What is the future of the NHS in the 21st century?

In his 1942 Report, Sir William Beveridge, a Liberal patrician, identified five ‘giant evils’ — Want, Ignorance, Squalor, Disease and Idleness. The Welfare State was founded in the immediate post-war period to improve the social conditions in the UK. The country was then bankrupt from war exertions; despite warnings, mainly from Conservatives, that the Welfare State was unaffordable, the Labour government, trusting in Maynard Keynes’ assertion that ‘we can afford whatever we want’ went ahead.

The National Health Service was born on 5 July 1948; strictly, the term National Health Service applied only to England and Wales; there were very similar services in Scotland and N Ireland, though these weren’t called ‘the NHS’. Responsibility for Wales passed to the Welsh Office in 1969. With devolution, there has been divergence in the administrative structures of the four health services; in N Ireland, Social Services are integrated into the health service while elsewhere they are the responsibility of the local authority.

The health service in England is by far the largest. The Ministry of Health in Westminster and the Secretary of State for Health, at present Jeremy Hunt, are only responsible for England. Changes in organisational structures, often called ‘reforms’ are usually first introduced in England; the regions may choose to adopt them later, or come under political pressure to do so.

When first introduced, it was naively thought that once disease had been controlled, funding requirements for the NHS would reduce. In reality, such was the extent of ill-health that the service came under financial pressures almost from the start. While all service provision was initially ‘free at the point of service’, charges were introduced for prescriptions; later charges were more generally applied in dentistry, eye examinations and spectacles etc. Enoch Powell, when Minister of Health, thought that there would never be enough money for the NHS.

The Conservative manifesto before the 2010 election indicated that there would be no ‘top-down’ reorganisation of the NHS; as soon as they were in coalition with Liberal Democrats, they began such a reorganisation. This struggled through Parliament and emerged as a different creature at the end. The result is remarkably complex, as this video from the King’s Fund illustrates:

All organisations have problems; for the health services these have been about funding, staffing and the provision of services — what services, where and how. The population is changing; there are more older people, fewer younger people. Health costs are, for the individual, greatest at the extremes of life. In the not so distant past, management of many conditions was ‘expectant’. If you had a heart attack, you were put to bed to ‘rest’ and were dosed up with morphine, and that was about it. Today, you can expect a cardiac angiogram and a stent, and with luck, rehabilitation. And you need your angiogram and your stent right now. Medicine has changed from being ‘passive’ to being ‘active’; and such changes need even more staffing and equipment and thus more funding. You can read about the daily life of a junior doctor here, with expanded background information here. The health services are a ‘near-monopoly’ in terms of training, jobs and service provision.

In the past, the pyramid structure of the health services meant that more ‘worker’ medics were needed than ever could become ‘bosses’; this discrepancy was often covered up by immigrants from the sub-continent. More recently, the pyramid has ‘flattened’; and the EU is now a significant source of manpower. In nursing, what was once a ‘calling’, an occupation for life, is today reliant on migrants from both the EU and, for example, the Philippines.

To all of this, there is now the complication of Brexit and in what way the UK, or even just NI, can be expected to change thereafter. We don’t know if things will remain more or less the same, or whether the UK will become a low-tax, low-regulation, small-state ’Singapore on Thames’. Locally, we don’t know what will happen to the border and to cross-border cooperation in, for example, children’s heart operations. We might hope, but we have no clarity. We don’t know if the ‘free at the point of service’ model of the health services will continue, whether the state-funded and state-provided model will continue, or whether there will be ‘creeping Americanisation’ and privatisation. We can expect that there will be curbs on immigration, with the potential for recruitment of staff; we might expect that the UK will become less ‘migrant-friendly’.

Already, some consequences of Brexit are apparent. The EU’s medicines agency will move from London to Amsterdam; what was once a shared resource will, in future, have to be newly established and fully funded by the UK. The UK has also indicated a withdrawal from Euratom; although a separate legal entity from the EU, it is subject to the jurisdiction of the European Court of Justice, thereby apparently crossing a ‘red line’. This has major implications for the supply of isotopes used in medical diagnostics and cancer treatment. (The EU’s banking agency will move to Paris; in April 2017, David Davis said he saw no reason why either should leave London.)

A group of right-wing Conservatives published a pamphlet in 2005 about ‘direct democracy’. It included a chapter on Health. It’s not clear who wrote which chapters, though Jeremy Hunt was one of the group. The Health chapter relies on dubious evidence indicating that the NHS is neither effective nor efficient, makes unfounded assertions, and it quite clearly calls for an American-style privatised system. You can read a cogent critique here. There is an action against this pending.

