Problems

The Guillebaud report (1956) noted that the current net cost of the NHS as a percentage of gross national product (GNP) was lower than in 1948 (p. 9), and that capital expenditure in 1938–1939 was more than three times as high as it was in 1952–1953 (p. 33). It noted that while the advance of medical knowledge continually places new demands on the Service, and the standards expected by the public also continue to rise, population changes in themselves are not likely to exert a very appreciable effect on the future cost of the NHS (Guillebaud, 1956: 49–50).

While the Parliamentary Debate (Hansard House of Commons, 1958) was largely celebratory (Timmins, Reference Timmins2008; Klein, Reference Klein2013), Members pointed to various problems such as some ‘mental hospitals’ being in a disgraceful condition (Bevan, L, c1396; Robinson, L, c1442; Shephard, C, c1450), the ageing population (Walker-Smith, C, c1404; Blenkinsop, L, c1457; Thompson, C, c1499), the need for more on the preventative side (Williams, L, c1425) and the democratic deficit in the NHS (Messer, L, c1432).

Policies

Guillebaud stated that NHS had only been operating for seven years, and that “it would be in the best interests of the Service to leave the present administrative structure undisturbed” (1956: 53).

Problems

The Green Paper (Ministry of Health, 1968) stated that there was now widespread recognition that the time had come for the 1948 structure as a whole to be radically reconsidered. This ‘Tripartite’ structureFootnote ¹ was consisting of two systems of finance, with nearly 700 separate authorities with wide variations in size, resources, opportunity and scope.

The Parliamentary Debate (Hansard House of Commons, 1969) pointed to the ‘very serious problems’ facing the NHS: excessively long-waiting lists for surgical treatment; a shortage of doctors in all parts of the service; overcrowded waiting rooms; and a nursing profession disgruntled as perhaps never before (Dunwoody, L, c291). He considered that the cause of the problem of increasing demand was inevitable for two reasons: an ageing community (Marquand, L, c275) and medical advances (Macmillan, C, c243; Crossman, L, c256). Secretary of State, Richard Crossman (L, c254), pointed to the ‘basic fallacy’ of the assumption in the Beveridge Report of 1942 that a comprehensive Health Service would lead to the improvement in the health of the nation and the flattening out the costs within a few years (cf. Macmillan, c243). Marquand (c274) stated that everyone has agreed that at 5% of GNP, NHS funding was a long way behind other countries. Macmillan (c248) noted that we are proportionately spending less on mental health provision than we were 3 years ago. Crossman (c255-6) pointed to the problem of inherited inequalities.

Politics

Political differences were clear over the principles of the NHS. While the Conservatives argued that there was no question of finding all the extra money required by the NHS from taxation, requiring some system of insurance, charges or increased contributions (Macmillan, c250-1), Labour were broadly hostile to charges (even though the Labour government had just re-introduced prescription charges) (e.g. Dunwoody, c298; Crossman, c256-9). Pavitt (L, c285) and Snow (L, c307-311) were concerned that a larger private sector could lead to a first and second class service.

Policy

The Green Paper argued that the NHS required the closest collaboration between doctors, nurses and other workers, and its central theme must be the ‘unified administration of the medical and related services in an area by one authority’ [The Green Paper (Ministry of Health, Reference Jones, Peterson, Pierce, Herweg, Bernal, Raney and Zahariadis1968: 6]. It suggested about 40–50 Area Boards, with advantages of having a broadly similar pattern to local government.

Problems

The Royal Commission on the NHS (1979: 1) opened by stating that ‘we were appointed at a time when there was widespread concern about the NHS’: a recent reorganisation which few had greeted as an unqualified success; industrial disputes; and a chill economic climate.

In terms of international comparisons, it noted that the United Kingdom (as a percentage of national income) spent less than most other developed countries, and also performed relatively poorly in terms of health indicators such as life expectancy, and perinatal and maternal mortality (The Royal Commission on the NHS, 1979: 22–23). It stated that ‘a common criticism is that the NHS is a sickness service rather than a health service’ (The Royal Commission on the NHS, 1979: 35). In contrast to Guillebaud, it suggested that demographic change of the growing number of old people and particularly those over 75, ‘will be the greatest single influence on the shape of the NHS for the rest of the century’ (The Royal Commission on the NHS, 1979: 379).

The Parliamentary Debate (Hansard House of Commons, 1979) reflected this sense of concern. Stallard (L, c729) was “horrified at the state of the NHS … It cannot be denied that the NHS is seriously ill”. He continued that a recent editorial in the British Medical Journal stated: “most of the problems of the NHS are commonly attributed to lack of money”. Ridsdale (C, c763) considered that the Service was facing a crisis because of lack of funds. Unfavourable international comparisons, especially in terms of funding, were discussed (e.g. Miller, L, c760; Ridsdale, c763; Vaughan C, c809-10). Boscawen (C, c779) pointed to the initial assumption that in a few years it would pay for itself by cutting down the cost of ill health and the cost arising from people being away from work, but that had not happened. Miller (L, c782) pointed to the funding problem of technological advances. Many Members of the main parties pointed to planned hospital closures. As Stallard (c732) put it, “there is hardly an area (i.e. constituency) which has not been touched by this disease”.

