John Lister, Journalist and researcher
Health Campaigns Together and Keep Our NHS Public
Article first printed in Health Campaigns Together newspaper
When the NHS was launched by then Minister of Health, Aneurin Bevan, on July 5 1948, it was based on three core principles:
◼︎that it should be comprehensive – meet the needs of everyone;
◼︎that it should be universal – free to all at the point of delivery to access GP consultations or hospital treatment;
◼︎and that it be based on clinical need, not ability to pay.
And although Bevan did not make a further explicit principle out of public ownership, the nationalisation of the hospitals was also central to the 1946 Act which established the NHS.
Bevan was convinced it would have been impossible to ensure that that the chaotic mix of under-resourced and in many cases near-bankrupt voluntary, private and municipal hospitals would work together if they remained in separate hands.
Some Tories (not least Jeremy Hunt) have tried to argue that the NHS would have been set up whichever party had been in office. But the 1944 White Paper from Tory minister Henry Willink would have left the responsibility for the NHS in the hands of local government, and the scattered network of voluntary hospitals largely unchanged, with fees still in place.
Bevan insisted he had not felt any consensus behind him as he fought to get the Act passed and implemented: only Labour’s landslide 1945 majority ensured repeated Tory attempts to defeat the Act (and – as late as spring 1948 – block the launch of the NHS) were beaten back.
Public ownership and control, with public funding raised by central government through general taxation, rather than dependent on local council decisions or local taxes, was essential to ensure services would be equitably funded and available to all.
So most hospitals were nationalised, brought into a single system for the first time, and administered on a regional basis, although some public health, community health and ambulance services remained initially with local government.
Insurance model rejected
And with the call for hypothecated taxes or insurance based systems still doing the rounds in the right wing news media, it’s useful to note Bevan’s argument that by raising the necessary funding through taxation rather than insurance, the NHS also worked as a mechanism for redistribution of wealth and addressing inequalities:
… we rejected the principle of insurance and decided that the best way to finance the scheme, the fairest and most equitable way, would be to obtain the finance from the Exchequer funds by general taxation, and those who had the most would pay the most.
It is a very good principle. What more pleasure can a millionaire have than to know that his taxes will help the sick? … The redistributive aspect of the scheme was one which attracted me almost as much as the therapeutical.”
The principles of the new NHS immediately proved so popular with voters that for almost four decades it enjoyed consensus support from both Conservative and Labour parties.Aneurin Bevan
However subsequent ‘reforms’ imposed by governments have served to fragment, disorganise and demoralise the NHS, undermining its principles to make room for private profits in place of the focus on patient care.
This began in the mid-1980s with the Thatcher government contracting out hospital support services (cleaning, catering, laundry, porters, security) to profit-seeking and generally poor quality private contractors, which broke up NHS ward teams and effectively casualised vital jobs.
Then 1990 legislation implemented by John Major’s Tories established an “internal market”, which separated NHS ‘purchasers’ from providers. It set providers in competition and rivalry with each other, making collaboration and cooperation difficult or impossible.
These changes, which emerged from Margaret Thatcher’s secretive “review” of the NHS in 1988 and the 1989 White Paper “Working for Patients,” brought the alien notions of neoliberalism and “new public management” into the NHS, supplanting Bevan’s 1948 values of public service and social solidarity.
The same 1990 Act included similar plans for what we now call social care, implementing proposals from Sainsbury boss Sir Roy Griffiths in 1988. The new policies, implemented from 1993, transferred responsibility for “community care” – most notably for long term care of older people – to local government social services.
This made these services subject for the first time to means tested charges. It deepened the divide between care for vulnerable people inside and outside hospital.
Specialist beds axed
As a result, most NHS specialist beds for older people were closed down, while government restrictions on councils’ use of funding for community care forced a growing level of privatisation of domiciliary services and long-term care.
To make matters worse, tightening ‘eligibility criteria’ imposed by councils from the mid 1990s, driven by growing constraints on local government budgets, ended any possibility of proactive and preventive care that might keep potentially vulnerable patients out of hospital.
Despite Tony Blair’s repeated empty promises up to 1997 to end the ‘costly and wasteful’ internal market, the fragmentation of the NHS was deepened from 2000 by even more far-reaching competitive market measures which included for the first time tendering out contracts for clinical care under New Labour’s NHS Plan, as well as the use of private capital to finance new hospitals and other projects under the Private Finance Initiative. (1)
Unlike Bevan, who had been forced to compromise and permit private beds for consultants and independent contractor status for GPs in order to establish a new publicly owned system, New Labour actively pursued policies to privatise what had been core NHS services.
They signed a Concordat for NHS patients to be treated in private hospitals, and established Independent Sector Treatment Centres to treat elective cases funded by the NHS, as well as for-profit ‘Diagnostic and Treatment Centres’ – all at higher cost than NHS provision.
Even primary care was opened up for private corporations. Meanwhile substantial annual real terms increases in spending in the 2000s ensured that NHS performance increased and waiting times were drastically reduced.
