sums to engage in activities that endanger health, for example, smoking and skiing, and which are costly to the NHS. Powell said that even the wealthiest country could not afford to finance in its entirety a health service free to the consumer, open to all and offering every procedure from which anyone might benefit. Something has to give. It cannot be the exclusion of particular individuals or groups. It must be a priority system based on the nature of the clinical problem and the efficacy of available treatment. The notion of an equitable health service implies that somebody makes a judgement, or somehow a judgement is made. Although we distrust experts and challenge professional judgements, as patients we lack the information of cost and benefit that would enable a rational choice. Because professionals treat, and people are treated, at somebody else’s expense, the patient cannot take all decisions in the way that is possible with one’s own disposable income. Some new forms of treatment such as anti-cancer drugs produce only minimal advantages in survival for a substantial additional cost. Choices need to be made and Karol Sikora asks: should they be administered to a frail, elderly and demented patient? It may be that the elimination of less-effective forms of treatment would free resources for more effective ones, but the decision is seldom a black and white one. There is always the possibility that the patient under consideration will be one of the few who will gain from a procedure; and who is to make the judgement when there is a finite chance of improvement? Two extreme positions only need to be stated to be rejected. First, rationing could be handled purely by the individual’s ability to pay, either personally or through an insurance scheme. Alternatively, eligibility might be determined solely by the professional expertise of an organisation that allocated treatment on the utilitarian basis of the maximum benefit for the maximum number, or to those best able to make an economic contribution to society.
The NHS has tried a number of strategies. Attempts to improve the efficiency of hospitals go back to the early years of the King’s Fund. Since the NHS began, there have been attempts to constrain expenditure by seeking clinical and organisational efficiency, better information and costing systems, improved methods of management, the introduction of the management systems said to operate in the private sector, and by systems re-engineering. Among the methods used to restrict demand have been co-payment by patients, much used in the USA, and seen in the UK as prescription charges. Although it was never stated as public policy, the scope of the NHS has also been restricted. Patient charges for optical and dental services increased the number of people seeking private care, and reduced the strain on the NHS. Payment by patients when they need care, widely used in countries with insurance-based schemes, was anathema to Bevan, although is not necessarily inappropriate when a population is comparatively wealthy.
Another approach has been the transfer of care from hospital to the community, unimagined at the outset of the NHS. The place for serious illness in 1948 was in hospital, until medical science could clearly do no more. Clinical progress has made it possible to handle many conditions safely in the community, and the maintenance of the general practitioner/primary health care system has made this practical and largely acceptable to the community. The hospice movement provides substantial services for the terminally ill. Successive governments of both political persuasions advocated shifting the care of those with chronic conditions and the mentally ill from institutions into the community, a policy judged to be socially compassionate, that freed expensive hospital beds while imposing a financial and social burden on the community and primary care services. Long-term care, commonly provided by the NHS in 1948, was increasingly moved to local authority social service departments. The Griffiths recommendations on community care followed, transferring the lead role to local authorities. Offloading commitments where possible was inevitable if money was to be found for developments.
One of the saddest features is a common belief that nursing is not as good as it ought to be. Changes in the nature of society, which have provided increasing employment opportunities, and the pressures of family and social activities have played their part. Within the profession there is the view that nursing, an honourable and worthy job, needed academic status to give it respectability. The wider roles of nursing today and the more complex environment of health care points in the same direction. However, at times there seems to be less compassion in nursing than in the golden age of our memories.