The NHS wasn’t founded as a ‘socialist experiment’ rooted in ideology. The basic principle had been in operation in for decades in places such as Tredegar in south Wales. There, workmen paid a halfpenny per week to subsidise the local health services — the basic funding concept of the NHS. Nye Bevan worked in Tredegar, and was the local MP and Minister who steered the NHS Bill through Parliament. The physician AJ Cronin also worked there; his pre-war novel The Citadel describing conditions there is widely thought to have been a major influence in the formation of the NHS and the Welfare State. Harry Leslie Smith grew up in great poverty in the pre-war years; his memoirs are a poignant story of what conditions were like for many people then.

By contrast, neo-liberalism is a theoretical ideology. Initially, it railed against central ‘socialist’ — communist — planning; it was taken up and expanded as Reaganism and Thatcherism, with assistance from Ayn Rand. Such ideology now embraces the idea of a ’small state’, one where individuals are entirely responsible for their destiny, where ‘red tape’ and regulation should be reduced to a minimum, where the ‘rights’ of individuals should be minimised, and where private enterprise is (almost) always better than the state at the provision of services. There can be little doubt that hard right-wing Brexiters have embraced this private enterprise model. Private enterprise is neither altruistic nor it is charitable; it exists purely to make a profit. The theory has it that private enterprise is more ‘efficient’ than the state can be, and so provides services more cheaply, yet still turns a profit. I said that individuals were responsible for their destiny; this is a reworking of the Victorian moralistic idea of the ‘deserving’ and the ‘undeserving poor’. Those who through no fault of their own were impoverished could seek assistance; those who were considered to be indigent deserved neither pity nor mercy. There are distinct echoes of this today in the application of universal credit and other ‘benefits’, for they are ‘benefits’ and not ‘welfare’.

Many of the activities in the infographic above lend themselves to privatisation, and many have been. It’s estimated that about 8% of new NHS contracts go ‘privately’. As Brexit is a time, we’re told, to grasp opportunities, we can expect much more of this. A note of caution; Hinchingbrooke Hospital was run for a while by a private consortium. Unable to run it and make a profit, they walked away. Walking away is not an option for the state. And when a private contractor has fulfilled a quota of whatever they provide, then that service stops until the next financial year. As for funding, the NHS has been expected to make ‘efficiency savings’ when many Trusts were in deficit. Many see this as ‘death by a thousand cuts’, itself a precursor to red-blooded privatisation. Deliberate underfunding of the health service is a political choice, though it may be camouflaged as ‘austerity’; and austerity is the bed fellow of neo-liberalism.

Private Finance Initiatives (PFIs) were popular for a while; they were introduced to the UK by John Major, but greatly expanded under Labour.  A consortium would provide the capital for a project, and the state would then lease it back for a period, often about 30 years. This model was politically attractive, for it kept the costs off the government’s balance sheet. It’s now very clear just how expensive this is over the course of the agreement; The Irish News reported on this recently. Further, given that interest rates are so low, there is little economic argument for the government not borrowing. Indeed, the previous chancellor, George Osborne, provided an excellent example of how governments can borrow. He boasted that the government had paid off the South Sea Debt. The South Sea Bubble burst in 1720; it was a fraudulent scheme, involving the elite. To avoid a scandal the then prime minister, Robert Walpole — who had profited from the scheme — borrowed to pay off the debts. It took nearly 300 years to repay this. No individual could ever borrow over such a term — balancing the budget and avoiding debt which are ideas originating from personal financial management do not apply to governments.

The banking crisis in 2007-2008 again indicated problems with ‘rampant’ and at times criminal capitalism; when the banks went bust, it was governments — for which read taxpayers — who had to rescue them. Yet it seemed no time before the recidivists were saying that the time for remorse was over; taxpayers would disagree.

Locally, problems with the health service are well known; the closure of GP practices in Fermanagh and Portadown, the difficulty staffing the A&E at Daisy Hill, and the waiting times in hospitals, some of which extend now to several years. The Bengoa Report lies gathering dust; health service costs are much higher here than in Britain. There is no local Executive, no Minister responsible for decisions; there is stasis. The two major political parties have totally opposing views on Brexit, with the DUP in favour and Sinn Féin against, views graphically represented in the geographical distribution of Remain/Leave votes in the Referendum. There are problems enough without the complication of Brexit. But many fear that if Brexit is accomplished as true-Brexiters expect, then the health services will be sold off and privatised, and that provision may well become ‘means tested’ with many failing that test. Low taxation will not be a sufficient reward for something that we as individuals simply can’t afford. If you think that this is outrageous scaremongering, then look at the US; there the President is determined to roll back ‘Obamacare’, what he calls the Affordable Care Act. And in the US, medical and hospital fees are a leading cause of personal bankruptcy. In the UK, there is still a ‘free’ health service, even if it is imperfect, and treatment under it neither requires wealth, nor does it bankrupt. But for how long?