Other problems include a loss of morale (Stallard, c730; Vaughan c809), poor management and leadership (Stallard, c730; Raison, C, c758); remote administration (Vaughan, c811), staff shortages (Wise, L, c796-7; Vaughan, c801), increasing waiting lists (Ridsdale, c766; Wise, c796; Vaughan, c806-7); industrial action (Vaughan c807-8); regional inequality (Stallard, c 731; McKay, L, c786; Raison, c755); and the recent reorganisation (e.g. Jeger, L, c768; Miller, c786; Moyle, L, c816; Vaughan, c803).

Politics

Boscawen (c780) argued that some new thinking is required with regard to the funding of the NHS (cf. Vaughan, c811). Miller (c783) stated that most of the carping against the Health Service comes from those who are lukewarm about accepting the basic principles of the Service. Labour Members claimed that the Conservatives would ‘increase charges all around’ (c811). However, Vaughan (c811) stated that the Conservatives were as determined as Labour to have an NHS that provides proper, first-class health care to every person who requires it, but the differences lie in the way in which that sort of care is achieved.

Policy

The Royal Commission on the NHS (1979) stated that easily the most popular remedy for the failings of the NHS, especially and understandably with those working in it, was that much more money should be made available. Others included alternative methods of financing (e.g. charges); taking the NHS out of politics; integrating health and personal social services; and further NHS reorganisation (The Royal Commission on the NHS, 1979: 35–36). In total it made 117 (largely minor) recommendations.

Problems

‘Working for Patients’ (Secretary of State for Health, 1989: 2–3) pointed to rising demand and an ever-widening range of treatments made possible by advances in medical technology. The Parliamentary Debate (Hansard House of Commons, 1988) saw Labour Shadow Health Secretary, Robin Cook (c913), arguing that the NHS Review was born out of panic, as the Government reeled from the publicity last winter about the underfunding crisis in our hospitals. The term ‘crisis’ was also used by Fearn (Lib, c946) and Kinnock (L, c991). A number of Members across the parties agreed that the NHS was underfunded. Knight (C, c955) stated that Lord Beveridge thought that the cost of the NHS per annum would fall, but ‘how wrong he and others were’. Price (C, c950) pointed to exponentially increasing demand. Moonie (L, c940) pointed to demographic change (cf. Price, c950) and the supposedly inexorable increase in medical technology (cf. Sims, c966). Former Labour Health Minister, Dr David Owen (SDP, c 932), pointed out that the United Kingdom spent about half as much of national wealth on health as the United States, and argued the need to increase the spending on the NHS as a percentage of national wealth by a full 1 to 1.5 to 7.5%, which would bring us nearer the average figure for Western industrialised democracies.

Politics

The White Paper reaffirmed the (minimalist interpretation of) principles of the NHS: the NHS is, and will continue to be, open to all, regardless of income, and financed mainly out of general taxation. Cook (c911) noted that the ‘largely’ in the ‘financed largely from taxation’ claim was beginning to disappear, and pointed to increases in prescription charges of 1200% and the introduction of charges for eye tests by the current Government. While Conservatives broadly rejected the insurance-based approach and tax relief for private insurance (Raison, c930; Yeo, c939), they broadly supported ‘a pluralist provision of health care’ (Yeo, c 939), with the private sector expanding (cf. Knight, c957-8; Sims, c968; Shephard, c980), and supported ‘some slight extension of charging’ (Yeo, c 939). They also supported the internal market approach. As Maples (C, c974-5) put it, a free service does not necessarily have to be provided by the state. In general, they claimed that they supported the ends of the NHS, but were more relaxed on means (Moore, c916, 922; Whitney, c942; Knight c956; Newton, c988). However, opponents argued that the Tory regime did not in its heart of hearts believe in an equitable health service, free at the point of delivery (Fearn, c946).

Policy

The White Paper did not use the term ‘internal market’ or ‘purchaser/provider split’, although those terms were used by both sides in a Parliamentary Debate just before the document’s publication (Hansard House of Commons, 1988). Rather, it tended to use the language of delegation: for example, delegating responsibility as closely as possible to where health care is delivered to the patient (Hansard House of Commons, 1988: 3). It discussed several key ingredients of a market including new structures such as NHS Hospital Trusts, GP Fund Holders and incentives, choice, contracts, tax relief for health insurance for elderly people; and the public and private sectors working together. Taken together the reforms amounted to ‘the most significant review of the NHS in its 40-year history’ (The Royal Commission on the NHS, 1979: 100).

Conservatives such as Moore (c921-2), Sims (c943), Maples (c972-3), Burns (c978) and Shephard (c980) argued that Labour was wrong to simply call for more expenditure. Other problems included substantial waiting lists (Owen, c932); monopolistic structure (Raison, c929); being monolithic and centralised (Forth, C, c981); being largely a sickness service (Moonie c940); lacking autonomous local hospitals (Whitney, c945); and having centralised rather than localised services; large rather than small services; distant rather than and local services (Price, c950).