The increased tempo of hospital life alters many assumptions traditional to a hospital nursing service, just as the development of primary health care has affected community nursing services. In 1948 trained nurses could expect to care for very sick patients for many days or weeks. Student nurses gained much practical experience and were supervised by competent ward sisters. Explicit standards of care were stressed in the school of nursing. There was time to get to know patients as individuals, and the nurses’ role was careful observation, the maintenance of the physical and, if possible, the mental comfort of their patients, and to work co-operatively with others. Many patients came from poor social circumstances, some were malnourished and few knew much about their ailments. Now people are fitter, more knowledgeable and can face major illness or surgery with more resilience. Patients are discharged so fast that there is often little chance for nurses to establish a relationship. Medicine has a confidence that makes the provision of skilled nursing over days or weeks less important to physical recovery. Clinical observation is replaced by tests and monitoring equipment. Specialisation in medicine demands increased specialisation in nursing if the two professions are to work side by side. Many basic and technical nursing duties are now performed by others – health care assistants, relatives or technicians. Some of the territory vacated by nurses was occupied by others while some nurses moved into medical territory. The sick, however, always need kindness and compassion.
Better management of acute illness and of diseases in the neonatal period, childhood and the young adult exposed more clearly the problems of chronic illness – mental and physical. Here the inheritance of the NHS was not a good one, either in terms of staff or of building stock. From the early 1960s, the priorities have always been to improve the care of those who need protection.
The results have been mixed. In the field of those with learning difficulties, few people would wish to see the return of the large institutions that have now all but disappeared. Local units have enormously increased the quality of life. For the mentally ill, the picture is not so good. The NHS inherited a service based on the asylums. Stimulated by media interest and public pressure, a move towards community care was partly a response to the scandalous conditions behind the walls of the institutions. In the 1950s and 1960s, policy changed and psychiatric units within the curtilage of the DGH, supported by services in the community, were seen as the way forward. In the event, though it was a good policy, better community support should have matched the impetus as Enoch Powell would have wished. It did not. The mechanics went wrong, and health and welfare services that should have been bonded together remained in opposing camps.
Many of those who have special needs, or are disruptive, are not appropriately housed in the middle of a busy acute hospital. Small local acute units, dispersed throughout the community, and outreach teams, have their place but there remains anxiety about community care and the regular reports of assaults or murders committed by the mentally ill following what is usually a failure of community-based care and follow-up.
A health service reflects many of the changes taking place in the society it serves. Whereas the fundamental task of the doctor and nurse remains much as ever, management repeatedly redefines its philosophies, goals and techniques. Strategic planning, centralised decisions, devolution, large organisations, small and closely focused ones, democratic representation of the community or management by technocrats, competition or collaboration have followed in swift succession. For the staff delivering care at the ‘grass roots’ where the majority of the expertise lies, the cumulative effect on morale has been detrimental. Sadly there is no sign that the naive hope of salvation through reorganisation has disappeared.
The introduction of a managerial culture sought to improve efficiency. Griffiths and the Thatcher reforms emphasised management of the money, and sight was lost of the original ethos of community-based and regional collaborative service. Member-based management authorities, at region and district, disappeared and with them the work of many people from local government and the local community. The last vestiges of local democratic participation were removed, creating a single managerial hierarchy from hospital to central government. Central government’s most recent anxieties become local imperatives. In the face of problems, such as scandals of poor care, experts and gurus were summoned to provide an instant and eye-catching response – Don Berwick, Stewart Rose, or from within the NHS itself, David Dalton and Bruce Keogh. Managers on short-term contracts ignore central guidance at peril to their jobs, and long-standing institutional loyalties became a relic. There was a perception that the centre, the Department of Health and NHS England, was increasingly dysfunctional and only distantly aware of the problems clinicians and managers faced. To fine Trusts that did not meet targets only made matters worse, as to pay the fines, finance officers cut the budgets on which good staffing depended.
By introducing the idea of markets and competition, the NHS reforms (1989) risked the development of fragmented pieces of care, sometimes organised on the basis of least cost and with little local involvement of the population. The purchaser–provider division owes as much to dogma as to logic in a service in which key decisions are usually taken near to the patient. Some of the most effective services in the world (for example, Kaiser-Permanente HMO in the USA) do not follow this pattern. The NHS was designed to bring together disparate units, to reduce inappropriate competition and to eliminate gaps in the system. The NHS needs to work as a whole, and the elimination in 2013 of organisations with strategic oversight was probably an error which now is being, with difficulty, mitigated.
