65th birthday of NHS in London (Photo: Velar Grant)In 1946, following on from negotiations with the professions and others we would now call ‘stakeholders’, the Act to establish a national health service was finally passed.

It was a hard won achievement and full of compromises. But it has served the United Kingdom well over its history and is still providing better health outcomes at lower cost than other equivalent countries. It has given people peace of mind while, in the US, health costs are people's greatest financial worry.

With increasing privatisation of health services, we are having to fight to keep our NHS. Cartoonists portray it as a building riddled with cracks, fought over by the global private sector giants in healthcare. Allyson Pollock’s excellent Reinstatement Bill undoes a lot of the damage. But it is worth revisiting the initial compromises to see how we could make the NHS even better.

To get the original NHS Bill through parliament, Labour's health minister, Aneurin Bevan, adjusted his design to address the objections of medical professionals.

The separation of health and social care

The first compromise saw local authority services separate from health services, despite opposition from within the Labour Party. Bevan argued that if health services were planned and run by local government, inequalities would remain. So planning would need to be central and management health specific. Home helps, homes for the elderly, and environmental health came under local councils and could be means-tested. District nursing and midwifery moved to the NHS. This opened a split which has been problematic ever since.

As Pollock shows, this allowed successive governments to shunt costs by redefining needs of people with chronic conditions as ‘social care’ rather than ‘health’ related. Costs and care were covered by people and their families and friends. Over the last decades of the twentieth century, ‘health’ procedures were increasingly labelled as ‘social care’. Long-stay wards in hospitals closed. Gradually, families had to pay for more procedures with a decline in those free at the point of access. Now many nursing functions happen in residential homes. Disagreements between the NHS and local authorities have led to a series of panels being set up at great expense to make case decisions, and have led to a mushrooming of court cases which centre around the question of ‘who pays’. 

Parliamentarians should now address this particular fault line by making health and social care both ‘free at the point of need’. The cost of means testing, together with court and panel costs, would go a long way to funding such a sensible decision.

Private practice within the NHS

The second compromise in the original Act concerned NHS hospitals. Free hospital care was opposed by a powerful professional lobby. Doctors campaigned hard to keep their private practice. Compromises were struck. Specialists agreed to work for the new NHS providing they were allowed to keep a proportion of their time for their own private practice, which could take place in the NHS hospital. At the time, this seemed like a corner of the old system coexisting with the new. As time went on, however, it became the curious system we have today. If there's a waiting list, the consultant's secretary can suggest an appointment as a private patient where the patient can be treated right away in an NHS or private hospital. In an emergency the patient can be referred back through A&E to the NHS. Private practice and private hospitals flourish at minimum risk or cost to the private practitioner. Doctors, nurses and other staff are trained by the NHS and when things go wrong the NHS picks up the bill.

As a result, the system still contains the kind of inequalities it was set up to get rid of. This fault line, built into the system from the beginning but increasing in severity with limited NHS funding, has resulted in exactly what the NHS was set up to stop – comprehensive health care is not open equally to all. The treatments which cash-strapped Clinical Commissioning Groups (CCGs) are denying their NHS patients are given by NHS-trained consultants and surgeons in their private consulting rooms to those who can pay.  Leaving the poorer families in the population to cope with a reduced quality of life has a vast impact on our communities, as more people struggle with varicose veins, hernias, and other non-life threatening but none the less debilitating conditions for the remainder of their lives.

GPs, public health, local authorities: the disjuncture

The third compromise, built in from the beginning, was the disjuncture between public health, GP practices, and local authorities. Public health was left to grow in whatever way it could in the district health authorities. In 1946 the medical health officers with responsibility for epidemics, preventive health, community nursing, emergency dental treatment and ophthalmology were removed from the local authorities and put under district and regional bodies. GPs were paid under contract for their practice in single-handed surgeries or clinics with several doctors. All these other functions were managed outside GP practices. The effects were immediate with long-term consequences. Public health campaigns could no longer rely on the local democratic process to make them work while drainage, clean water, and decent housing were not in the same organisation as the public health departments. Teams were forced to work across boundaries, which made working together difficult.

Local authorities increasingly took the attitude that health was not their concern, so when budgets were set, health was down the list. Hospitals increasingly dealt with budget problems by putting the bar higher, making ‘health services’ distinct from something they called ‘social’ services, thus shedding responsibility for all kinds of problems that could not be resolved by surgical or pharmacological interventions. Health budgets were protected for more and more complex medical interventions, which became more and more costly. In the meantime, those public health, preventative services which had grown up in the 1930s to reduce ill health through early intervention, such as education, exercise, campaigns for healthy eating, good infant care, to name a few, were dislocated from everything else.

The moving of the deckchairs around this three-way disjointed system has now, through the link to Clinical Commissioning Groups, reunited health with the local authorities and to some extent with the GP surgeries. However this does not extend to hospitals, which now are mainly ‘foundation trusts’, the health equivalent of the school ‘academies’, in that they are competitive and required to manage their own budgets even if this means selling services on the open market. GPs, as ‘gateways’ to the rest of the health system, still have to refer to different agencies for their patients’ care, routinely to the local authority for ‘social’ care, the hospital for expert intervention, community nursing or midwifery for health needs at home, and (rarely) to the public health teams for healthy living, local walks, or gardening clubs.

The solution to fragmentation

What is the solution? All political parties toy with what they call integration of health and social care. They can see the waste of money and energy in the panel squabbles over ‘hospital discharge’ and which branch of the service pays for changing bandages or delivering and administering medicines. They can appreciate the sense of no gaps, no duplication, one point of access for the family. But this is hardly more than lip service at a time when the fragmentation of all health and social care is a growing reality. They may all have ‘NHS’ or ‘City Council’ on the logo, but more and more services are provided by private profit-motivated firms who deliver the medicines, do the diagnostics, provide the beds, do the cleaning, and make the instruments. The list of fragmentations seems endless.

Allyson Pollock’s Bill suggests we want to stop this accelerating privatisation. But we also want to reunite our ‘health’ and ‘social’, our community, GP and hospital services in a sound way, without means tests or payment at the point of need, in a way that really would deliver an equal health system to the whole population. If private medicine remains at all it should be clear that it runs outside our own NHS, and that training and emergencies cannot conveniently be obtained for the private sector free of charge from the NHS – they should be paid for. And the democratic principle could easily be reinstated through our organs of local government having a real place, with the professionals, in the design and management of our services.