Problems

According to the White Paper, the pressures on the NHS are exaggerated, and have always been exaggerated. Bevan noted some 50 years ago that ‘expectations will always exceed capacity’. It continued that demographic pressures can likewise be overstated. Labour Secretary of State, Frank Dobson (c796) argued that the Conservative internal market was wasteful and bureaucratic. The proposals would break down the Berlin wall between health and social care. Maples (c799) pointed out the difficulties of achieving policy objectives in the context of an ageing population, medical advances, rising expectations and limited money. Hinchliffe (L, c802) pointed to the problem of fragmentation under the internal market, and considered that historically, one of the most damaging decisions for health care in this country was the 1974 Conservative reorganisation.

Politics

The White Paper aimed to improve the NHS through evolutionary change rather than organisational upheaval, building on what has worked, but discard what has failed. In the Parliamentary Debate (Hansard House of Commons, 1997), Dobson (c796) stated that Labour would abolish the internal market, because it has failed. But the proposals went with the grain: ‘what counts is what works’. There would be a third way – a new model for a new century. For the Conservatives, Maples (c799) welcomed the Government’s acceptance of many of the principles of the internal market, which ‘builds on principles that were established by our reforms. However, this apparent ideological pragmatism contrasted with some Labour backbenchers who argued that the only basis for the competition in the health service under the previous Government was that they were preparing it for privatisation (Lewis, c808), and that the NHS was on its way to the hands of insurance companies and other speculators, which would probably create a service costing twice as much and similar to that in America (Skinner, c809).

Policy

The White Paper stated that the internal market would be replaced by a system of ‘integrated care’, based on partnership and driven by performance. Dobson (c796-7) explained that while the separation between planning and providing services would be retained, competition would be ended, and short-term contracts would be replaced with long-term agreements. However, Hughes (Liberal Democrats, c803) believed that the internal market was not being abolished: if there are purchasers and providers, and if there are contracts – even if they are called service agreements – the reality is that there is a market. Dobson (c804) replied that there was no internal market: there cannot be a market unless there is competition, and there is not going to be competition.

Problems

The White Paper (Secretary of State for Health, 2009) talked a good game of the NHS being ‘in a strong position’ with ‘a huge turnaround in fortunes and a great success story’. However, among this ocean of positivity were small islands of concern. Almost as an after-thought, the elephant in the room was mentioned: finding some £15–20 billion in ‘efficiency savings’ over the 3-year period from April 2011 (The Royal Commission on the NHS, 1979: 51). This would be a ‘new financial era’ and ‘the greatest challenge the NHS has taken on in its history’. Moreover, in the section ‘Strengthening regulation, dealing with failure’ (The Royal Commission on the NHS, 1979: 54) there was no mention of the other elephant in the room of ‘Mid Staffordshire’, the subject of a damning Healthcare Commission Report in March 2009 and an apology by the Secretary of State in April 2009 (Klein, Reference Klein2013: 266–267).Footnote ²

In the Parliamentary Debate (Hansard House of Commons, 2008), Lansley (c222) and Dorrell (c222), pointed to poor international comparisons. Lamb (Lib, c 235-7) praised Labour for its increase in expenditure, but criticised the NHS being ‘ludicrously over-centralised’ and having dreadful waste and inefficiency and an absolute failure to let go of a democratic deficit. Conservatives pointed out Labour’s large increases in NHS expenditure had not resulted in proportionate increases in outcomes (e.g. Dorrell, c222, 243). Bone (C, c 251) pointed to the Government’s missed opportunity: while doubling the amount of money spent on the NHS, they have increased output by only 29%.

Policy

The White Paper set a new ambition: to take our improving NHS from good to great, including a new drive towards a more preventative and people-centred service. It built on and implemented the Darzi vision of quality (DH, 2008).

Problems

The House of Lords Committee on the Long-term Sustainability of the NHS (2017) report stated that the NHS was in crisis and the adult social care system was on the brink of collapse, with many witnesses portraying an NHS at breaking point. It noted that while the NHS had seen previous crises, ‘this crisis is different from the other crises’. The drivers of change – from demographic factors and changing disease patterns, to technological and medical advances, income effects and increasing relative health care costs – are intensifying at a relentless pace and fuelling rising public expectations. It noted that in comparative terms, the United Kingdom has historically spent less on health when compared with other nations, has fewer hospital beds, fewer doctors and fewer nurses per head, and often worse outcomes for survival from stroke, heart attacks and many cancers.

Policy

The Report stated that ‘our conclusion could not be clearer’: ‘Is the NHS and adult social care system sustainable? Yes, it is. Is it sustainable as it is today? No, it is not. Things need to change’. It argued that whatever short-term measures may be implemented to muddle through today, a better tomorrow is going to require a more radical change.