On the positive side, however, was the accent now placed on quality of care and outcomes, a managerial as well as a clinical goal, responding to a society that sees no reason to exempt health care from the expectations of a customer-service oriented society.
Some long-range strategies for the NHS have always existed. In 1959 the Acton Society, in its sixth report, said that there was a central responsibility, which could not be abdicated. It was the responsibility to inspire, lead and guide; to interpret the lessons of decentralised experience; and to invoke national resources for dealing with problems that could only be dealt with effectively on a national basis.
Initially they key problems were the unevenness of specialist services and financial expenditure, and these took several decades to handle. More recently the problems have been the escalating costs of therapy, (for example, genetic medicine and drugs for cancer), the ageing of the population and care of multiple chronic diseases, the recognition that quality of outcome costs money – be it a good nurse staffing or the centralisation of life-threatening illness such as stroke and heart disease – and, importantly, the understandable and rational increase in expectation of the population for accessible round-the-clock primary and hospital health care.
The record of the NHS in the development of long-term strategies has been mixed. More even distribution of skills and money took a while to achieve, although the strategies were comparatively clear. In the 1970s and 1980s, strategies to reduce the number of beds and improve the quality of provision met a degree of success. The development of National Service Frameworks and the Darzi initiatives in the early years of this century provided an imperative for quality and a sense of direction in hospital, if not in primary care. And more recently, the Stevens’ Five Year Forward Look with its new models of care, and the development of Academic Health Science Centres, have the potential to ease some difficulties. Health service think tanks, Nuffield and the King’s Fund, have usually been more successful at identifying problems than pointing the way to their solution. Given that health care presents wild problems, difficult to define and ever changing, this is perhaps not surprising.
Finance is, of course, an international problem and one only too obvious in times of austerity. Where resources come from a central budget, as in the UK, there will always be, not only a limit, but a risk that changes in the economic performance of a country will change long-term predictions of the money available. Many long-term strategies are therefore designed to make the money available go further, while maintaining the quality of care. Some proposals, for example, moving care from the expensive hospital into the allegedly cheaper community, mergers of organisations, or the integration of health and social care budgets, are interesting ideas, the outcome of which is seldom as wonderful as their protagonists believe.
Some things are not going to change. Medical innovation – for example, genetic medicine, diagnostic imaging and ever-increasing expertise – will result in continually growing expectations, both public and professional. Since 1948, there have been massive changes in societal values, and the NHS operates against the background of these. Not all have been predictable; few would have imagined the widespread doubts in many quarters about the future of the welfare state or the impact of IT. We are in an era of uncertainty and a clash between social obligations and personal autonomy. Even within the limited confines of the health service there is conflict between, on the one hand, the older public service ethos and a belief in the need for solidarity in society, and, on the other, a belief in the primacy of the individual and an acceptance that not everyone will receive an excellent service. Valid questions are raised about the proper role of a health service. Some patients with apparently minimal claims on the welfare state appear to receive costly care, while others – for example, the elderly – do without. The gaps are too obvious: waiting lists for routine procedures of proven efficacy, intolerable conditions in some emergency rooms, rapid transit through wards with little rest or nursing care, and a hospital environment that may be unsatisfactory. In spite of everything, we support the NHS and look for a solution that is equitable, provides the best care to all, allows us to take charge of our own bodies and does so at a cost to ourselves personally that we believe we can afford.
Striking a balance between cost, quality, equity and the timeliness of care is an international problem. Since 1948 people have repetitively challenged the ability of the NHS to contain the pressures for increased expenditure, but the service is still here, with all its faults. Clinical advance will continue to create costly opportunities to extend life or improve health. It is probable that we will be able to maintain our traditional vision of the NHS, trimming here and advancing there, for neither the public nor politicians wish the service to fail. The NHS may continue to muddle along, as Lord Horder said in 1939, making an apparently unworkable system work. The honourable partnership between the professions and the state, for which Lauriston Shaw argued in 1918, is sometimes nearer than many would admit.