The NHS: challenges old and new

As part of our 75th anniversary, we asked renowned NHS historian Geoffrey Rivett to look back at some of the perennial challenges that have dogged the NHS from its inception.

The health service is an example of a wild problem – that is, a problem that changes under one’s eyes, forever presenting new challenges as older ones are solved. Most arise from problems relating either to the conditions demanding care or to the resources needed to provide it: money, personnel and capital assets.

Finances 

Finance has been an issue since the earliest days. Five years after the NHS began, the Guillebaud Committee was appointed to suggest how rising costs could be avoided. It found that the rise had not been unreasonable; however, Guillebaud’s main achievement was to quieten those opposed, on the grounds of cost, to having an NHS at all.

Financial crises, if not annual, have never long been absent. Those with long memories will recall planning for ‘negative growth’ in the mid-seventies – in other words ‘how are we not going to spend the money we are not going to have?’

Nineteenth Century hospitals perfected the art of shroud waving, for as long as they were bankrupt they could launch an appeal. The BMA have learned the technique. But we are still here. We will survive, tough though it may be, and no political group is campaigning for the abolition of the NHS.

One problem has largely been solved, to politicians’ credit. The massive misdistribution, south and north, was solved by resource reallocation. It did take 25 years, though, to begin to redress the balance and another 15 years to achieve some measure of parity.

The pattern of financial flow that will best ensure efficiency remains uncertain. Whether separating purchasers from providers is effective is still in dispute. An idea current in the 1980s, and suggested in Enthoven’s book commissioned by Nuffield in 1985, it has become part of the health service scenery. It certainly imposes substantial transaction costs as the bureaucracy of CCGs demonstrates. Organisations such as Kaiser Permanente do pretty well without it, and if collaboration is better than competition, where does that leave commissioning?

Workforce 

Personnel issues have been ever present too. In 1948, Bevan faced a service in which whole swathes, whole counties, could be without a single consultant in a major discipline such as radiotherapy. His enlightened decisions to pay the same salary everywhere – and in every specialty – as well as the development of new medical schools where staff were most deficient, have largely solved the problem in the hospital services.

Other problems seem intractable. As medical specialists take ten or more years to train, a rapidly changing field such as medicine has difficulties balancing supply and demand. Few other countries attempt medical workforce planning, but without it there can be unfortunate consequences such as misdistribution between specialities and areas. In general practice, we had a solution that we threw away: the Medical Practices Committee, with a system of benign direction of labour that led to something approaching equity of distribution of GPs over the country. Local autonomy and the Deanery system have been accompanied by widening disparities of the doctor/patient ratio.

Nursing has always been and remains a problem. The drop-out rate of nurses in training remains horrendous. The ‘half-life’ of a student may be affected by the economic state of the country – whether other jobs compete. Why should we worry, some have argued, when we can import nurses trained overseas lower cost?

Buildings and other capital investments 

We inherited horrendous capital assets: ancient poor law hospitals and in primary care, little fit for purpose. From the sixties, practice premises improved amazingly under a new contract agreed between the profession and the Department. Progress was slow on the hospital side, for capital programmes were cut back at times of stringency under the mantra ‘people not buildings’.

Much as I dislike the near bankruptcy of many trusts that has resulted from private-finance initiatives (PFI), which of us would really wish these buildings to disappear? Some argue that in the brave new world of community-based care they are white elephants. Personally I see a long and useful life for them.

Evolving expectations, evolving technologies

New challenges that Bevan probably did not foresee, and with which we have to grapple, include demography, changing illness patterns, costly technology and patient information and expectations.

In 1948, the population of London was declining and it was public policy to shift people out to new towns. Now central London is repopulating. The island nation of 1948 could not have imagined that we would see such an influx of immigrants in the early 2000s, although the NHS remains heavily reliant on this as a source of labour. 

In 1948, we had a vast and ineffective service of tuberculosis hospitals based on the norm of one bed for every two annual deaths. Death came from infectious disease, not from our lifestyle. Our resources are now bent to these new objectives.

The docile population, trained to accept death and disability as inevitable, is no more. If one can bank and buy books at midnight, why not also have the same health service – and a service that delivers the same outcomes – 24/7?

Technology, imaging and genetic medicine have ensured that our NHS is the best it has ever been, but at a cost. Multiple chronic diseases, any one of which would have been fatal in 1948, now do not stop us from taking cruises. Paternalistic views have had their day. IT and apps are coming to reign in the hands of both patients and doctors. Now, how many moles have developed on my forearm recently?

Please note that the views expressed in guest blogs on our website are the authors' own and do not necessarily represent the views of the Nuffield Trust.