Austerity since 2010
But in 2010 David Cameron’s Tory-led coalition slammed on the financial brakes, ending a decade of NHS funding increases. Within weeks of that election Health Secretary Andrew Lansley also unveiled wide-ranging and complex proposals – none of which had been put to the electorate – to further entrench the competitive market within the NHS and create new opportunities for the private sector. (2)
Lansley’s hugely controversial 2012 Health & Social Care Act brought a wholesale top-down reorganisation of the NHS and compelled commissioners to put an ever-widening range of clinical services out to tender, while encouraging foundation trusts to expand their income from private medicine to as much as 49 percent of turnover. (3)
For almost 40 years various so-called ‘reforms’ have served, piece by piece, to undermine the initial values of the NHS as established in 1948.
NHS managers have been diverted down costly cul-de-sacs of ‘new public management’, ‘business-style’ organisation, competition and privatisation, often urged on by unhelpful advice from expensive management consultants.
The huge historic achievement of the NHS in 1948 was always more than as simply the first universal health care system to be funded from taxation and free from charges.
It was a decisive modernisation, which made it possible to supersede the previous “mixed economy” of health care, in which voluntary, private and municipal hospitals and GP services had functioned in parallel, with no coordination between them, while patchy insurance cover left a majority of the population unable to afford to access a full range of services.
Although it began with old and inadequate building stock, with an ad-hoc and undemocratic regional management structure, and even though it inevitably took time to develop, the seeds were sown in 1948 for the development of a qualitatively new service.
It was as fair in raising its funding as the taxation system, and could be shaped around the needs of the population rather than the charitable whims of the wealthy or the quest for profit.
The creation of the NHS as a national organisation also meant systems for training doctors and nurses could be put in place, and more specialisms were encouraged. Consultant numbers since 1949 have increased more than ten-fold from 5,000 to almost 55,000 in 2023. The Nurses Act 1949 established a modern framework for the role of nursing increasing and nurse numbers almost three-fold, to 333.000 in 2023.
As a national system, the NHS created – for the first time – the possibility of planning the allocation of resources according to need.
This was especially important for establishing hospitals in post-war new towns and other previously under-served areas, and rectifying inequalities between regions and within regions. (4)
A new role for primary care
A specific arrangement was eventually agreed with General Practitioners, who had remained diehard opponents until the very eve of the launch of the NHS on July 5 1948.
They would not accept Bevan’s plan to make them salaried employees, and were only eventually drawn to work with the NHS as independent contractors.
Nonetheless the rapid enrolment of so many families in the new NHS meant almost all GPs immediately found themselves dependent on NHS contracts.
From the mid-1960s as more, younger GPs embraced this link with the NHS, new policies increasingly focused on the development of a specific role for primary care as the first point of engagement and gatekeeper controlling referrals to specialist services and elective treatment.
The early NHS, funded almost entirely from general taxation, but launched in a period of generalised rationing and austerity, nevertheless provided all services free of charge at point of use – including prescriptions, eye-tests and spectacles, and dental checks and treatment.
Even overseas visitors living in Britain were covered. This removed any of the deterrents that might prevent poorer families from accessing the full range of treatment.
However this principle came under attack from the beginning, and there were soon discussions about imposing charges for prescriptions and for dental treatment, which have persisted.
This has been revived by post Brexit racism and chauvinism, with new requirements on front-line NHS staff to enforce mean-spirited charges on overseas visitors (also requiring some British residents to produce ID or face punitive costs).
Charges have only ever been marginal to the total NHS budget. Almost 9 of every 10 prescriptions are dispensed free of charge in England; and they have been abolished in Wales, Scotland and Northern Ireland.
Prescription charges in England, now £9.65 per item – are a problem for the working poor, but raise less than 0.5% of NHS England spending.
Charges mainly deter people from accessing the full treatment they require – regardless of their level of need for treatment. Like so many of the counter ‘reforms’ that have disfigured and distorted the NHS since 1980, charges have made the service less effective, less efficient and less focused on patient care.
Having superseded the limitations of the market in 1948, every reversion to competition and market-style methods has been a step backwards: even plans claiming to aim for “integration” threaten loss of accountability and potential privatisation. There is no evidence of any benefits to compensate for the extra costs, bureaucracy and complex reorganisation.
Bevan was right
And the NHS founding principles are still valid and essential.
75 years on from its launch the task of restoring the core values of the NHS and reinstating it as a public service is a vital one for staff, patients and the wider public.
(1) Lister J. (2008) The NHS at 60: For Patients or Profits, (Libri) Chapters 6 and 9
(2) Tallis, R. (ed) (2013) NHS SOS, Oneworld, London
(3) Davis, J., Lister, J. and Wrigley, D. (2015) NHS For Sale, Merlin, London
(4) Timmins, N. (1995) The Five Giants: A Biography of the Welfare State, HarperCollins.